THE VALUE OF VR

Pediatric Intervention

Managing pain, fear, and anxiety remain difficult in the pediatric population as they are often under-recognized and undertreated. Patient distress is common during treatment and procedures. This can especially be true with the intense pain experienced by burn and cancer patients who endure ongoing testing and treatment.42 Additionally, immediate pain and distress are not the only concerns. It is well documented that patients experience long term sequelae from inadequate pain management creating a negative impact on their future psychological health, including increased pain sensitivity over the course of their lives.43 Managing pain with the use of sedation and analgesia have been routinely used over the last 40 years, but experts have voiced serious concerns about the adverse effects of combining opioids with benzodiazepines for pain and anxiety control.44 Non-pharmacologic interventions have been somewhat effective including cognitive behavioral therapy (CBT), guided imagery, relaxation techniques, toy distraction, and hypnosis, but new and effective interventions are needed. Multiple clinical trials demonstrate that pediatric patients receiving VR intervention have statistically significantly reduced pain and anxiety as opposed to those treated with standard care. Recent studies examining VR intervention as a tool for pain and anxiety reduction in the pediatric population include a study comparing the effectiveness of VR intervention to conventional care in children receiving peripheral intravenous catheter placement, and a study examining the use of VR intervention among hematology, oncology, and blood marrow transplant patients undergoing painful and distressing procedures.,45, 46 Both studies suggest VR intervention can be clinically significant in reducing pain and anxiety. The use of VR is increasingly applied in children’s hospitals, such as Stanford Children’s Health where AR and VR software are part of a patient’s care plan to engage and distract them during painful procedures. The Childhood Anxiety Reduction Through Innovation and Technology (CHARIOT) program at Lucile Packard Children’s Hospital Stanford has composed a team of physicians, engineers, researchers, and child life professionals in an effort to implement new non-traditional immersive technologies for young patients.47 The hospital uses VR during treatment as a means to decrease pain and stress, for example, by offering AR goggles for patients in the pre-op so they can watch movies and play games prior to being wheeled back for surgery, and by using VR games in the intensive care unit (ICU). A study published in the Journal of the American Medical Association (JAMA) in June of 2021, suggests VR may be effective in reducing pain during dressing changes for pediatric burn patients. The intense pain associated with burn dressing changes is often worse than the initial burn injury and highdose opioids are routinely required. As well, a direct relationship between pain and anxiety exists amid pediatric burn patients leading to increased anxiety over the course of treatment and creating long-term challenges.48 Amidst the increased application and positive outlook of VR in the pediatric population, there is a lack of clinical professional guidelines and quantitative studies looking at the effects on children. Preliminary results show improvements in anxiety and pain symptoms with little side effects, but the possible impact on vision, brain development, and issues with stimulus intensity are all considerations for further investigation.49, 50 This is a greater concern in younger children given brain neuroplasticity for development in the early years of life. Evidence shows excessive exposure to screen time negatively impacts brain development, including a connection between increased screen time and diminished language, literary, and executive functions of the brain in preschool-aged children.51 Coordination may be negatively impacted due to VR’s influence on the brain’s interpretation of sensory stimulus such as vision and vestibular balance.52 Additionally, studies have investigated electronic media use and sleep disturbances, depression, and anxiety.53 Age appropriateness is likely to be more critically reviewed as utilization grows and more studies are completed. Currently, some manufacturers of VR headsets do not recommend them for children younger than 13 years.54, 55 Furthermore, cau-

tion should be used regarding material that may be inappropriate or harmful to children. Meta Quest recently announced VR parental supervision tools to be implemented over the next several months while using the Quest headset. A paper published in Pediatrics suggests instead of using VR to fix a child’s impairment, it could be utilized as a tool to gain more insight and awareness of the difficulties the child may experience due to the impairment.56

