2020 VR 

Research

Accepted vMed20

Research Abstracts

2020 DISTINGUISHED ABSTRACT PLENARY PRESENTATION WINNER

Predictive analysis of the responders of avatar therapy in treatment-resistant patients with schizophrenia

Authors: Beaudoin, Mélissa (1,2); Potvin, Stéphane (1,2); Dellazizzo, Laura (1,2); Phraxayavong, Kingsada (3); Dumais, Alexandre (1,2,3,4).

 

  1. University of Montreal, Montreal, Canada.

  2. Institut universitaire en santé mentale de Montréal, Montreal, Canada.

  3. Services et Recherches Psychiatriques AD, Montreal, Canada.

  4. Institut national de psychiatrie légale Philippe Pinel, Montreal, Canada.

Background: Auditory verbal hallucinations (AVH) are amid the most distressing and prevalent symptoms of schizophrenia. Although pharmacological interventions are a considerable way to minimize symptoms, 30% of patients do not respond adequately and require other types of treatment regimens. A novel Avatar Therapy (AT) using computerized technology has shown large therapeutic effects on AVH severity by enabling patients to engage in a dialogue with a representation of their most distressing voice. These very hopeful results have been extended by our team using immersive virtual reality. Our AT comprises nine weekly sessions: one avatar creation session and eight therapeutic sessions, where the patients are confronted to their reproduced hallucinatory experience and are encouraged to enter in a dialogue with their virtual persecutor. The results of our pilot trial involving patients with refractory AVH were clinically promising for the severity and distress related to hallucinations, illness symptomatology, depressive symptoms and quality of life. However, the differences between responders and non-responders have not been studied.

 

Methods: To deepen our understanding of the therapeutic processes of AT, we first separated patients (N=29) into two groups based on a decrease of at least 20% in the severity of their hallucinations. Then, binary logistic regressions were conducted to identify the best predictors of good treatment response. Following, content analysis was used to identify the main themes characterizing the avatar’s and the patient’s speech that were common across a subsample of randomly selected cases. This allowed to analyze how these themes contributed to the therapy’s success. The variation in the frequency of these themes throughout therapy sessions were also compared.

 

Results: First, the responders were statistically more educated and had fewer positive symptoms at baseline evaluation. Secondly, content analysis revealed that responders developed markedly more prevention strategies throughout the therapy. They were also more likely to value themselves, especially toward the end of the therapy, and their emotional reactions toward the avatar were increasingly positive. On the contrary, non-responders did not develop many prevention strategies and had more neutral/indifferent reactions toward the avatar. Interestingly, the avatar used more confrontational techniques for non-responders from the second session until the end of therapy, while the use of positive techniques remained similar across the two groups.

 

Conclusion: These preliminary results allow us not only to better understand the differences between responders and non-responders, which is particularly relevant in the context of personalized medicine, but also to have a better understanding of the therapeutic processes of AT. However, future studies will have to be carried out on a larger number of patients to confirm the observed associations found in our content analysis.

 

2020 ACCEPTED RESEARCH ABSTRACTS

Randomized trial of a virtual reality tool to teach surgical technique for tibial shaft fracture intramedullary nailing

Authors: Blumstein, Gideon MD MS; Zukotynski, Brian BS; Cevallos, Nicolas; Ishmael, Chad MD; Zoller, Steven MD; Burke, Zach MD; Clarkson, Samuel BS; Park, Howard MD; Hori, Kellyn BS; Bernthal , Nicholas MD; Barad, Justin MD; SooHoo, Nelson F. MD. 

  1. University of California, Los Angeles, David Geffen School of Medicine - Department of Orthopaedic Surgery

Background: Active learning methods have accumulated popularity due to improved results in knowledge acquisition as opposed to passive learning methods. For surgical resident physicians with limited training opportunities outside of the operating room due to time constraints, virtual reality (VR) is a relatively inexpensive and time-efficient active training method for procurement of surgical skills. We conducted a simulated intramedullary nailing (IMN) of a tibia to demonstrate VR training programs as a more effective modality of learning orthopaedic surgical techniques compared to passive learning tools such as a standard guide (SG) through trained novice medical students performing a SawBones simulation of intramedullary nail fixation.

 

Methods: An IRB approved, randomized prospective study was conducted. First and second-year medical students without prior experience of the procedure were recruited and randomized to SG or VR training. Participants were observed performing simulated tibia IMN procedure immediately after training and evaluated by a blinded attending surgeon using procedure-specific checklist and 5-point global assessment scale. Participants returned after 2-weeks for repeat evaluation.

 

Results: 20 participants were recruited and randomized into VR (n=10) and SG (n=10) groups. All 20 participants completed the first phase and 17 completed the second phase of the study. Aggregate global assessment scores were significantly higher for VR than SG group (17.5 vs. 7.5, p<0.001), including scores in all individual categories. The percentage of steps completed correctly was significantly higher in the VR group compared to the SG group (63% vs. 25%, p<0.002). Average improvement between the first and second phases of the study were higher in the VR group compared to SG group across all 5-categories of the global assessment scale, and significantly higher for knowledge of instruments (50% vs. 11%, p,0.01).

Conclusion: VR training was more effective than a passive SG in our model of simulated tibia IMN for novice medical students. Virtual reality training may be a useful method to augment orthopaedic education.

 

Efficacy of virtual reality in pain reduction in orthopaedic pediatric patients measured by patient feedback and heart rate monitoring

Authors: Desai, Bhumit MD; Haber, Lawrence MD; Sarkar, Korak MD; Waldron, Sean MD; Nammour, Michael MD; Reese, Jeffrey MD. ​

Background: Pediatric orthopaedic patients are frequently exposed to procedures that can result in pain and anxiety. There is a trend to avoid opioid medications when alternative therapies are available.  Distraction techniques range from breathing and music to interactive play therapy. These. Virtual reality (VR) has been studied in the context of hematology-oncology and burn patients for pain reduction, however the technology remains largely novel in the pediatric orthopedic field. The investigators evaluated the benefit of using VR distraction techniques with a head-mounted display for procedures in clinic..

 

Methods: Pediatric patients presenting to a tertiary center pediatric orthopedic clinic for post-injury care were included if between the ages of 5 and 18 years, had no significant co-morbidities, and were not undergoing an emergent procedure. 43 patients underwent either cast removal or percutaneous pin removal as per the study parameters. All pre-procedure parameters for the groups were kept similar. The intervention consisted of a fully immersive and interactive in-house developed rock-skipping application via VR headset. Objective measurement consisted of baseline heart rate via pulse oximeter, peak heart rate during, as well as post-procedure HR. Subjective measurement involved post-procedure Visual Analog Scales (VAS) for perceived pain and anxiety. Control group patients underwent the same procedures with identical monitoring. All patients were informed and consented about the requirements, risks, benefits, and other relevant information of the study.

 

Results: A total of 43 patients met inclusion criteria - 24 patients in the VR cohort and 19 patients in the control cohort. The average patient age in the VR cohort was 10.6 years and an average heart rate change of 20 bpm. The average patient age in the control group was 10.5 years with an average heart rate change of 12 bpm. A greater magnitude in heart rate change was observed in the control group compared to VR group (p = 0.12). A lower perceived anxiety was observed in the VR group (2.2) compared to controls (3.1) after the procedure (p = 0.15). 13% of VR had a decrease in heart rate during the procedure.

