Dr. Brennan M. Spiegel and his research team at the Cedars-Sinai Medical Center have been experimenting with virtual reality (VR) for years. I had a fruitful and very exciting correspondence with him about moments of immersion, virtual pharmacies or how to travel to Iceland without leaving your hospital bed. Read on!

VR is an area of endless possibilities
VR has not just moved the imagination of science-fiction fans, but also clinical researchers and real life medical practitioners. As a doctor, you could assist in the OR without ever lifting a scalpel. If you are a medical student, you could study the human body more closely and prepare better for real life surgeries. As a patient with mental health problems, you could fight your possible fear of heights, schizophrenia or paranoia more successfully.

And perhaps the most successful application of VR so far is its utilization for stress release and pain reduction for patients suffering from chronic pain. For example, enthusiastic university students developed a VR game called Farmoo. As its main creator, Henry Lo says “it is intended to help teen cancer patients get distracted during chemotherapy treatments so that they can focus more on the activities inside the game, rather than the treatment itself”. Researchers at the University of Washington showed in an experiment that a 40 year old patient with 19% of his body covered in burns benefited greatly from the combination of hydrotherapy and VR usage. They even developed a Pixar-like app with a relaxing snow scene together with Firsthand Technology to help alleviate pain felt during wound care.

Virtual Reality in Healthcare
Brennan Spiegel and his research team
There are many examples already, but perhaps the most well-known is the research team at Cedars-Sinai Medical Center in Los Angeles led by Brennan M. Spiegel, MD as the director of Health Services Research. The multidisciplinary team has a wide palette of research interest, including wearable biosensors (both developing and testing), mHealth apps, electronic health records (EHRs), patient-provider portals, and social media analytics, among other platforms. For example, they developed a biosensor that adheres to the abdominal wall, monitors digestion sounds via computer, and displays the results on an app. The device called AbStats was approved by the FDA. It can be used in hospital settings to determine when to start feeding patients after an operation by using a “feeding stoplight” with three colors – red for “no feeding,” yellow for “start liquids,” and green for “start solids.”

They are also working on how to mine data out of EHRs to provide feedback and evidence-based decision support for medical professionals. The team received a $2 million grant from the Patient Centered Outcome Research Institute (PCORI) to use clinical decision support (CDS) with “Choosing Wisely” alerts to reduce inappropriate opioid over-prescribing in primary care guidelines.

However, VR embodies the most important line in their research area. They have already treated more than 300 patients with VR therapy in a pilot project. The team accumulated the first experiences with the technology, and they are aiming to conquer new horizons as well. Spiegel mentioned that they are working on an innovative VR solution for high blood pressure management.

Patient with Virtual Reality Goggles
How does VR work in reality?
The research team carried out the project at Cedars-Sinai with inpatients admitted between Aug. 5, 2015, and Dec. 31, 2015. The patients could experience VR worlds for up to 20 minutes through wearing a Samsung Gear headset. They could choose to travel to Iceland, participate in the work of an art studio or swim with whales in the ocean.

Spiegel told me that their experience showed that when VR works, it really works. But not everyone is willing yet to try it out, particularly older patients. In their first study, published in JMIR Mental Health, they found that the average age of patients willing to try VR was 49.7 years old, whereas those unwilling to try it were 60.2 years old on average. This is consistent with the known “digital divide” between generations with regard to comfort and familiarity using digital technologies.

Moments of cognitive and physiologic immersion
The team found that there are two distinct moments indicating VR is working. Spiegel calls them “the moment of cognitive immersion” and “the moment of physiologic immersion”. The first refers to the first 20 seconds of using VR, when patients realize alone or with the help of the research staff that VR has a 360-degree extension and only if they move their head, are they able to explore the scene in its entirety. Spiegel mentioned that the moment they begin to move, invariably, there is a recognition that VR is different from anything experienced before. The patient almost always smiles, laughs, or says something like “that’s amazing!”

“The moment of physiologic immersion” comes after 3-5 minutes of using VR, after patients cognitively recognize that they are in a 3-D environment. After this realization happens in the brain, the next step is when the body also adjusts to the experience. “This is most evident when we use relaxing environments, such as a nature tour or a mindful meditation experience. We can actually see that very moment, when the patient takes his or her first, deep, purposeful breath”, explained Spiegel. This involuntary physiologic cascade does not always occur, but when it does, we know VR is having its impact. We can see it without question. It’s a beautiful thing, he added.

