There are many differences between the UK and the US and these have been well documented over the years from language, culture, food, policing and so the list goes on. But now we are united in one unprecedented threat, our addiction to opioids. In the US over 100 Americans die daily directly as a result of opioids while in the UK 24 million opioids were prescribed in 2017 alone resulting in just over 10 deaths daily. This crisis has been described as the silent killer. But why has it happened? Drug companies minimised opioid addictive properties and exaggerated their benefit over the long term for chronic pain. However research shows that opioids are not effective for daily long-term use and evidence further suggests that chronic use of opioids can make pain worse, in a phenomenon called hyperalgesia.
In light of this what is a patient to do? They still need to find a way to manage their pain - a condition that affects 28 million people in the UK and over 100 million Americans - this is where technology and in particular virtual reality can and does help. So for the first time at the Virtual Medicine conference with the world’s leading VR exponents at Cedars-Sinai from 28 to 29 March 2018 with over 300 delegates we had an opportunity to:
review the evidence supporting the efficacy of medical VR;
study patient stories where VR worked and did not work to improve outcomes;
learn best practices and tips for implementing VR into clinical workflows;
discuss the cost-effectiveness of therapeutic VR programmes and
hear directly from patients who have received VR therapy.
Brennan Spiegel’s (Director & Founder, Virtual Medicine) opening remarks were poignant, “we are sitting in a building where 900 people are suffering, patients who are socially isolated. We have to be careful about what we promise our patients in terms of what VR technology can achieve. We have to understand the patient’s point of view. How do we enable patients to escape their four walls? We have to be able to evaluate what happens when patients do escape. The key is to talk to patients to find out what works and what does not work. If VR is a therapy then we need a VR pharmacy.”
"We have to be careful about what we promise our patients in terms of what VR can achieve"
Brennan Spiegel and Deepa Mann-Kler
With over twenty different speakers over the two days, there was much to think about in terms of the science of immersive therapeutic technologies. Here are my key takeaways from Virtual Medicine, they are in no particular order, just an insight into what we as a community working in this space need to be mindful off, if we are going to achieve positive outcomes for patients - the reason we do what we do.
Critical to all action, thought and approach for therapeutic VR is to remember Jason Lanier in “Dawn Of The New Everything” where he suggests that VR can heighten our appreciation of reality. Once you emerge from the experience, you see the world with fresh eyes. The only meaningful gauge to test virtual reality's effectiveness, is if it makes real life better. Skip Rizzo echoed the same sentiments later in his presentation, adding that effective VR teaches people skills they can use in real life and in some ways this became a mantra for the conference. Furthermore Lanier says that “humans should never be passive consumers of VR but must play a proactive role in the experience.”
Effective VR teaches people skills they can use in real life
With this in mind the first person experiences of patients using VR were compelling, key and informative. Patients stories ranged from using VR in labour instead of an epidural - this was Erin’s second pregnancy and she felt her bonding experience with her first baby was negatively affected as a consequence of the numbness from the epidural and wanted a different experience second time round - and VR gave her and her husband the birth that they wanted and the full bonding experience with their baby, where she connected straight away. Amanda suffers from Lupus and lives daily with chronic pain but through VR has found a way to escape her pain. Her most favourite immersive experience includes swimming. Finally Harmon, who suffers from Crohn's disease and has undergone over thirty procedures. For him the stressful point was having the IV inserted but VR was a way for him to distract his attention from the procedure. In a nice twist of personalising VR - Brennan Spiegel and his team took a 360” camera and filmed the park that Harmon often goes to relax - and then surprised him with it in VR. It was a very moving moment when this story was shared. The patient panel made several recommendations they feel are necessary to move VR therapy forward. There is a need for VR Doctors and a VR Pharmacy; to involve patients as early as possible; for the doctor to stay connected with the patient and to update frequently and to give patients choice in terms of accessing technology and its content. Harmon’s final quote was that “VR is the bicycle of the mind” and he may well be inclined to create his own VR content one day.
“VR is the bicycle of the mind”
Part of the learning over the two days was to explore the limitations of VR, apart from the obvious motion sickness which will affect a small number of people. One of the patients, Amanda shared a story of her friend who suffers from complex regional pain syndrome and that VR can trigger a seizure. Harmon said that in a hospital setting where you cannot move there is no need for a 360” video when an 180” is most appropriate and that content creators should be responsive to this. Brennan Spiegel was also sensitive to this where he explained that the wrong content can be harmful to a patient if you do know their full history.
One of the most powerful stories from Virtual Medicine came from Pastor Kelvin Sauls and Bernice Coleman in the “So-Help” initiative where VR reduced blood pressure in people attending the Holman Methodist Church. The project came about because African Americans with hypertension do not have the same outcomes as the general population after heart surgery and this is most affected by high levels of salt intake. The project was successful because it offered real and meaningful engagement that was culturally sensitive with co-design and co-production at its core. It involved 50 people over 3 months. A lot of ground work was established before the start of the project and there were very clear and distinct phases. Ultimately VR gave participants new ways to engage in their own health. The success of the initiative is that the community at a grassroots level utilised the capability of what technology had to offer AND they owned, designed, produced and invested in the whole end-to-end process where all the people with a stake in the process invested their time, resources and energy. It’s like Pastor Sauls says “being a religious leader means also being a health leader.” So-Help enabled a further and deeper connection between the person and the clinician without placing more walls between patients and providers.