Mental Health Treatment

An estimated 52.9 million adults suffer from mental illness, according to a 2020 survey by the Substance Abuse and Mental Health Services Administration (SAMHSA). This equates to 1 in 5 American adults. Moreover, US young adults, ages 18 to 25 years old, were reported to have the highest prevalence of mental health illness.57 One of the biggest challenges today is the rising demand for mental health treatment and a shortage of available providers.58 As the pandemic unfolded, the need to provide continuity of care remotely quickly became a necessity and telehealth appointments offered mental healthcare delivery outside of a traditional face-to-face setting. In fact, early studies show the potential benefits of this viable option, including improved accessibility for low-income, racial, and ethnic minority adults and children.59 Mental health treatment at a distance has the potential to break down the barriers of high cost and limited accessibility. As virtual-based treatment moves into mainstream medicine, more is understood about its potential as a mental health treatment. One of the advantages of VR in mental health treatment may be utilization of VR for mental health assessment and exposure therapy, which is traditionally performed in a lab or clinic rather than a real-world setting. Through VR software, real-world settings designed to closely resemble surroundings of daily life offer insight into triggering stimuli such as anxiety, paranoia, fear, and cravings. This gives therapists the ability to provide highly controlled environments for assessment and obtain real-time feedback to implement therapeutic strategies.60 Virtual reality exposure therapy (VRET) shows promise as a scalable tool for anxiety disorders and is already being used in panic disorder and phobia treatment.61, 62 Considerable research indicates efficacy for exposure-based therapy for anxiety, but it remains a treatment gap and is underutilized due to patient fears and therapists’ concern for only having limited control in real-life stimuli scenarios.63 A virtual environment allows more control regarding the insertion of stimuli, contexts, and tasks not possible in in vivo exposure therapy. Smartphone-based VR apps such as EASYHEiGHTS (created to treat Acrophobia) are low cost and can be accessed with a VR headset and conventional smartphone, enabling patients to receive treatments in a therapist’s office or even in their own home. This option removes the difficulty of patients, for instance, having to stand on a tall building for acrophobia treatment, also removing the extra liability for clinicians conducting treatment in a real-world setting. Evidence shows patients are more willing to receive exposure therapy when they can do so in the comfort of a therapy office or their home rather than in the physical world.64 There is activity in PTSD using exposure therapy. PTSD, caused by traumatic life events, affects 3.6% of US adults.65 Studies show VRET produced a significant reduction in PTSD symptoms, including sustained improvements at 6- and 12-month follow-ups.66 Created at the University of Southern California (USC) Institute for Creative Technologies, BraveMind, a clinical, interactive, and VR based exposure therapy tool is currently being used by numerous hospitals and universities to treat PTSD.67 Autism Spectrum Disorder (ASD) researchers and therapists have been using VR since the mid-1990’s in an effort to help patients with autism practice being in stressful situations, combat phobias, and prepare for public speaking.68 A research initiative recently investigated the efficacy of VR incorporated with CBT resulting in marked improvements in specific phobias among children with ASD.69 With hopes of reducing depression and loneliness, Rendever has created an innovative engagement VR platform to assist seniors suffering from social isolation.70 They are currently working with senior living communities and hospitals including the University of Cincinnati (UC) and the National Institute on Aging (NIA) to help bridge the distance between seniors and family members living apart. Moreover, they have created platforms allowing seniors to explore far away cities, travel back to their childhood homes, and even fulfill lifelong bucket list items.71

Of notable importance to mental health practitioners is a small January 2022 published study that compared face-to-face interaction with VR interaction suggesting participants reported a slight preference to face-to-face interaction overall, but when asked to disclose negative information 30% of the participants preferred to interact with an avatar rather than a real person.72 Preliminary study results suggest VR can be an effective treatment for individuals suffering from certain mental health disorders. Notably, some users may require VR-created platforms with special accommodations, such as programs designed around impaired cognition, memory, and language skills, or for individuals with mental health conditions that involve dissociative states or hallucinations.