What are the first results concerning pain reduction?
Spiegel and his research team concluded another experiment, whose results were published in 2017. They enrolled 100 patients suffering from gastrointestinal, cardiac, neurological and post-surgical pain. Fifty patients watched a 15-minute nature video with beautiful mountains and running streams, accompanied by calming music. The other 50 patients wore VR goggles to watch a 15-minute animated game called Pain RelieVR, which was specifically designed to treat patients who have to stay in bed or have limited mobility. The experiment showed that among 100 patients who watched the nature video, there was a 13 percent drop in their pain scores, while patients who watched the virtual reality game had a 24 percent decline in their pain levels. That’s a very promising result!

The research team concluded that use of VR in hospitalized patients significantly reduces pain versus a control distraction condition. However, further trials and experiments are necessary for confirming the results. Spiegel added that they are currently performing an even larger, randomized, controlled trial with a minimum of 120 patients for measuring longitudinal outcomes and plan to have more results in the next 6-8 months.

During this study, the research team not only examines the impact of VR on patients more profoundly, but also the effect of the method on resource utilization, including use of pain medications and length of stay in the hospital. Since it is assumed that VR has the potential to reduce the cost of medication as well as the days spent in a medical facility.

Virtual Reality Pain Relief
VR and its side effects?
I was wondering whether there is any truth to the fear, which appears in a lot of sci-fi movies and books, namely that VR is so addictive that its users no longer want to live in their real environment, but rather in a virtual one. The dilemma of living on/offline and its possible, utopian consequences is shown brutally for example in the sci-fi short, Uncanny Valley.

So I asked Spiegel, whether they experienced any sign of addiction during their clinical practice. He said that compared to something like opioids, which have caused a worldwide dependency epidemic of catastrophic proportions, a non-pharmacological pain remedy like VR is highly desirable and not meaningfully addictive in the same manner. He emphasized that the team has not seen patients becoming addicted to VR – far from it. The expert added that they electronically track exactly how much VR exposure each of their patients experiences as part of the study, and the average per day is around 10-15 minutes of usage. The maximum they have recorded to date is 134 minutes in a day. Spiegel added that they are just not seeing abuse of VR so far.

Is VR for everyone?
On the other hand, there is also a concern whether VR is for everyone or are there any conditions, when it is not recommended. Spiegel mentioned that for their studies, they excluded patients who could not consent (for example individuals with dementia), who were placed in contact isolation, or who had head wounds or bandages that interfere with the VR headset.

The researcher reminded that VR may cause motion sickness in some users. So they excluded patients with a history of motion sickness and vertigo, and anyone experiencing active nausea or vomiting. Patients with a history of seizures or epilepsy were also excluded to limit the theoretical risk of inducing seizures with VR (Samsung Gear user manual cites a 0.025% risk from pediatric data). However, Spiegel also emphasized that they are much stricter during their experiment to maintain the appropriate statistical crowd.

How long do we have to wait until VR pharmacies appear in hospitals?
Spiegel believes it is fascinating how exponentially interest has grown among their colleagues at Cedars-Sinai. Their lab routinely receives calls and emails from clinicians asking us to use VR in their patients. The main limitation has been time and equipment availability. Clinicians understand the potential value of VR and are interested in trying it with their patients. Time and evidence will tell if this excitement should be sustained. We think it will, he added.

The researcher said that they have to shift their focus towards the visualizations themselves, as VR is just the platform. Patients have different tastes: some like to relax on a beach, others prefer to play games, some are annoyed by real-life footage, some by dynamic environments. According to Spiegel, the solution might be a so-called “VR Pharmacy” of evidence-based, well-characterized visualizations that clinicians can pull of the shelf and “prescribe” to individual patients. It would also help to have a formal way to match patient knowledge, attitudes, beliefs, and preferences with specific off-the-shelf visualizations.

He believes a new type of provider, “The Virtualist” will be born out of these needs. The Virtualist will be trained in clinical medicine, bio-psycho-social illness models, and VR technology (also augmented reality [AR] and, in the future, mixed reality [MR]), and will evaluate patients to determine the correct VR prescription. This may become a medical specialty one day. Spiegel added that they are testing a “Virtualist Consult Service” that other doctors can call to help with pain, anxiety, and inpatient distress.

Digital health has to make a difference
Spiegel stressed that digital devices, such as VR have to have the overall goal to improve clinical outcomes that matter. If it will not happen, they will remain in the entertainment category. Digital interventions should pass the “so what” test. How will the results be employed in the clinic? Can we act on the results? How do patients react to the innovation? These are the most relevant questions also in relation to VR and its application.

I truly hope developers will find the right answers; and in the 2020s, we will be able to immerse in VR worlds anywhere while being stuck in a hospital bed.