Conclusion: The findings from our study suggest an interactive and immersive VR experience can be effective in reducing pain and anxiety for procedures in pediatric orthopaedic clinics.  The benefits of avoiding narcotic use, while reducing the morbidity associated with untreated pain, epitomize improvement of patient care through technology.

 

Virtual reality smartphone-based smoking cessation program: A pilot RCT on initial clinical efficacy and adherence

Authors: Goldenhersch, Emilio; Thrul, Johannes; Rosencovich, Nicolas; Waitman, Cristian. 

Background: Obstacles to current tobacco cessation programs include limited access and adherence to effective interventions. Digital interventions offer a great opportunity to overcome these difficulties, yet virtual reality has not been used as a remote and self-administered tool to help increase adherence and effectiveness. Our novel intervention combines 1) exposure to smoking-related cues in ecological situations using virtual reality, and 2) mindfulness as a tool to cope with in-situ cravings, bodily sensations, affective states, and automatic reactions. Moreover, these virtual reality and mindfulness sessions are part of a classic cognitive-behavioral smoking cessation program that provides information on relevant topics on a daily basis through CBT notifications and community support among users moderated by psychologists and mindfulness facilitators.

Objectives: This study aimed to evaluate participant adherence and smoking cessation outcomes in a randomized pilot trial of the digital intervention Mindcotine® utilizing a self-administered treatment using virtual reality combined with mindfulness.

 

Methods: The design of the study follows the recommendations for clinical trials in health using virtual reality, in particular, Tier VR 2 [41], focusing on acceptability, feasibility, tolerability, and initial clinical efficacy. We conducted a clinical trial with a control group, including baseline and follow-up assessments at days 1 and 90 post-treatment. The application consists of a 21-day treatment that includes 2 main activities each day, which become available after completing the activities of the previous day. Adherence was assessed on the effectiveness of a participant in performing all daily activities as recommended, understanding that it might take longer for each participant to complete all activities.

 

Results: Follow-up rates at day-1 were 93% (56/60) for the TG and 100% (60/60) for the CG. At day-1 follow-up, the TG reported 23.3% (14/60) abstinence on that day compared to 5.0% (3/60) in the CG. This difference was statistically significant (Chi2 (1) =8.3; P = .004). The TG reported sustained abstinence of 33% (20/60) at 90 days. Among participants still smoking at day-1 follow-up, the TG was significantly more ready to quit compared to the CG (TG: M = 7.71; SD = 0.13; CG: M = 7.16; SD = 0.13; P = 0.005). A total of 41.1% (23/56) of participants completed the treatment in the time frame recommended by the program.

Conclusion: Results provide initial support for participant adherence and efficacy of Mindcotine® and warrant testing the intervention in a fully powered randomized trial. Further research is needed on ways to promote app engagement and on the VR-MET influence over long-term outcomes.
 

Trial Registration #: ID ISRCTN50586181

Keywords: Smoking cessation; nicotine dependence; virtual reality; mindfulness; craving; digital therapy; mHealth

Placebo analgesia in virtual and augmented reality

Authors: Ho, Jasmine; Krummenacher, Peter; Roel Lesur, Marte; Lenggenhager, Bigna. 

Background: The sense of presence induced by immersive virtual reality, coupled with the precise sensory control, signify a potentially effective new tool for the management of pain. While several lines of research focusing on virtual reality have evinced successful analgesia through momentary distraction 1, others have utilized embodiment paradigms to examine how experimental alteration of the bodily self in virtual reality can minimize pain perception 2-3. Effective analgesia has ensued from modification of physical attributes for both experimental 2-3  and chronic 4  pain, suggesting that the sense of embodiment could play a significant modulatory role in the management of pain. Recently, a novel study demonstrated that the application of a sham analgesic cream to an embodied rubber hand, even when not applied to the physical hand, can effectively induce placebo analgesia 5.

 

Methods: The current study bridges the domains of placebo analgesia and virtual embodiment to examine whether a virtual placebo can successfully induce analgesia, and whether the magnitude of analgesia experienced from a virtual placebo differs from that of a placebo administered in physical reality. Participants (n=48) were assigned to either a Placebo or Control group and completed all experimental procedures in virtual (VR), augmented (AR), and physical reality (PR). Placebo participants (n=24) were informed that the efficacy of a physical, heat protective glove in physical reality would be compared to the analgesic efficacy of its purely virtual counterparts in virtual and augmented reality, whereas Control participants (n=24) were only told that the glove served to conduct the experiment under different visual conditions. Participants received noxious thermal stimulations to the right lower forearm while pain threshold, subjective pain (i.e., how painful was the stimulation) and affective pain (i.e., how unpleasant was the stimulation) were measured.

 

Results: Results from the mixed ANOVA evince that participants in the Placebo condition, after the intervention, exhibited significantly higher pain thresholds (F(1,114) = 22.31, p < .001), lower subjective pain ratings (F(1,114)

= 15.20, p <.001), as well as lower affective pain ratings (F(1,114) = 9.85, p < .01) than Control participants, independent of the reality used.

Conclusion: Our results further inform the growing field of virtual therapy by demonstrating that, compared to PR, the strength of placebo analgesia is equally effective when the placebo is completely virtual, yet administered to a physical body (AR), and even when a (virtual) placebo is administered to an embodied virtual avatar (VR). With therapeutic virtual reality on the rise as a potentially indispensable tool for clinical healthcare, our findings could complement other sensory manipulations in virtual reality, such as modulating the physical attributes of the virtual avatar, for pain management.

References:

 

  1. Wiederhold, M D & Wiederhold, B K. Virtual reality and interactive simulation for pain distraction. Pain Med. 2007;8(3):S182 S188.

  2. Romano, D, Lobera, J, & Blanke, O. Size and viewpoint of an embodied virtual body affect the processing of painful stimuli. J Pain. 2016;17(3):350 358.

  3. Martini, M, Perez-Marcos, D, & Sanchez-Vives, M V. What color is my arm? Changes in skin color of an embodied virtual arm modulates pain threshold. Front Hum Neurosci. 2013;7(483):1 5.

  4. Pamment, J, Aspell, J E. Putting pain out of mind with an ‘out of body’ illusion. Eur J Pain. 2017;21:334 342.

  5. Coleshill, M J, George, D N, & Mazzoni, G. Placebo analgesia from a rubber hand. J Pain. 2017;18(9):1067 1077

Virtual reality in intensive care

Authors: Lynch, Ceri; Jones, Gemma. 

Background: Patients on ICU experience low mood, anxiety & fear which can impact on sleep, perceptions of pain and motivation for rehabilitation. Family members also experience depression, anxiety & fatigue during a relative’s ICU admission. Anxiety, stress and burnout are common in ICU staff. Virtual reality (VR) has shown some utility as a tool to improve outcomes in variety of settings, including pain and anxiety.  The objectives of this study were to explore feasibility of VR for patients, relatives and staff in ITU and to seek feedback from users about their experience.

 

Methods: After written informed consent, users were invited to choose from 6 VR experiences or 3 guided relaxation exercises.  They completed a brief questionnaire pre- and post-experience.  This used validated visual analogue scales to assess mood, anxiety and pain, with a free text box for further feedback.

