16 October 2017
Uses of virtual reality in healthcare are rarely far from the headlines, whether it’s cheering up hospitalised kids with cancer, as a distraction technique for painful procedures or treating life-controlling phobias. But what is virtual reality and what promise does it hold for healthcare?
Virtual reality - hot or not? View the infographic here
Virtual reality is a computer generated simulation of an object or an environment that the user can interact with in a realistic manner. A similar concept is augmented reality, where the simulated object is projected onto the real world, such as the now defunct Google Glass or the popular game Pokémon GO. In pure virtual reality, however, there are no visual inputs from the real world. A typical virtual reality set-up consists of goggles, headphones and some method to track head movement and position, linked with a computing system that integrates the user’s movements to update the graphics. By displaying different images to each eye, the illusion of three dimensional scenes and objects is created.
The idea of virtual reality has been around for decades, but improvements in technology over the last few years have been stunning at both the high and low end of the market. Developed for gamers, there are three commercial systems: the Oculus Rift, HTC Vive and Sony Playstation VR, which cost over £500 when the accessories are included and require a high performance gaming PC or video game console. Headsets that are compatible with certain smartphones, Samsung Gear VR and Google Daydream View, are available for less than £100. The cheapest option is Google Cardboard, which costs £15 and turns a smartphone into a 3D viewer with a cardboard headset. Of course, the lower priced options have less functionality and are not as immersive.
The list of ways virtual reality can be used in healthcare seems endless. There are applications in the maintenance of wellbeing, medical testing, diagnosis of disease and treatment. Virtual reality also has promise in areas of research, training and improving patient experience. It is impossible to summarise all the uses, so I will focus on two very different aspects: surgery and phobia treatment
There’s a first time for everything, and surgeons have traditionally learnt on the job (ie. on the patient). Virtual reality allows trainee surgeons to practice operations and make mistakes, without potentially harming a patient. But there is a danger that if a simulation is not sufficiently realistic as it might encourage poor technique. There have been quite a few studies of virtual reality in different surgical specialties, and the results suggest that virtual reality training improves some skills and help trainees work faster. However, none of the studies assessed patient outcomes, because they were not big enough to pick up these effects, so we cannot be sure that virtual reality is helpful.
Virtual reality can also be useful for experienced surgeons. Cross-sectional medical imaging, such as MRI or CT scans, can be transformed into a 3D representation which can be used to plan a personalised operation and reduce the operation time. A dramatic example is a life-saving heart operation on a baby called Tegan Lexcen, enabled by viewing the medical scan images through Google Cardboard. More repeatable scenarios have generated useful evidence. A randomised trial was performed using a specific virtual reality technique for planning brain tumour operations. The virtual reality planning group did better:
A key technique for treating phobias is called “exposure therapy”. This involves the patient imagining or being exposed to the object of their fear in a controlled, graded manner while learning how to keep their emotions in check. This method is effective, but it is often a challenge to expose someone to their fear. For example, if your fear is of flying, it’s not practical to take a therapist with you on a flight. Real world situations cannot be controlled as easily, and there is a risk that the patient may become overwhelmed by their fear which would be counter-productive.
People with autistic spectrum disorders are especially prone to phobias, which can make it difficult for them to leave the house. A new NHS service, the Blue Room, is a virtual reality experience that allows children with autism to face their fears in a controlled environment with a specially trained therapist. Avoiding the traditional virtual reality goggles that would distress some children with autism, the Blue Room consists of four screens which play out a personalised fear scenario. The only published report so far was on a small number of children, but showed that the technique worked well and had a durable effect. A larger study has been carried out, with results expected later this year and the service is now accepting NHS referrals from local child mental health teams, paediatric services and GPs.
There are several challenges that virtual reality will face in the healthcare setting, such as legal and regulatory issues, excluded users and cost. Some of the problems relate to the uncertainly related to a new technology. There are no studies of long term use of virtual reality or any understanding of the effects of immersive advertising.
Virtual reality may seem like a technology of the future, but it still has to play by the rules of today. Many of the potential uses would need to be regulated as a medical device, by providing evidence that the technology is safe, the benefits outweigh the risks and it performs as claimed. This can slow down innovation, but protects patients from useless or harmful technologies. Of course, any applications of virtual reality will be required to safeguard users’ data as per the Data Protection Act.
Some people will not be able to use virtual reality, such as those with visual impairment or who suffer from nausea when using virtual reality technology. Additionally, some people may not wish to engage because of lack of technological skills, conflict with their personal beliefs or dislike.
There are set-up costs when introducing virtual reality into healthcare, as even the simplest systems require smartphones (relying on user smartphones is an obvious way of removing this barrier).
Successful ventures that incorporate virtual reality into healthcare have happened serendipitously, when healthcare professionals have interacted with companies that specialise in game design. An example is the virtual reality aspect of a training package for nurses and care workers provided by Fusion 48, the product of a chance meeting. Rarely, it can be one person who has both the clinical knowledge and technical skills, such as Jonathan Ashmore, an NHS MRI physicist, who developed an app with 3D video tour of the MRI suite to dispel children’s anxiety associated with the scan.
This fragmented approach may be best for the moment, as the set-up cost for virtual reality systems is fairly low and it allows flexibility. In some settings, virtual reality gear could be used in multiple ways, for example in elderly care homes to entertain residents and train care workers. In others, that will not be feasible (no-one will be happy if the cardiac surgeons try to take over the games room for teenage cancer patients).
The benefits of virtual reality are difficult to assess, so funding for studies to show that virtual reality is clinically useful and cost-effective would be helpful. And more opportunities for interested clinicians to collaborate with virtual reality experts will generate exciting new products that will hopefully widen access to high quality care.