"Being a religious leader also means being a health leader"
Pastor Kelvin Sauls and Bernice Coleman
Les Posen talked about veridicality and verisimilitude, that is truth, the stimuli and cognitive processing required in everyday life, where we see the world as we are and not as it is. One of the outcomes for people who suffer from anxiety, is that they seek a safe place. Key to powerful VR therapy is haptics, smell, sound, bio-feedback that detects heart rate variance and the vagal nerve. When you are anxious you do two things, you either overestimate the presence of danger and thereby generate symptoms that you think are real or you underestimate your ability to cope. The problem is that people cannot interact with their environment. This needs tailored and specific VR for each person. Anxiety won’t kill you as Les says, stay curious not calm.
Matthew Stoudt outlined seven clear areas where action is needed if VR therapy is to succeed:
there has to be strong clinical evidence and efficacy;
have to develop a protocol standard for using VR in the clinical setting;
need to embed a VR workflow design for health staff otherwise the headset will not be used;
have to improve technology connectivity inside hospitals;
the economic value and impact of VR has to be proved;
need to find alignment between patient, provider and payer where you build meaningful partnership;
there has to be a shared sense of urgency to bring technology to the patient more quickly - it can take two years to bring innovation into a hospital at times.
Josh Sackman demonstrated that when patients choose their own content their pain reduction falls even more - so when VR is personalised it has a bigger impact. One size is not going to fit all. But how do you target the right experience to the right person? People who suffer chronic pain often have complex needs and avoidance of pain is not a goal, where you are often dealing with catastrophisation, anxiety and insomnia. Critical to all of this is to leverage biodata to treat, train and track the VR therapy. This feedback loop is a way for the patient to know they are doing the right thing. In this way VR is being used to connect the heart and mind. For VR to truly succeed with patients we need a staged and personalised approach.
Ted Jones, a pain consultant of East Tennessee is at the frontline of the opioid crisis. In a study he conducted with patients he found VR to be twice as effective as morphine in reducing pain for his patients, where the pain fell by 66% for those using VR and 33% for patients using morphine. The study was with 10 subjects over 3 sessions of 20 minutes each on VR. Up to 90% of patients also experienced a lingering analgesic effect for up to 30 hours. At a clinical level Ted’s wish list include easy plug and play that is ready for clinical use; develop systems and applications that specify what the app will do; provide a bank of machines for groups; know the specific needs and have paths for reimbursement via insurance.
Ted Jones outlining his use of VR
Next up was Keith Grimes, digital health guru, who outlinined that on average GPs see 90% of all patients in the UK with over 340 million consultations per year. He then shared his experiences of using VR with patients and said for it to succeed and scale it needs better interaction; training; easier transition when switching between apps; screen mirroring and tailored content for individual use cases.
Kim Bullock clearly stated that it was “exciting to have the technology but deeply frustrating getting it to the bedside.” However one of the unintended consequences is that VR is de-stigmatising mental health and technology is moving so fast that we the community have to work together.
Aenor Sawyer and Jeffrey Gold shared their paediatric perspectives on VR as a non-pharmalogical analgesia for children where it has been hugely successful with routine procedures for blood draw, cast application and removal, pin extraction, venipuncture, wound care (including suture, staple, removal and debridement), IV placement. Their goals in using VR in the paediatric setting are to minimise fear and pain; avoid lasting medical trauma; avoid risks and known harmful effects of anaesthesia and systematic medication on developing brains. The most successful VR headsets were those driven through eye movement with no hand use. Interestingly kids who are most anxious are most likely to benefit from using VR.
VR and paediatrics
The second round table kicked off on key issues. By far the biggest challenge is getting the hardware to the bedside, who actually “owns” the hardware? We have to think about who drives the adoption forward in the clinical setting. Safety has to be considered where there are clear protocols for safe and effective use of VR. Hospitals tend to suffer from a double edge problem where they want to be innovative but don’t want to take risk. Using VR will add time and money and this needs to be taken into consideration, where it can add an average of extra 10 minutes consultation time. Who pays? A question from the audience focussed on key concerns for VR paediatrics and the need for age specific content. Another delegate asked if there is a novelty aspect to VR where its impact wears off after a while? Skip Rizzo’s reply was interesting, his comparison was does the novelty wear off after the first time you read a book? The answer is no. What actually happens is you understand and refine your taste, in the same way that you do with film, TV etc and so people will take the same approach with VR. Fundamentally films only have three ideas at their core and yet people continue to watch them. Kim Bullock interestingly said that her mindfulness patients want to experience the same VR content over and over again, almost like booster shots.
Then the sessions moved onto surgical training where VR is particularly effective in high risk and low frequency situations. It enables surgeons to practise and to warm up before procedures. However the industry faces a lack of agreement on a step by step simulated approach for procedures and this is a problem that needs to be resolved.
Jeremy Soule, described as “the John Williams of video games music” talked about the importance of virtual soundscapes and how immersive audio compositions will revolutionise therapeutic VR. Music is key to contributing to interactivity and is often so poorly utilised in VR.
As the conference drew to a close David Rhew talked about how we are at the cutting edge of therapeutic VR and shared Sam Sharar’s studies clearly showing brain activity using MRI with and without VR.
VR has the capability to retrain our neural networks and pathways - we call this neuroplasticity where Walter Greenleaf also said that for it to be effective it needs repetition and has to be engaging. Walter surmised his perspective by saying that current technologies and concepts are founded on more than 30 years of research and development; recent changes in cost and access finally make VR affordable; VR is currently used for prevention, evaluation, treatment and chronic disease management and after years of validation and use by early adopters, the technology is finally poised to move to the mainstream. For VR to be truly successful it has to connect with other parts of the healthcare system and not sit in isolation. Ultimately the real competition will be to do nothing and to do nothing will be to fail patients.
Virtual Medicine Agenda
Virtual Reality Research
Neon would like to thank Invest NI for their support.