 

Results: Interim results for 59 VR users in 28 staff members, 17 patients and 7 patient relatives.  The mean change in mood score was +2.3 points; anxiety score -1.89 points and pain score -0.8 points. Relatives of critically ill patients were the least happy and most anxious group.  They benefitted most from VR with a mean increase of 3.86 points in mood score and a reduction of 4.43 points in anxiety score.  61% of patients reported improvements in pain after VR, 13% said pain was worse and 26% said there was no change. 100% of patients with higher pain scores (>6/10) reported improvement in pain after VR, with a mean reduction in pain score of 3.8 points.

100% of users reported positively.

A short patient interview: https://youtu.be/gh654P_ycaA

Four main themes emerged:

 

1. Positive experience (40 statements)

  • “The virtual reality made me feel as if I didn’t have a care in the world.”

  • “Wow... I was bored and down a little but when I went on this I have never in my life seen anything like it. Fantastic is too small a word.”

 

2. Relaxation (23 statements)

  • “…After using it I now feel calm, peaceful and grounded.”

  • “I felt relaxation flowing all around me. Any problems I currently face did not surface.”

 

3. Escape (15 statements)

  • “Just for 5 minutes it took me away from the ward environment and made me smile and forget my problems.”

  • “I think it takes you out from what is going on around you. It gives you that break from hospital and the ward”.

 

4. Would recommend for others (12 statements)

  • “An essential piece of kit for ITU.”

 

5. Negative comments (4)

  •  “Thoroughly enjoyed. Pain increased when looking directly down… Great tool.”

Conclusion: VR distraction therapy is feasible to use in critical care patients, their relatives and staff.  It has potential to improve mood, anxiety and pain.  Users reported overwhelmingly positively, with themes of relaxation and escape mentioned frequently. Further research in the form of randomised controlled trials to investigate the use of VR for specific patient and staff groups is now needed (e.g. for physical rehabilitation, pain relief, PTSD).

The role of virtual reality in surgical residency education: A randomized control trial demosntrating superior surgical accuracy and completion rates

Authors: Orland, Mark BS; Patetta, Michael MD; Wieser, Michael MD; Gonzalez, Mark MD, PhD. 

Background: Artificial reality technologies are currently being explored as potential options to improve surgical education. Previous studies have primarily examined the efficacy of artificial reality in laparoscopic and endoscopic procedures. Our study examined whether virtual reality (VR), when compared to the current standard of a technique guide, would show an improvement in procedural accuracy and completion for an intramedullary (IM) tibial nail procedure.

 

Methods: 25 first and second-year medical students, without prior exposure to an IM tibial nail insertion, were recruited. Participants were randomly assigned to the technique guide control group, the VR group, or the VR and technique guide group. Each participant completed a pre- study survey establishing their baseline confidence to perform the procedure and a quiz testing their knowledge of the IM nail procedure.

The technique guide was derived from Zimmer Biomet’s Natural Nail System, which subjects in the assigned groups could use as much as desired. The VR simulation was based on the same procedure purchased from OssoVR, an orthopaedic VR company. Participants in the VR experimental groups went through the simulation in three separate sessions, at a set interval of 3- 4 days apart. Following 10-14 days of preparation, all participants performed an IM nail on a SawBones tibia (Figure 1).  Before the procedure, each student completed another quiz testing their procedural knowledge and confidence. The procedure was recorded and blinded for ANOVA and post-hoc Tukey analysis.

 

Results:

In the technique guide group, 2 of 8 (25%) participants successfully completed the procedure. Both VR groups demonstrated significantly increased procedural completion rates (p

< .05) with the VR group having a 6 of 8 (75%) completion rate, and the VR technique guide

group having a 7 of 9 (78%) completion rate.  The number of normalized incorrect steps displayed a significant difference between both the VR and VR technique groups when compared to the technique guide group (p = .037, p = .041). No significant difference was found between the two VR groups (p = .864). Full results can be found in Table 1.

 

The experimental groups both showed significant improvement in the procedural accuracy quiz (p < .05) while the control group showed improvement but failed to reach significance (p = .08). All groups showed significantly increased overall confidence to perform the procedure after preparation (Table 2, Table 3).

Conclusion: VR significantly increased procedural accuracy and completion rate of an IM nail procedure when compared to the utilization of a technique guide alone. Its potential in surgical residencies, medical school clerkships, and operating room team cohesion should be further explored.

A prospective randomized blinded study evaluating virtual reality simulation for orthopedic surgery training

Authors: Seem, Michael; Marquez-Lara, Alejandro; Rosas, Sam; Gwam, Chukwuweike; Halvorson, Jason; McAllister, Beck. 

Background: 

Current hands-on orthopaedic surgery training is limited to scarce cadaver specimens, expensive imitation models, and operative shadowing.  Virtual reality (VR) surgical simulation has become an accepted practice for surgical training.  The purpose of this study was to assess the transferability and effectiveness of a VR orthopaedic surgery training simulator using the validated Objective Structured Assessment of Technical Skills (OSATS).  We hypothesize that 1) the improvement of time will be greater in the VR group compared to the PDF group, and 2) the VR group will score better on the OSATS compared to the PDF group.

 

Methods: A prospective randomized trial evaluated the VR trained and PDF trained residents’ performance on tibial nailing.  Each participant performed a baseline tibial nail on a saw bones model, then underwent randomization and training with either a PDF technique guide or VR simulation, then repeated the tibial nail.  Their performance on each attempt was timed and evaluated by an orthopaedic trauma attending using OSATS out of a maximum score of 30. The attending surgeon was blinded to the participants’ baseline and trained performance.  This study included the participation among 4-5 orthopaedic residents from each training level (PGY 1-5) with 21 participants total.  Our group has no financial ties to the VR or PDF companies.

 

Results:  When controlling for each participant’s time on their baseline attempt and confounders, the VR group demonstrated a greater change in time compared to PDF (1.27, p = 0.001). There was a significant difference in the mean improvement in the VR and PDF groups on the OSATS (10.3 vs. 2.8 respectively, SD +/- 6.4, p = 0.003). All Residents were satisfied with VR use.

Conclusion: VR may be a safe, time efficient and reproducible adjunctive method of training for residents to develop proficient surgical skills at a faster rate.

Effect of a virtual reality-enhanced exercise and education intervention on patient engagement and learning in cardiac rehabilitation 

Authors: Gulick, Victoria. 

Background: Cardiac rehabilitation (CR) is a vital part of recovery following a cardiac event. Many patients do not attend or complete the recommended number of CR treatment sessions. Research suggests that, after accounting for socioeconomic factors, this is due to a lack of motivation or a lack of understanding on why treatment is needed.

Virtual reality (VR) had previously been seen to increase patient engagement in stage III (at home) CR, but had not been studied in stage II (out-patient) CR. The aim of this study was to evaluate if a VR program that included patient education could increase patients’ motivation, understanding and adherence to CR treatment.

 

Methods:

Eligible patients (able and medically safe to use treadmill for 15 minutes) were enrolled between January 2018 and May 2019. At session one, patients took a 5-question cardiac education pre-test, completed a 6-minute walk test (6MWT) and were randomized into either the control or intervention group. The control group used the treadmill for up to 15 minutes  per session without any alterations, while the intervention group did so in front of Bionautica Trails, a set of virtual walking trails (Figure 1). This setup was chosen as a safe immersive alternative to use while on the treadmill, as opposed to traditional VR headsets. The trails incorporated 109 audio files of cardiac education facts, delivered through wireless headphones, while patients walked.