Chronic Pain Treatment

According to a Centers for Disease Control and Prevention’s (CDC) survey in 2019, 20.4% of adults in the US reported having chronic pain.73 Persistent pain has also been linked to depression and anxiety and can become an overlapping symptom. The CDC and the Centers for Medicare & Medicaid Services (CMS) recommend non-opioid and non-pharmacologic therapies as first-line treatments. Both agencies have raised concerns in response to the increasing rate of opioid abuse and overdose deaths.74 A randomized comparative effectiveness trial conducted at Cedars Sinai revealed VR significantly decreased pain in hospitalized patients and was most effective in patients experiencing severe pain. The patients, using VR goggles, engaged in virtual environments that included swimming with dolphins, and reported a 24% drop in pain scores.75, 76 Seeking non-pharmaceutical solutions for pain management, AppliedVR received De Novo approval from the US FDA in November 2021 for the first VR therapeutic to treat chronic low back pain.77 RelieVRx (formally EaseVRx), a prescription-use medical device, is an immersive VR system based on cognitive therapy methods delivered in an 8-week program and has been proven to improve chronic pain outcomes.78 A trial conducted in 2020 looked at 179 adults experiencing non-malignant chronic low back pain and reported a substantial reduction in pain, mood, and stress suggesting that home-based VR programs could open up access to effective non-pharmacologic on-demand treatments for chronic low back pain.79 Access to treatment and therapists remain obstacles for patients with pain, further exacerbated by COVID-19. A new and promising option for chronic pain sufferers is on-the-spot VR treatment, including automated behavioral programs. One such company, XRHealth, provides virtual treatment rooms inside the Metaverse. Patients can go to the website, choose a therapist, order a VR headset, and begin personalized occupational therapy (OT), physical therapy (PT), or mental health therapy. XRHealth is covered under some insurance plans and offers out-of-pocket plans.80

Virtual Rehabilitation

Telerehabilitation, or rehabilitation through VR, has been gaining traction for a number of years due to the growing advancement of hardware and software technologies designed to treat patients with a range of conditions, including chronic pain associated with injury or illness, traumatic brain injury (TBI), spinal cord injury, stroke, Parkinson’s disease, multiple sclerosis (MS), Alzheimer’s disease and dementia, and cerebral palsy (CP).81, 82, 83 Telerehabilitation methods are being implemented as alternatives to multiple traditional therapies like PT and OT. Although the benefits of PT have long been established, between 50% and 70% of patients who would benefit from PT are unable to receive therapy due to limited access.84 This number is believed to have been higher during the COVID-19 pandemic. Traditional therapies are helpful for recovery, but novel approaches have been suggested to improve patient compliance and outcomes. The use of VR in rehabilitation may offer potential positive advantages for patients.85 Noteworthy advantages of VR-assisted rehabilitation have been reported in the literature including, improved patient engagement and motivation, post-stroke functional recovery and increased mobility, and quality of life in Parkinson’s patients.86, 87 Multiple clinical trials demonstrating VR’s

effectiveness in treating symptoms associated with Parkinson’s disease have been completed with promising results, including studies focused on balance, postural control, and gait disorders to prevent falls.88 VR environments provide interactive and customized platforms that allow patients to elicit realistic reactions that can be used to track patient performance, which is essential in recording patient progress.89 MindMaze, a company specializing in neurorehabilitation and enhancing the recovery potential of patients with neurological diseases, received FDA clearance for 2 gamified neurorehabilitation systems.90 MindMotion GO received FDA-clearance in May 2018 and can be used in inpatient, outpatient, or home settings and offers rehabilitation through upper and lower limb, and hand or trunk exercises.91 MindMotion Pro received FDA-clearance in May 2017 and was designed exclusively for inpatient acute stroke patients with upper limb hemiparesis.92

