Virtual Healthcare – Ready Player One?

Notas do Editor

1. First slide as I disconnect from Oculus Rift
2. Play video
3. Walking to mark on thrust stage.   “But what is reality?” asked the gnome-like man. He gestured at the tall banks of buildings that loomed around Central Park, with their countless windows glowing like the fire caves of a city of Cro-Magnon people. “All is dream, all is illusion; I am your vision as you are mine.
4. This an excerpt from a short story about a man that puts on a pair of glasses and enters a dream world without leaving where he stands. Stanley Weinbaum wrote Pygmalian’s Spectacles a staggering 84 years ago. An eerie prediction of what would become known as virtual reality.  
5. I’m not here to be a digital prophet. I am just an intensive care nurse, curious nerd, and father to kids growing up with this technology. I’m sure the hard core gamers will be furious, typing their hatred for me on Reddit while eating Cheetos and slamming cans of red bull. This guy didn’t know a Rift from a Vive 2 months ago! But that is my point. The technology is here and the learning curve is shallow. And I can’t help but be seek out any therapy that may offer relief from the persistent terrors of pain and delirium for our patients in Intensive Care.
6. So What is VR? Virtual reality is the term used to describe a three-dimensional, computer generated environment which can be explored and interacted with by a person. Early models of VR tech emerged in 1950s with the Sensorama, and there have been commercial production attempts each decade until the second worst selling Nintendo platform of all time – the 1990s Virtual Boy.
7. Today, VR can be anything from 360degree video to the fully immersive set-ups with headsets, motions sensors and haptic controllers like you saw me wearing just then.Today, we won’t be discussing the healthcare training applications of VR, although this is a rapidly growing space. We are going to instead peer into the world of clinical VR and and ask what might this offer for our patients?
8. So like most rapidly evolving technologies, the challenge is when to adopt, for what purpose and what is the risk? We have to be cautious of the novel treatment searching for a disease. But we have to also ask what does this technology let us do that we currently struggle cant? In clinical studies thus far, adverse events reported secondary to the VR use itself are limited to nausea, headaches and dizziness. These side-effects also have potential to be mitigated by higher quality, low latency devices and can also become less pronounced with repeated use due to eye muscle adjustment and headset calibration. So the tool itself is pretty safe. But does that mean we are ready?
9. At present the clinical VR literature can be pretty neatly themed into three domains. Treatment for anxiety and PTSD, neuromotor rehab and acute pain therapy. To step through this, I am going to pose a problem that I have encountered in my work in a general med surg ICU for each case and explore what VR may offer.
10. Sarah is a 42 year old lady who was in ICU for 10 days for influenza pneumonitis. She is attending our Post-ICU outpatient follow up clinics 2 months later. She remembers very little about being in ICU other than pain. She really wants to come back and visit the ICU to try and fill in the gaps in her memory, but has declined offers to do so because of a fear of it being too traumatic and her worry about seeing other patients.
11. So this is a really exciting example (it must be because of guns, smoke and binary code), the program Bravemind was developed as a means of treating soldiers with PTSD, whom had persistent suffering in spite of traditional “imaginal’ Prolonged Exposure Therapy.
12. Alfonse is a 65 year old man, who is day 21 in ICU with profound critical illness associated weakness following a septic illness requiring dialysis. John is being seen twice per day for physio and occupational therapy and engages well, but needs significant support and motivation to do shoulder exercises, which is posing a challenge due to limited funded physical therapist hours.
13. In short, the data supports a complementary effect with the combination of VR therapies and Stroke Rehabilitation. The strongest summary of the evidence is a Cochrane review from 2017, concluding that VR rehab apps have little benefit in improved motor function scores. However when used in conjunction with conventional rehab therapies had some improvement in performance of activities of daily living, but these where not followed up long term and we are unsure if benefits were sustained. Another quirk in this research area is that the majority of successful studies using VR for adjunct therapy, used the apps in addition to standard rehab, resulting in greater total hours in therapy. I’ll just let that hang there for a second and move on. There is not strong evidence of benefit, but I feel like it is an area we will probably see some soon as the motor and cognitive app market is the biggest current area of FDA approved commercial clinical apps. And where there is money to be made, we will see evidence, will it be good quality? I’ll keep agnostic on that for now. Interestingly the American Heart Association has made pretty strong recommendation that VR be considered as complementary therapy in stroke rehab. There really is something about stroke hey?
14. Jamie, a 32 year old man admitted following a complex abdo surgery, requires his vacuum dressing changed, this has caused Jamie excrutiating pain in spite of opioid and he has required small doses of midazolam to facilitate dressing changes. The largest and I think most compelling body of literature for clinical VR relates to pain relief both as an opioid adjunct and a replacement for medications. Current areas in which VR has demonstrated an enhancing of analgesia or medication sparing effect are operative procedures, labour and delivery, oncological pain, orthopaedic procedures such as joint reductions and most notably, by a landslide, the treatment of pain during burns treatment. The most promising feature in this field is that open source reigns supreme. Off the shelf and cheap custom apps are the mainstay of present therapies in this area. It would appear that there is little other than research grant money to be made in this territory. Also, the intervention studies are generally well conducted, with clear comparisons, and industry involvement that is logical and generally disclosed,
15. Hunter Hoffman and David Patterson, the creators of the snowball throwing app SnowWorld, have been pioneers in this area since the early 2000s. Burns present an interesting pain dilemma due to the procedural frequency of dressing changes and the pain of skin stretching during physical therapy. With this frequency comes a burden of time spent thinking about pain and anxiety relating to next interventions. Hoffman’s team found that the addition VR for dressing changes was 7 times more effective than opioid alone, reduced time spent thinking about pain by about 50% and improved a novel measure by 80% - fun during dressings – ps. It was 0% in the non-VR study arm. Not content in just showing it worked for patient reported measures, Hoffman and Patterson built an MRI compatible headset. fMRI studies showed a significant reduction in activation of the pain centres of the brain when using VR compared to when not, in response to a thermal noxious stimulus.
16. The mechanisms by which VR is proposed to affect pain are described as threefold. 1. Pain requires conscious attention to be perceived. 2. Gate control theory suggests that non-noxious sensory stimuli can compete for neural passage with painful stimuli, reducing gate capacity for transmission to the CNS. 3. stimulation of the motor cortex can modulate perception of in the sensory cortex, thus suppressing pain. Sorry to the pain specialists in the audience for any unintended butchering of complex neuro-physiology. The implication of these theories is that the greater the range of senses engaged in the VR experience, the greater the potential for multi-modal suppression of pain.
17. So this is where we come back and sitting here, right now ask Are we ready?
18. VR shouldn’t be the next flavour of the day, the ECMO of 2020. But let’s commit to go back to work and just be robots, accepting the problems that we are yet to be solved for our patients. There just might be some answers if we look through Pygmalion’s Spectacles.
19. For me, this is what I see? I think the evidence, low financial gain murkiness, and low risk for harm, makes VR for acute pain management in ICU a real and ready option to trial, albeit with strong clinical governance. VR offers a huge additional option in reducing ICU related delirium, through both distraction and reduced need for opioid analgesia and sedation. So through shared decision making with my patients and their families and engagement with our multidisciplinary team, I am ready to try. That really only leaves one question…
20. Are you?