At their last visit, patients repeated the 5-question education test, completed a post- 6MWT and were asked to complete a survey on their experience. Finally, patients were contacted again after two months and completed the 5-question test a third time.

 

Results: 72 patients (52 male/20 female, mean age 61 ± 9.9 years) were enrolled to either the control (n = 31) or intervention (n = 41) groups. Patients in both groups showed improvement between pre- and post-6MWT distances, (p=0.227) without significance between groups. Looking at education test scores, no significant difference was seen between groups at baseline (p=0.88), final visit (p=0.56), or follow up (p=0.50) time points (Figure 2).

On satisfaction, patients from both groups responded positively to treatment, resulting in no significant difference between groups for any question. Attendance comparison shows  the control group as having a statistically significant higher rate of completion (p=0.024), but no correlation was seen.

Conclusion: Limitations in study design—including scheduling difficulties and patient exposure to education—contributed to the lack of statistical significance seen between groups. However, patients responded positively to the experience, and the Bionautica Trails system is still in use by request of both patients and nursing staff. Projects like this one that introduce VR to  patients are important in furthering the acceptance of VR implementation in clinical spaces. It is hoped that it will lead to further investigation into the benefits of VR for patient care.

 

Immersive virtual reality for nerve conduction study and electromyography (NCS/EMG) procedure-related discomfort: Results of a randomized controlled trial 

Authors: Yang, T MD. Chau, Brian MD. 

Background: Electrodiagnostic study methods such as nerve conduction studies (NCS) and needle electromyography (EMG) are often associated with a degree of pain or anxiety in patients. While this procedural-related discomfort may be considered a minor inconvenience, others experience pain levels high enough for clinicians to alter or abort the study altogether. Current options for alleviating procedural related pain have limited evidence for practical use during electrodiagnostic studies and are mitigated by potential significant adverse events. In recent years, the use of virtual reality (VR) has become more prevalent in the medical field with promise in the ability to alleviate discomfort in other commonly painful procedures. The objective of this current study was to determine whether immersive virtual reality (VR) during electrodiagnostic studies has utility in diminishing procedural related pain.

 

Methods: The study was designed as a randomized controlled trial in which participants received either the intervention of virtual reality therapy during electrodiagnostic studies or standard care. A total of 20 patients already scheduled for outpatient NCS/EMG examinations were recruited, and randomized into groups of 10 at a large academic center.  The control group underwent standard electrodiagnostic study procedure without additional interventions. The treatment group consisted of patients wearing a Merge 360 VR Headset to view an immersive video for the duration of the procedure. This phone-based VR setup was utilized along with the mobile application software "VR Relax". Prior to the procedure, patients in both groups were given a pre-questionnaire rating their level of pain as measured by the visual analog scale (VAS). This questionnaire was repeated immediately after the procedure measuring their level of post procedural pain. Patients were also surveyed on subjective feedback regarding their experience with the VR setup.

Results: Average visual analog scale (VAS) pain scores increased in the immersive VR treatment group but decreased in the control group. However, the difference did not reach statistical significance in either group (p-value=0.651, 0.158 respectively).

Conclusion: Immersive virtual reality (VR) may not be efficacious in diminishing procedural discomfort from electrodiagnostic (EMG/NCS) studies and may actually increase post-procedural pain compared to standard care.

Benefit of an electronic head-mounted low vision aid 

Authors: Crossland, Michael D; Starke, Sandra D; Imielski, Piotr; Wolffsohn, James S.; Webster, Andrew R. 

First published: 06 November 2019. https://doi.org/10.1111/opo.12646

Purpose: To evaluate the efficacy of electronic head‐mounted low vision aid (e‐LVA) SightPlus (GiveVision, UK, givevision.net) and to determine which people with low vision would see themselves likely using an e‐LVA like this.

 

Methods: Sixty participants with low vision aged 18 to 93 used SightPlus during an in‐clinic study session based on a mixed methods design. Visual acuity (ETDRS), contrast sensitivity (PelliRobson) and reading performance (MNREAD) were measured binocularly at baseline (no device), with the device in ‘normal’ mode (zoom only), and with preferred enhanced mode (zoom and one of four digital image enhancements). At the end of the session, a short questionnaire recorded willingness to use an e‐LVA like SightPlus, potential use cases, positive/negative comments and adverse effects.

 

Results: Binocular distance visual acuity improved significantly by 0.63 logMAR on average (p < 0.0001) to 0.20 logMAR. Contrast sensitivity improved significantly by 0.22 log units (p < 0.0001) to 1.21 log units with zoom only and by 0.40 log units to 1.37 log units with zoom and preferred image enhancement. Reading performance improved significantly for near visual acuity and critical print size (p < 0.015), although reading speed signicantly decreased (p < 0.0001). Nearly half (47%) of the participants indicated they would use an eLVA like SightPlus, especially for television, reading and entertainment (e.g. theatre). Multivariate logistic regression showed that proportion of lifetime aected by sight loss, baseline contrast sensitivity and use of electronic LVAs explained 41% of the variation in willingness to use

Conclusion: SightPlus improves visual function in people with low vision and would be used in its current form by one half of the people who tried it. Adverse eects were infrequent and resolved when the device was removed. Future work should focus on comparing e‐LVAs through repeatable real‐world tasks and impact on quality of life.

Ascertaining physician skill in resuscitation using cognitive load measurement in virtual reality simulations

Authors: Elkin, Rachel (1). Beaubien, Jeff (2). Chang, Todd P (3). Damaghi, Nathaniel (1). Kessler, David (1). 

  1. Emergency medicine, New York Presbyterian Columbia University Irving Medical Center. New York, NY.

  2. Aptima, Inc., Woburn, MA. 

  3. Children's Hospital Los Angeles/University of Southern California. Los Angeles, CA. 

Background: Competency-based medical education with milestone assessment is becoming the new standard for training learners. However, it is difficult to accurately assess milestones and competency attainment for low-frequency, high-stakes events, and it is difficult to predict clinician performance in a stressful emergency room.  Cognitive load (CL) during a Virtual Reality simulated emergency room, along with measures of task performance, could ascertain expertise (Table 1).  As clinicians gain expertise in a particular task or skill, their cognitive load, or extent to which their working memory is occupied, decreases.  CL measurement can be done simultaneously with Virtual Reality simulations.

Objective: We sought to measure whether cognitive load, derived using non-invasively obtained physiologic data, could be used to differentiate learners across a spectrum of expertise as they completed simulated resuscitations in virtual reality.

 

Methods:

6 novice (PGY1 and PGY2 pediatric residents) and 6 expert providers (pediatric emergency medicine attendings and fellows) each completed four virtual reality-based pediatric resuscitations as team leader. Two cases focused on status epilepticus and two on anaphylaxis (Figure 1). The VR simulations replicated the urgency of an emergency room with audiovisual distractions such as overhead pages, monitor beeping, and crying family avatars.  While completing each simulation,

participants were outfitted with non-invasive monitors to collect electroencephalography and electrocardiogram data. These raw data were processed in real time through previously studied algorithms to generate a dynamic CL output. Higher CL values indicate higher cognitive load.

 

Results: Mean CL for novices ranged from 40.06 to 48.03, while mean CL for experts ranged from 27.34 to 40.25. Across all scenarios, the mean CL of the expert providers was lower than that of the novice providers (p = 0.02).

