Extending the reach of health care with Virtual Reality (VR) and Augmented Reality (AR)
With VR and AR for gaming and leisure becoming commonplace, use of head-mounted displays (HMD) will become normal for other uses in everyday life, including health. High-end HMDs are wearable computers with complex sensor systems. Devices will be designed with more sensors and AI for interfacing with their human host, which enable another purpose for HMDs – remote health care.
VR and AR will be used for remote medical diagnostics and prescribed for daily therapy. Using HMDs will enhance telehealth visits by measuring patient vital signs, give remote assistance to home health providers, enable vision tests away from the clinic, and lead to better outcomes for mental health and physical therapy at home.
For this article mixed reality (MR) and extended reality (XR) and other near-eye displays are implicitly included. Which type of HMD would be best depends on the specific health care scenario.
Enhancing telehealth with VR and AR wearable devices
A limitation of current telehealth visits is assessing patient health status outside the clinic. In future, VR and AR displays may be worn by patients during part of telehealth visits to measure vital signs and other health metrics for the physician, then add data automatically to the electronic health record with the patient’s permission. Health monitoring sensors can be built into head-worn displays, such as heart rate and heart rate variability, respiration rate, skin temperature sensors, and blood pressure. It is important for the sensors to be validated in clinical studies and approved for medical use by agencies, such as the FDA in the U.S. and MDR in the EU. Thus, the forehead, face and eyes should be considered as important locations for monitoring health. VR and AR devices as head-worn computers can integrate data from smartwatches, other wearables, and nearby sensors to for use as medical devices in telehealth and remote patient monitoring.
Remote expert assistance for in-home care
Medical care to manage on-going health conditions can be challenging for patients who have difficulty traveling to a clinic. Travel adds barriers to health care for reasons as varied as time constraints of the patient or their care partner to travel to a clinic, additional expenses due to travel, and lack of access to transportation. Getting to the clinic can be especially challenging for patients in rural areas or for individuals whose conditions require an ambulance for safe transport. Whereas telehealth appointments with physicians occur occasionally, routine treatment may require a home visit by a nurse, medical technician, or care partner. For example, a patient might remain at home for hemodialysis, chemotherapy, wound care, injections, and blood draws.
AR glasses can facilitate and improve the quality of routine health care and disease management for patients at home. Home health care providers can receive guidance and training via AR glasses as they perform procedures via remote guidance from an expert at a different site. A person, skilled at performing a procedure, views what the home health care provider sees using the camera in the smart glasses, talks them through each step, and answers questions.
Similarly, emergency medical technicians (EMT) helping patients on location or in an ambulance can benefit from expert guidance given by an emergency room physician, who views what the EMT sees, to better assess the medical situation and instruct the EMT on next steps. Wearing the AR glasses keeps hands free to do the task and cleaner because they do not touch a display.
Robots are in development to assist EMTs and other health care providers in the field. The robots may save time by fetching items for the EMT, lifting the patient, or bringing the patient to a safe location or ambulance. An EMT would supervise the robot and provide instructions through AR glasses or mixed reality headset. Assistance by robots can reduce the number of humans needed in hazardous situations where injury or safety is a concern.
Defibrillators can save the life of a person having a heart attack. Automatic external defibrillators (AED) are placed in public locations and on airplanes for individuals with no medical training to use. In a stressful situation like aiding a person in cardiac arrest, a good outcome depends on fast-action, accurate use of the defibrillator, and providing cardio-pulmonary resuscitation (CPR). AR glasses may be included in the AED equipment kit, so that the person assisting can see and hear instructions provided by an interactive app while hands are free to operate the device and perform CPR.