VR in Training and Education

The complexity of the ever-changing healthcare system and pressure to ensure learning objectives are met through standardized medical training is an ongoing challenge and a potential opportunity for medical educators. The use of VR in training and education offers the ability to train personnel in a controlled environment while minimizing risks to a real patient. Communication skills and simulation-based training have become increasingly more important as a part of the clinical learning experience.93 Dramatic developments have taken place in the drive for better educational tools, including internet and mobile device options. A growing number of hospitals are implementing VR systems to train residents, assist surgeons in surgical planning, and educate patients. Partnering with hospitals and institutions such as Yale University and University Hospitals Cleveland Medical Center, PrecisionOS received FDA 510(k) clearance for the InVisionOS tool for surgical planning in November 2021.94, 95 Further, Stanford University, Department of Neurosurgery is now utilizing Surgical Theater’s medical visualization platform Precision XR. The platform transforms patient’s 2D scans and data into a 360-degree 3D view, allowing surgeons to explore a patient’s anatomy in a way never before possible. Stanford surgeons can reconstruct a patient’s brain through 3D imaging which allows greater visualization, surgical mapping, and planning to improve surgical accuracy and create safer procedures.96, 97 In 2019 George Washington University Hospital became the first hospital in the US to perform surgery using the AR system OpenSight, ushering in what has been called a revolution in pre-surgical planning. This followed Microsoft’s release of a newer version of the HoloLens, the HoloLens 2, which was granted 501(k) clearance for use with OpenSight for surgical planning which renders 2D, 3D, and 4D images in an interactive display and directly onto a patient’s body allowing surgeons to more accurately plan and perform surgeries with precise accuracy.98, 99 According to a recent randomized controlled trial from University of California Los Angeles’s (UCLA) David Geffen School of Medicine, participants using the Osso VR platform improved their overall surgical performance by 230% compared to conventional training methods.100, 101 Osso VR technology combined with Oculus headsets uses customized training platforms to provide reimagined surgical training. The platform allows dozens of hospital staff to collaborate and train in virtual operating rooms and has been demonstrated to accelerate learning memorization.102 Doctors from around the world recently collaborated in a 24-hour surgery facilitated by Microsoft featuring 12 holographic surgeries, including a shoulder replacement in South Africa and a knee procedure in the United Arab Emirates (UAE).103

Moreover, VR is assisting medical students and practicing physicians to create awareness and a better understanding around the patient-doctor relationship, including patient empathy. A study published in 2018 demonstrated VR immersion training as an effective tool to help medical students and other healthcare providers (HCPs) develop empathy for older adults dealing with vision and hearing loss and Alzheimer’s disease.104 The training is currently being used at the University of New England. Additionally, the recently developed mobile app, HealthVoyager, is designed to help

physicians enhance medical comprehension for patients and families following surgery or medical procedures and is currently being used at the Boston Children’s Hospital.105, 106 Early studies demonstrate the importance and potential of VR in improving performance and decreasing medical training costs. While the advantages of VR come into focus, the possible limitations such as overdependence on technology, reduced classical training and standardization in training should be a part of the dialogue.

Inequities in Health

Structural racism in the healthcare system has been evidenced in multiple studies and continues to affect the wellbeing of all people, but specifically those who have been historically marginalized in society. Socioeconomic status and long-established residential segregation remain two strong determining factors of racial health disparity.107 It is important to consider how evolving healthcare technologies like VR may impact the future of healthcare equality. During the COVID-19 pandemic disparities in the healthcare system were profoundly visible as mortality and hospitalization rates were significantly higher among marginalized populations. As the healthcare system adapted to reach individuals who needed care amid the threat of a burgeoning pandemic, telehealth and remote care implementation exploded, emphasizing what is widely known as the digital divide: the inequality between those who have access to technology and those who do not.108 Access obstacles to digital health tools like video enabled smartphones and limited broadband access are common in vulnerable populations with low social economic status and limited health or English literacy and could create an even greater barrier to the potential beneficial application of VR in healthcare.109 Although the pandemic established telehealth as an effective way to reach patients that may have been unreachable otherwise, technology access and literacy remain a challenge. Thus a continued investment in broadband access is warranted. The fact that VR technology is not widely available cannot be overlooked. Not only could individuals face barriers in obtaining access to the technology, but entire communities, including the healthcare organizations that serve them may lack the means to obtain or adopt the technology. As these challenges and the solutions to them unfold, researchers are learning how VR could be used as a catalyst to understand racial bias. VR is currently being implemented as a training tool to better understand the cultural and social needs of patients, and although study in this area has just begun there is potential for VR to become a tool to increase empathy and give users a more positive perspective when interacting with people from different ethnic or social economic backgrounds. Stanford University recently conducted a preliminary study suggesting that individuals who were able to imagine themselves in someone else’s circumstances report feeling empathetic, however individuals who actually experience someone else’s circumstances through VR had longer lasting empathy and the experience even motivated prosocial behaviors.110 While promising, the field is still underexplored regarding using technological means to bolster empathy as a step towards equality. Although the benefits of VR are recognized in this paper, as the technology becomes more commonly used by HCPs it could inadvertently leave underserved populations vulnerable if they are unable to access the growing wave of technology, in lieu of traditional methods to see and treat patients. This discussion acknowledges current healthcare disparities and how new technologies such as VR may positively or negatively impact select populations.