Conclusion: In this pilot study, non-invasively measured, physiologically-derived cognitive load was able to distinguish novice from expert providers within a VR simulation. Notably, these data can be obtained without the need for a supervisor present. CL may provide useful to evaluate a physician’s experience in specific, simulated emergency situations in Virtual Reality.

JoiRide: VR physio-cognitive exercise

Authors: Hamman, Jacob. 

Background: Alzheimer’s Disease (AD) is a rapidly growing public health crisis and there is currently no effective treatment. While much of the last 50 years devoted to medication discovery has been highly unsuccessful (90%+ drug failure rates) a shift towards interventions focused on lifestyle factors have shown to have substantial impacts on cognition such that current neurological guidelines recommend exercise and cognitive stimulation as now first lines of treatment for the diagnosis of mild cognitive impairment. Despite the many benefits of exercise including its role in the prevention and risk reduction for AD, we are currently facing what some researchers have begun referring to as the “pandemic of inactivity.” For example, only 1 in 3 adults receive the recommended amount of exercise per week; less than 5% of adults participate in exercise 30 minutes per day; and more than 80% of adults do not meet the guidelines for both aerobic and muscle-training activities.

Methods: Zenjoi has been developing and using a virtual reality (VR) exercise and cognitive training application, JoiRide, with the goal of helping to prevent AD and related dementias. The execution of concurrent cognitive and physical task with separate goals, also known as dual-tasking, has become a focus of research and clinical interest with an emerging body of literature pointing to the synergistic effects of exercise in close temporal proximity to (i.e., right before or at the same time) cognitive stimulation. A focus on dual-tasking (both as a target for intervention and phenotypic measure of illness that should be monitored) has the potential of enormous healthcare benefits over time, not only via risk reduction but also by reducing the gap between life expectancy and disability-free life expectancy by delaying the decline of ADLs/IADLs and quality of life (ADLs and dual tasking).

 

Results: Zenjoi has been pilot testing in senior living communities and an outpatient clinical setting and has observed positive reactions, tolerability, perceived benefit and acceptability among residents. Existing users of Zenjoi across various spectrums of physical and cognitive ability levels have been able to use and enjoy Zenjoi without difficulty or confusion, especially in comparison to computerized brain training or non-gamified exercise modalities.

Conclusion: After having established user tolerability and enjoyment, Zenjoi is proceeding to evaluate preliminary clinical efficacy through a small pilot study consisting of 10 residents within an independent living community. We are in week 2 of a 5 week pilot and are measuring the effect on QOL (Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form), cognition (Saint Louis University Mental Status), and balance (Timed Up & Go-manual). We plan to use this preliminary data to design and execute a VR3 trial with patients at the Pacific Neuroscience Institute.

Adaptive virtual reality avatars for chemotherapy induced peripheral neuropathy sensorimotor rehabilitation

Authors: Kurz, Dana MD (1). Axenie, Cristian PhD (2). 

  1. Interdisciplinary Breast Center, Helios Clinic, Munich, Germany. 

  2. Audi Konfuzius-Institut Ingolstadt Lab, Technical University of Ingolstadt, Germany.

Background: Virtual Reality (VR) avatars can stimulate patients’ perception in a rich and customized environment [1], where sensorimotor deficits, such as in Chemotherapy-Induced Peripheral Neuropathy (CIPN) [2], could be corrected. In such scenarios, motion prediction is a key ingredient for realistic immersion. Yet, such a task lives under hard processing latency constraints and the inherent variability of human motion. We propose a learning system exploiting patient motion parameters in VR-based rehabilitation.

 

Methods:

Our system uses affordable convenience digital technologies, such as sensors, VR and Machine Learning (ML), for an innovative CIPN rehabilitation solution. It basically fuses two representations of patient’s motion: one rendered and tracked in VR (i.e. avatar) and one sensed in physical reality (PR). ML algorithms learn motion kinematics and kinetics in order to build a dual patient profile (Fig.1).

 

The two pipelines are used to parametrize the VR stimulation to compensate for the mismatch within the profile (i.e. VR vs. PR). The system promotes personalized transfer of learning to the PR (i.e. neuroplasticity).

Preliminary Results: Our preliminary (non-clinical) experiments show that the system is able to precisely assess motion patterns. It achieves that by learning underlying correlations in patient’s motion kinematics and kinetics. The system offers in average a 35% accuracy improvement in body joint positions estimation and 83% accuracy improvement in body joint rotation estimation [3] over other similar systems. These results tap into the importance of the fidelity of virtual to physical world movements in sensorimotor rehabilitation.

Conclusion: We propose a platform for personalized CIPN VR-based sensorimotor rehabilitation including a ML learnt assessment of patient motion to support clinicians to better detect and correct CIPN symptoms compared to relying solely on patient-reported measures. Our long-term goal is to train the system in the lab setup and deploy it for personal home-based rehabilitation.

References:

 

  1. V. C. Tashjian, et al., “Virtual reality for management of pain in hospitalized patients: Results of a controlled trial,” JMIR Mental Health, 2017.

  2. S. M. Monfort, et al., “Gait, balance, and patient-reported outcomes during taxane-based chemotherapy in early-stage breast cancer patients,” Breast cancer research and treatment, 2017.

  3. C. Axenie et al., Meta-Learning for Avatar Kinematics Reconstruction in Virtual Reality Rehabilitation, 2019 IEEE International Conference on Bioinformatics and Bioengineering.

Feasibility and Acceptability of using a Standalone Distraction-Based Virtual Reality Headset to Reduce Perceived Pain and Anxiety in Patients Seen in the Pediatric Emergency Department

Authors: Mittal, Ajay. Daga, Anshut. Wakim, Jonathan. Wynn, Tung MD. 

Background: In the pediatric emergency department (PED), suturing is a recurrent procedure considered to be painful and anxiogenic. Virtual Reality (VR) is an emerging technology that provides an immersive user experience and has the capacity to distract patients from the negative or painful experiences commonly associated with suturing procedures at the PED. The purpose of this inaugural pilot study at UF Health is to assess the feasibility and acceptability of a standalone virtual reality headset as a distraction-based intervention for pain management during suturing procedures in a pediatric hospital setting.

Methods: Over 50 participants are being actively enrolled in this study. Participants are divided into three groups; a

control group that does not receive VR intervention, an experimental group receiving the VR intervention, and another group with a Certified Child Life Specialist intervention during the suturing. Each participant enrolled in their respective group will complete a pre and post-procedure survey that utilizes the Hamilton Anxiety Scale and Child Fear Scale (CFS) as well as a Verbal Numerical Rating Scale (VNRS) pain scale to determine the effect of VR during suturing procedures. Time of each group’s intervention will be measured as a feasibility assessment.

Additionally, this study incorporates two phases of VR intervention to assess the efficacy of kindVR’s commercial content compared to original VR content created at the University of Florida. Furthermore, the original content utilizes the stand-alone Oculus Go headset, providing a low-cost, more easily transportable VR therapy modality for VR intervention.

 

Qualitative data analysis is also being gathered from physicians and nurses at the PED to assess the acceptability of VR-based therapy. Statistical analysis for both data sets include kappa coefficient using STATA to measure variations between pre and post-procedure patient surveys.

 

Results:

The preliminary 10 participant dataset includes 3 participants receiving the VR intervention (VR), 3 participants not receiving VR intervention (no VR), and 4 participants receiving a Certified Child Life Specialist intervention (CL) during the suturing.