Vision tests in the home via VR headsets
Vision tests that are routinely done at the office of an ophthalmologist or optometrist have potential to be conducted at home using a VR headset. Assessments of visual field, visual threshold, color vision, contrast sensitivity, and stereo vision are possibilities, as well as determining a prescription for vision correction. Patients can be guided through instructions by a technician via telehealth or by an avatar. For example, for a visual field test, the patient fixes their gaze on an image in the center of their view and clicks a button on a hand-held game controller whenever they see a pinpoint flash of light generated by the testing app. Eye tracking sensors in the headset can verify that the patient keeps focusing on the central image, as per instructions. Patients could take the tests at home with data transmitted to their eye doctor. Eye tests through VR headsets make eye exams available to more patients. When an in-person appointment is recommended by the doctor, vision test results can be completed at home and reviewed in advance, allowing patients to have shorter office visits.
Immersive settings for mental health therapy
Anxiety and depression as significant health conditions gained more awareness when the pandemic took its toll on mental health and led to increased recognition of the need for therapy. At least one in eight persons worldwide have anxiety or depression, based on findings from the World Health Organization. Only a fraction of persons with mental illness have access to a therapist or may not meet frequently enough, due in part to a shortage of providers. Individuals may seek self-care for their mental health that includes a VR experience designed for stress reduction and mindfulness.
Psychiatrists, psychologists, and licensed therapists are starting to include VR-based treatment in their practices. For example, Prof. Kim Bullock leads the Stanford Virtual Reality and Immersive Technology (VRIT) Clinic and Program through which researchers, providers, and developers of immersive technology can connect and learn from each other’s professional experiences. Providers may recommend patients continue VR therapy at home after trying it in the clinic or via telehealth. The provider could opt to join the patient via telehealth to see and hear what the patient experiences and talk with them during treatment.
VR therapy outside the clinic has benefits for practicing techniques at home that have been taught in a session, such as, mindfulness for stress reduction in PTSD, focusing attention for ADHD, reinforcing skills taught in Cognitive Behavioral Therapy or memory and cognitive training for neurodegenerative diseases. Patients can be guided through activities, for example deep breathing techniques, by a virtual avatar or online therapist. Prof. Kim Bullock with colleagues at Stanford U. performed the first randomized control trial to test a protocol for enhancing behavioral activation psychotherapy with immersive XR via telehealth for persons with depression and found evidence that it could be effective.
VA Immersive, the most advanced program of the Strategic Initiatives Lab at U.S. Department of Veterans Affairs, is perhaps the largest pilot deployment of VR with at least 3500 headsets provided across more than 170 clinical sites. Evidence from VA Immersive is that VR-based experiences may reduce Veterans’ symptoms of loneliness, anxiety, depression, pain, stress, and PTSD. VR sessions promote mindfulness and wellness and are administered at VA centers by a wide variety of clinicians, including social workers, recreation therapists, physicians, nurses, pharmacists, physical therapists, occupational therapists, blind rehabilitation therapists, and more. In some circumstances, Veterans may choose to continue VR on their own using a headset they may have at home.
A helpful mindset for physical therapy
Physical therapy done alone at home requires personal motivation to continue over weeks, months or years. Therapy exercises are crucial for regaining or retaining capabilities, however, compliance at home can be low due to an ineffective mindset. Therapy in VR can help treat the mental aspects of loss and rehabilitation. For example, persons with stroke may feel disheartened by the uncertainty of regaining abilities they have lost. For some patients, physical therapy causes discomfort on their path to recovery, especially after surgery or injury. Athletes may wonder if the pain is worth it, doubting they can participate at the same level in sports in future. Exercising to stave off effects of neurodegenerative diseases, for example, Parkinson’s or multiple sclerosis, may serve as a reminder of slow deterioration. To overcome the doubts and discomfort, immersive VR or AR experiences can establish a positive mindset, which is key for finding self-motivation to continue physical therapy at home.
Performing exercise movements in an immersive environment alongside a healthy avatar or digital twin of the patient, improves body-image and how patients perceive that others view them, as well as contributing to lasting gains in ability to control motion. An animation during physical therapy shows the avatar exercising in a virtual mirror. Prof. Kim Bullock and Prof. Jeremy Bailenson with colleagues at Stanford U. investigated virtual reality-assisted physical therapy with mirror visual feedback and found that it may give patients with cerebral palsy the perception and mindset of being more capable.