 

The reported averaged VNRS pain measurement (1-10 scale) were 4.33 for the VR group, for the 6 no VR group, and 5 for the CL group. The reported average CFS and Hamilton Anxiety Scale (1-5 scale) indicated a reduced perceived anxiety level in the VR group at 2.33, compared to Child Life groups at

3.67 and no VR group at 4. Time variations between groups were averaged to be 28.35 mins for the VR group, 34.22 minutes for the no VR group, and 29.49 minutes for the Child Life group.

Conclusion: Current analysis indicates that VR therapy may be useful in reducing perceived pain and anxiety in pediatric patients during suturing. The preliminary data suggests no notable difference in the quality of experience surveyed from participants between kindVR and the original content.

Virtual relaity simulations and behavioral sciences

Authors: Rama, Asheen MD. Rodriguez, Samuel MD. Caruso, Thomas MD. 

Background: Simulation can be an ideal learning tool to facilitate behavioral science curricula that teach conflict resolution and effective team dynamics. However, traditional simulation is high cost due to staffing and facility needs. Virtual reality (VR) is a versatile tool that can deliver high fidelity simulations without the cost of freestanding simulation centers. We present an ongoing study of the efficacy of VR as a learning tool for the behavioral sciences across different levels of trainees including anesthesiology fellows, residents, medical students, and undergraduate students.

Methods: We created a 4 minute VR video with the aid of professional actors playing the roles of perioperative staff. The scenario was an unstable neonate presenting to the operating room (OR) for emergent surgery. A script displayed numerous examples of anger, frustration, and conflict amongst staff. We filmed in an actual OR and incorporated concepts of “presence” and a “sense of being there,” to create a video of high immersive quality. (Cummings) Currently, 6 anesthesiology fellows immersed in VR simulation and received a facilitated 20 minute debrief on conflict resolution. Measures of curricular efficacy were evaluated with a 7 item questionnaire, using a scale of 1 to 5. Ongoing assessments will be made in a similar fashion for medical and undergraduate students, and anesthesia residents. 

 

Results: When asked to compare the simulation with the type of workplace training received on similar topics, 4/6 participants rated the effectiveness of this simulation as “much better.” When asked about the effectiveness of the VR to prepare the participant to handle difficult workplace scenarios, 5/6 participants selected, “prepared me very well.” Finally, when asked about whether they would “choose to receive this type of training again,” 6/6 participants reported “yes.”

Conclusion: Preliminary data from this ongoing study supports the notion that behavioral science topics are well received and highly valued in VR simulation.  Preliminary survey results show trainee desire for additional educational experiences involving behavioral science topics presented in a VR simulation. VR shows promise as an effective and highly valued tool to provide behavioral science simulations. 

Super-training collegiate soccer players in virtual reality

Authors: Reneker, Jennifer C. Pannell, W. Cody. Babi, Ryan. Zhang, Yunxi. Lirette, Seth T. Adah, Felix. 

Introduction: Contact sports push humans to the limit of performance. Success requires simultaneous execution of speed, balance, and agility, while navigating the trajectory of other players and a ball. Precise sensorimotor control, the ability to sub-consciously receive multiple types of sensory information, centrally integrate and use to direct motor output, is necessary for optimal performance and injury avoidance. At this time, it is not known whether a sensorimotor control training intervention, delivered to healthy athletes via virtual reality (VR), is effective to super-train an already stable system. Therefore, the purpose of this study was to investigate whether athletes who engaged in an intervention, including novel VR training exercises, would demonstrate enhanced measurements of sensorimotor function compared to a control.

Methods: Athletes on the 2019 men and women’s soccer teams were enrolled from Mississippi College (experimental) and the University of West Alabama (control), Division II institutions. An Immersive Visual-Vestibular Interface Sensorimotor System (IVVISS) was developed utilizing commercially available headset VR and original software, including nine gamified training exercises targeting the sub-components of sensorimotor control. The athletes engaged in team-training 2 times per week for 6 weeks. Change in performance (pre- to post-intervention) was compared between groups for the score on the exercises to quantify the training effect. Multivariable regression with relevant covariates was used to estimate the transfer effect on clinical tests of sensorimotor control.

 

Results: In total, 130 athletes enrolled in the study (78 experimental; 52 control). Comparing change scores, the experimental group demonstrated a significant training effect for 6 of the 9 VR exercises compared to the control. This included enhanced oculomotor control (smooth pursuit, p<.0001, saccades, p<.0001 and convergence, p<.01); peripheral visual acuity (p=.0001); figure-ground perception (p<.0001); and cervical kinesthetic awareness (p=.01). Transfer of the training was evident by significant improvement in the experimental group on clinical tests of cervical neuromotor control (p<.0001), standing balance (p=.001) and inspection reaction time (p=.02). There was no significant difference in the change score on the clinical tests for simple reaction time, impulse control and point of near-convergence. 

Conclusion: The IVVISS system effectively delivered novel exercises, resulting in significant training and transfer effects. It is interesting to note that the three VR training exercises which did not result in significant score improvements in the experimental group did produce a significant transfer effect to related clinical tests, including overall standing balance and cervical neuromotor control. By fine-tuning or super-training these abilities, there is strong potential for IVVISS to enhance on-field performance and decrease risk of injury.

RescueRangerVR: A pilot study of moderate-to-vigorous cycling in a spatial navigation paradigm in older adults

Authors: Sakhare, Ashwin R (1,2). Stratford, Joy (2). Deng, Rong (2). Pa, Judy (1,2).

  1. Department of Biomedical Engineering, USC. Los Angeles, CA. 

  2. Mark and Mary Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, USC, Los Angeles, CA

Background: Cognitive decline is a significant public health concern in older adults. Identifying new ways to maintain cognitive and brain health is of utmost importance. Simultaneous exercise and cognitive enrichment have been shown to enhance brain function in both animal and human studies. Virtual reality (VR) is a promising approach for engaging in these combined activities. In our previous work, we found cycling in VR to be safe, enjoyable, and tolerable for younger and older adults. The goal of this study is to assess the impact of a combined exercise and cognitive training intervention in VR on cognition and brain health in older adults.

Methods: Twenty cognitively normal older adults, ages 50-85, will be recruited for this study. During this 12-week study, participants will cycle on a custom-built stationary exercise bike and navigate through novel virtual environments while wearing a head-mounted display. Cycling frequency will be 3 sessions a week for 25-50 minutes per session at moderate-to-vigorous (50-80% heart rate max) intensity levels. The cognitive training paradigm will consist of 5 navigation trials per session under the following conditions: delayed recall (route from previous session), learning, and immediate recall. MRI imaging and a neuropsychological cognitive battery will be administered to assess changes in brain fluid flow dynamics, hippocampal volume, memory, and executive function.

 

Results: Of the 202 older adults contacted to participate in the study, 35 expressed interest and completed a phone screen. Twenty-two individuals continued with an in-person screening visit assessing general physical health and tolerance to cycling in VR. 13 enrolled in the study, 3 discontinued due to adverse effects, and 6 discontinued due to time requirements or monetary compensation. Of those 13 enrolled participants (64±7.1 years old; 56-80 years; 7 females), 4 have completed the study, 6 are currently in training, and 3 have discontinued. Of those who completed the study, all were able to complete the navigation tasks and cycle at their prescribed target heart rate.

Conclusion: This ongoing pilot trial will assess a combination of exercise and cognitive enrichment in VR as a potential intervention to enhance brain health in older adults at risk for cognitive decline. To our knowledge, this is the first study to assess brain changes associated with this combined activity in VR. Data collected from this study will help inform future studies on the efficacy of VR as a tool to remediate cognitive decline in older adults.

Efficacy of Virtual Reality (VR) in Pain Reduction in Hematology/Oncology Patients Measured by Patient Feedback and Heart Rate Monitoring – Randomized Control Trial – In progress

Authors: Sarkar, Korak. Coote, Jeffrey. Desai, Bhumit. Chow, Darryl J. Mixon, Clifton. 

Background: Studies have shown that VR distraction therapy (DT) can significantly reduce subjective reports of anxiety and pain in pediatric patients during acute procedures. Few studies have included biometrics such as heart rate monitoring for further analysis of pain and anxiety reduction. This study aims to assess feasibility, adoption, and effectiveness of VR-based distraction therapy at reducing anxiety and pain during acute procedures through biometrics, specifically heart-rate variability in pediatric hematology/oncology patients

Methods: Participants are 100 pediatric hematology/oncology patients between the ages of 5 and 18 years old at a major hospital system in the Gulf South. Participants are recruited when presenting for phlebotomy, IV access, or Port-a-Cath infusions at the pediatric infusion center. Patients with significant co-morbidities and patients undergoing emergent procedures were excluded from participating. Once enrolled in the study, participants were randomized and equally distributed to one of two groups. Control group patients undergo normal standard of care. The intervention group utilizes a VR application developed at OMC, which allows patients to skip rocks in a simulated lake environment. Pain, anxiety, and change in heart rate are compared between the intervention and control groups. Change in heart rate is recorded via pulse oximeter throughout the procedure. Post-procedure feedback regarding patient pain and anxiety are recorded via visual analogue scales. This study and its procedures have been approved by the institutional IRB board.

 

Results: At this point in the study, the mean reported pain in VR intervention is 1.6, while mean control group pain is 1, with a difference of 0.6 (p = 0.268). The mean reported anxiety in VR intervention is 0.8, while mean anxiety in the control group is 2.67, with a difference of 1.87 (p = 0.2). The mean change in heart rate in the VR intervention was 8.5, while the mean change in heart rate in the control group was -1, with a difference of 9.5 (p = 0.41).

Conclusion: VR DT has been quickly adopted by the pediatric hematology clinic and staff and preliminary data collection is feasible.  Mean anxiety values have been lower in the VR intervention group than the control group, while mean pain values tend to be relatively similar. This trend has been seen in previous VR DT studies, so we believe these values will continue to trend this way as data collection continues. Implications for the use of VR DT will be discussed in terms of its effect on patient pain and anxiety, as well as considerations for its feasibility in a pediatric infusion center.

Next-generation Virtual and Augmented Reality in Surgical Education: A Narrative Review

Authors: Sheik-Ali S (1). Edgcombe H (2). Paton C (3). 

  1. Oxford Clinical Academic Graduate School, University of Oxford, Oxford, UK.

  2. Nuffield Department of Clinical Neurosciences (NDA), University of Oxford, Oxford, UK, Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust Oxford, UK.

  3. Centre for Tropical Medicine and Global Health University of Oxford, Oxford, UK, Nuffield Department of Medicine, University of Oxford, Oxford,

Background: Virtual and Augmented Reality (VR/AR) has been used in surgery for several decades. Over the past 5-10 years, however, new technological advances, including high-resolution screens, mobile graphical processing units (mGPUs) and position-sensing technologies, have been incorporated into relatively low-cost VR and AR devices. This review focuses on the current impact of the application of these "Phase 2" VR/AR technology in surgical training.

Methods: A narrative literature review was undertaken using PubMed and Web of Science to identify comparative studies related to the impact of Phase 2 VR or AR tools on surgical training, defined in terms of the acquisition of technical surgical skills. Eleven studies on the effectiveness of VR/AR in surgical education were identified for full review. Further, the grey literature was searched for articles describing the current state of VR/AR in surgical education. A quality analysis using the Newcastle Ottawa scale showed a median score of 7 (out of a maximum achievable score of 9).

 

Results: All studies showed a positive association between the use of VR/AR in surgical training and skill acquisition in terms of improving the speed of acquisition of surgical skills, the surgeon's ability to multitask, the ability to perform a procedure accurately, hand-eye coordination and bimanual operation. The grey literature presented a common, positive theme of the benefits of VR/AR in surgical training.

Conclusion: Based on the limited evidence available, VR/AR appears to have positive training benefits in improving the speed of acquisition of surgical skills. However, the significant heterogeneity in study methodology and the relative recency of wider VR/AR adoption in surgical training mean that only tentative conclusions can be drawn at this stage. Further research, ideally with large sample sizes, robust outcome measures and longer follow-up periods, is recommended.

3D Segmentation and Virtual Reality Visualization Facilitates Complex Live Donor Renal Transplant

Authors: Sonnier, Dennis MD. Curtis, Colin BS. Slayden, Alec. Seal, John MD. McGee, Jack BS. Sarkar, Korak MD. 

Live donor renal transplant (LDRT) involves highly technical operations in two patients, including robot-assisted minimally invasive nephrectomy in a healthy donor and kidney transplantation in the recipient with end stage kidney disease (ESRD). The donor kidney size and vascular anatomy (artery/vein number, length, diameter, orientation) are important in determining the safety and feasibility of the procedure. Contrast enhanced CT is used to assess donor anatomy, the interpretation of which becomes increasingly difficult as renal anatomy becomes more complex.  We present a case in which 3D segmentation of donor kidney anatomy and viewing with immersive virtual reality (VR) platform facilitated selection of the appropriate kidney for transplantation.  

 Our donor candidate is a healthy 35 year old male wanting to donate a kidney to his brother who has been on dialysis for 3 years due to focal segmental glomerulosclerosis. Initially the donor was declined by the selection committee due to (1) complex vascular anatomy of bilateral kidneys (early bifurcation of multiple renal arteries) and (2) estimated size discrepancy based on gross measurements on CT scan.  The patient was highly motivated to donate thus we decided to reconsider with the aid of 3D segmentation and VR visualization.   

Contrasted CT imaging of the abdomen was obtained and de-identified. 3D Slicer was used to segment DICOM data and create a 3D stereolithography (STL) object.   Physicians viewed STLs in VR using an internally developed application and commercially available head-mounted displays (HMDs). 

The resulting volumetric data suggested similar kidney volumes, 53% Left, 47% Right, allowing for either kidney to be safely donated.  In VR the vascular anatomy was clearly delineated.  The right kidney was confirmed to have a prohibitively short vein and two arteries, each bifurcating posterior to the IVC.  The left kidney had a normal vein and two arteries, each bifurcating at an acceptable distance away from the aorta, allowing for safe stapler placement.  The VR platform presented the imaging in an immersive, stereoscopic context that closely replicates the experience in the OR, making it easier to determine that the surgical approach is safe.   

Considering this new data, the initial decision was reversed, and the donor was approved by the selection committee.  The donor underwent robot-assisted left donor nephrectomy with an uneventful post-operative course.   His brother underwent a successful kidney transplant. As expected, a side-to-side reconstruction of the two left renal arteries was required prior to the transplant.   