Incorporating VR or AR into physical therapy reinforces a helpful mindset and more. Patients can view avatars in immersive environments that look like themselves, or a character of their choosing. The avatars can be shown to move like a human at peak performance, so that patients envision themselves as well. An exaggerated depiction in VR of physical ability has lasting positive effects on patient mindset regarding their capabilities and increases progress from physical therapy.
Chronic pain affects 14% of adults in the U.S., nearly 50 million individuals, according to survey findings of the U.S. Dept. of Health and Human Services. Physical therapy can alleviate pain with less medication and without opioids. An immersive game or augmented world environment can reduce pain and distract from discomfort. Persons with cerebral palsy may live with pain due to the disorder. Physical therapy not only can lead to increased strength, range of motion and dexterity, but also reduce perceived pain. Patients performing physical therapy in VR report reduction in pain that can last up to 4 days between sessions over a year. The visualization of oneself as a more able avatar can have lasting neurological benefits due to brain plasticity, such as reorganizing areas of the motor cortex that increase control of motion.
Physical therapy that includes VR has other benefits as well, such as increasing motivation via gamification, wearing sensors to guide and correct exercise form, and creating new possibilities for remote therapy. For example, patients “playing” their immersive therapy scenario can earn points while exercising, allowing the game story to progress to the next level. Patients can hold game controllers and wear additional devices with inertial measurement units (IMUs), such as wristbands or ankle bands, to more closely track movements in immersive therapy exercises for precise details about their motion. A virtual character or online therapist could participate with patients as a coach to prompt about which movement to do to do and to give encouragement. For companionship, a virtual character could play with the patient, or group classes in VR can be led remotely by a therapist allowing patients in different locations to interact as they do physical therapy in an immersive setting.
Go forward with evidence-based success
Development of future HMDs will follow the trend, seen in phones, watches, and earbuds, to add functionality that makes them suitable for health-related use. Electronics manufacturers can collaborate with universities on novel sensors for measuring bio-signals on the head. For example, novel sensors for electroencephalography (EEG) may be integrated into headsets and artificial intelligence algorithms used to find health insights in the data about changes in mental health or Alzheimer’s disease.
The expense of AR and VR headsets is a key factor for future medical use at home. VR headsets and software subscriptions can be expensive for medical practitioners or patients to purchase. Insurance providers will need strong evidence of efficacy and cost advantages to assign billing codes for VR therapy and for agreeing to cover it.
HMDs should be validated using clinical trials for specific medical uses and compared to the standard of care. Such validations will provide evidence for regulatory approvals, acceptance by insurance, and show the benefit to physicians who wish to include AR and VR headsets in their practices.
Providers of secure telehealth services and electronic health records (EHR) should consider integrating video and data streamed through HMDs from a variety of manufacturers. Suppliers of HMD solutions may wish to create open APIs (application programming interface) for compatibility with various EHR and telehealth platforms and with other wearable devices. Privacy of patient data must be maintained while integrating with multiple platform partners and making it easy for patients to share data with multiple health care providers.
The many possibilities for using VR headsets and AR glasses in health care at home provide strong reasons for designing HMDs to measure bio-signals, offer secure telemedicine video streaming, and deliver immersive therapies. HMDs are emerging for use with patients in the clinical setting and will expand the reach of health care at home. AR glasses are gaining attention, and VR headsets will become common for entertainment in middle income households. Especially consider HMD solutions that easily translate use cases for care provided at clinics to the home, make remote health care staffing more efficient, and lead to better patient experiences. Look forward to HMDs enabling new opportunities for remote health care.
The eWEAR-TCCI awards for science writing is a project commissioned by the Wearable Electronics Initiative (eWEAR) at Stanford University and made possible by funding through eWEAR industrial affiliates program member Shanda Group and the Tianqiao and Chrissy Chen Institute (TCCI®).