In conclusion, the use of 3D segmentation and VR visualization was able to provide precise understanding of a complex patient anatomy, enabling a life-saving transplant.  While not needed for routine LDRT, this technology was instrumental in this case and should be considered for cases requiring discreet appreciation of complex anatomy.  

VR helps patients see how radiotherapy targets their cancer

Authors: Wang, Liam. Castro, brian. Luh, Join. Wang, Samuel. 

Background: Patients who are preparing to undergo radiotherapy treatment often have difficulty visualizing how radiation will be used to treat their cancer. We have built an application that allows patients a VR preview of the delivery of their daily radiotherapy. Our objective is to determine if this app improves patients’ understanding of their radiotherapy plan and/or reduces patient anxiety.

Methods:We designed and built a novel virtual reality app that runs on the Oculus Quest. The patient's radiotherapy plan is exported from the clinical treatment planning system in standard DICOM-RT format. All DICOM-RT patient structures (e.g., target volumes, normal organs) are converted into 3D geometry meshes and saved in standard OBJ and MTL file formats, along with accompanying color and transparency information. Radiotherapy beam information is extracted from the DICOM-RT file and saved into an intermediate YAML file format and then imported to the Oculus Quest. Using Unity (Unity Technologies, San Francisco, CA), we created a virtual environment of a radiotherapy treatment vault which contains a life-sized 3D model of a linear accelerator with a fully movable patient table and gantry head. A full-scale 3D rendering of the patient's body is shown on the treatment table with semi-translucent skin so that the target volume and adjacent normal organs can be seen.

 

The patient's radiotherapy treatment plan can then be played in real time on the virtual linear accelerator. The radiation beams are simulated as yellow beams of light. The beams can be seen entering the translucent patient body and dynamically changing shape to conform to the target volume while avoiding adjacent normal body organs. Since this device is untethered and uses room scale VR, the user can walk around and view the radiation beam delivery from any perspective in the room.

 

We have started a single institution prospective clinical trial to determine if showing patients a VR rendition of their radiation treatment plan improves the patient's understanding of their treatment and/or decreases patient anxiety.

 

Results: To date we have enrolled a total of 25 patients. Of those surveyed so far, 21 (84%) indicate that they "agree" or "strongly agree" that the VR session gave them a better understanding of how radiotherapy will be used to treat their cancer. Of the 14 patients who expressed any anxiety about radiotherapy beforehand, 7 (50%) said the VR session helped decrease their anxiety about undergoing radiotherapy.

Conclusion: We have created a novel VR app that allows patients to view a virtual simulation of themselves receiving radiotherapy treatment from a linear accelerator. Our preliminary results show that the VR experience gives many patients a better understanding of their radiotherapy treatment plan and decreases anxiety for some patients.

How is pain and performance during cycling exercise affected by perceptual load within a virtual environment?

Authors: Wender, Carly L.A. O'Connor, Patrick J. Ahn, Sun Joo (Grace). 

Background: Cycling exercise performed at intensities greater than anaerobic threshold induces perceived quadriceps pain [1]. Visual perceptual load (PL) can be operationally defined as the number of unique objects present in the visual environment that may be targets of interest [2]. Increased PL within an immersive and interactive virtual environment (VE) may help explain pain relieving effects of VR during high intensity cycling [3]. No experiment has manipulated PL within a VE and measured pain, perceived exertion or performance during cycling.

Methods: Using a within-subjects design, participants came to the lab on 3 occasions, 1 week apart, to cycle at a perceptually “hard” intensity for 10 minutes then sprint at a maximal effort for 30 seconds. During exercise, participants rated feelings of pain intensity [4], perceived exertion (RPE) [5] and mental effort [6]. Participants completed pre- and post-exercise measures of anxiety [7, 8], mood [9], spatial presence [10] and physical activity enjoyment [11]. The same outcomes were measured during each visit. The first session did not use virtual reality and was called the “no perceptual load” condition (NPL).

Subsequent sessions employed VR during cycling so that participants perceived themselves cycling on a virtual bike path. PL was manipulated in 3 ways: the number of unique items along the trail, the number of target items for detection, and the inter-stimulus interval. The low condition (LPL) had 10 unique items, 1 target item, and had 3 blocks of trail between items. The high condition (HPL) had 40 unique items, 8 target items, and had 2 blocks of trail between items. Concurrent to the self-paced cycling task, participants were instructed to identify any target item they passed by (serial detection task).

 

Results: As of January 15, 2020, 5 participants have completed testing. Preliminary data analysis indicated a significant session x time interaction on mental effort during cycling (F=6.364, p<.001, ηp2=.614), such that it started low and increased over time in NPL while it started high and slightly decreased over time in LPL and HPL. There was a significant session x time interaction on the mood of mental energy (F=3.315, p=.037, ηp2= .453), such that, while mental energy in HPL remained stable, energy peaked in NPL and LPL immediately following exercise. There were significant main effects of time on pain intensity (F=11.243, p=.007, ηp2=.738) and RPE (F=27.125, p<.001, ηp2=.871), and a significant main effect of condition on state anxiety (F=9.543, p=.008, ηp2=.705). Statistical power was too low to detect other potentially significant effects (β<.50). Once 30 more participants are tested, we expect to find significant session x time interactions on pain intensity, performance and state anxiety, as shown in the figures below.

Conclusion: We aim to complete data collection by the beginning of March 2020.

 

References:

  1. O'Connor, P.J. and D.B. Cook, Exercise and Pain: The Neurobiology, Measurement, and Laboratory Study of Pain in Relation to Exercise in Humans. Exercise and sport sciences reviews, 1999. 27(1): p. 119-166.

  2. Lavie, N., et al., The role of perceptual load in object recognition. Journal of Experimental Psychology: Human Perception and Performance, 2009. 35(5): p. 1346.

  3. Wender, C.L.A., S.J. Ahn, and P.J. O'Connor, Interactive Virtual Reality Reduces Quadriceps Pain during High-Intensity Cycling. Med Sci Sports Exerc, 2019. 51(10): p. 2088-2097.

  4.   Cook, D.B., et al., Naturally occurring muscle pain during exercise: assessment and experimental evidence. Medicine and science in sports and exercise, 1997. 29(8): p. 999-1012.

  5. Borg, G., Borg's perceived exertion and pain scales. Vol. 104. 1998: Human kinetics Champaign, IL.

  6. Widyanti, A., A. Johnson, and D. de Waard, Adaptation of the rating scale mental effort (RSME) for use in Indonesia. International Journal of Industrial Ergonomics, 2013. 43(1): p. 70-76.

  7. Metzger, R.L., A reliability and validity study of the state‐trait anxiety inventory. Journal of Clinical Psychology, 1976. 32(2): p. 276-278.

  8. Barnes, L.L., D. Harp, and W.S. Jung, Reliability generalization of scores on the Spielberger state-trait anxiety inventory. Educational and Psychological Measurement, 2002. 62(4): p. 603-618.

  9. O’Connor, P., Mental and physical state and trait energy and fatigue scales. University of Georgia, Athens, GA, USA. Personal communication, 2004.

  10. Bailenson, J.N., et al., Transformed social interaction, augmented gaze, and social influence in immersive virtual environments. Human communication research, 2005. 31(4): p. 511-537.

  11. Kendzierski, D. and K.J. DeCarlo, Physical activity enjoyment scale: Two validation studies. Journal of sport and exercise psychology, 1991. 13(1): p. 50-64