Virtual reality is often associated with fun and games, but its clinical potential is enormous, says neuroscientist Walter Greenleaf of Stanford University. He has been working on its use in healthcare for nearly four decades. He will be speaking about the transformation of medicine at this year's Academia Film Olomouc festival.
Read the story in Czech translation here.
"Virtual reality is a powerful tool; it allows you to transport yourself to another place and provide a complex experience, trick the brain, engage the emotions," says Walter Greenleaf, who has been working on the use of virtual reality (VR) technologies in healthcare since 1985, when he finished his PhD in neuroscience.
"Over the last three to four years, there has been a significant development in VR technology. The current experiences are really compelling. For example, even if you know that you're in a lab, that you're wearing a VR headset, that what you're seeing isn't reality, most people still won't take a step off a virtual ledge; their brain won't let them because it feels extraordinarily real. Finally, low-cost and technically sophisticated virtual reality systems are available – this advance will accelerate the development of the next generation of clinical products that will bring about the long-promised revolution in healthcare," shares a pioneer in the field.
From research labs to practice
For many years, virtual reality systems were both unaffordable and inconvenient to use – VR headsets were too big and heavy, so their use was mainly limited to research labs. "However, many academic research groups saw the long-term potential to make a big difference in healthcare and jumped in to begin work despite the high cost and limited flexibility of the early VR technologies,” says Walter Greenleaf, who has been bridging the gap between academia, clinical practice, and the business world for almost forty years. “As a result of this early work, today we have a large number of research articles and scientific data showing that virtual reality is a suitable and effective way to address a range of clinical problems from addiction to stroke rehabilitation and post-traumatic stress disorder."
Technology has made great strides in recent years, Greenleaf continued. “Today's VR sets deliver a realistic experience, are more interactive, comfortable to wear, and above all affordable – a good quality VR system can be purchased for less than $300. Now virtual reality can truly enter mainstream practice and homes."
Breath visualization and olfactory stimulation
VR technology is now starting to incorporate various sensors to further intensify the virtual experience. These sensors also provide important data for both the users and the doctors. "For example, breath visualization helps patients practice pain management techniques,” Greenleaf says. “Anxiety or depression can be detected from the tone of voice. Similarly, a lot can be read from facial expressions, directions of gaze, or body movements – signals that are all very useful for making accurate assessments, providing feedback to the user, and measuring progress. All of this brings an important capability that we haven't been able to make effective use of until now."
The current trend is to incorporate additional physical sensations into the virtual reality experience – the next generation of VR systems will include the sense of smell, the weight of an object, and perhaps tactile stimulation in addition to 3D images and dimensional sound. After all, smell is evolutionarily the oldest sense that activates the parts of the brain responsible for experiencing emotions, memories, and associations. Virtual reality that includes the sense of smell thus delivers a truly enhanced experience.
Virtual return to natural communication
In addition to treating and preventing disease, Walter Greenleaf sees great potential for virtual reality to help us return to using more natural methods of communication and social interaction. "In the last twenty years, the way we communicate has changed significantly. With the development of technology and the internet, we communicate through short typed messages or, at best, video calls. This allows us to connect quickly even over long distances, but we lose a lot of information about the emotional state of the sender and the nuances of the message's intent – and this affects us," he points out, citing the last two years of the COVID pandemic as an example when many of us have personally experienced how tiring longer video calls are.
"We see each other, but we're missing an essential part of the experience – we lose much of the non-verbal communication of information that we usually receive by observing the complex movements use of body language by those we are interacting with – to fill in the missing information we need to work harder to extrapolate intent and mood and that's exhausting. By meeting and communicating using virtual reality systems that allow for a complex 3D interaction, we can return to more natural communication, even at a distance. This can bring huge benefits for improving mental health and social interactions," says the behavioral neuroscientist, who sees great potential in, for example, patient support groups where people with similar problems could meet. "We know that group therapy brings great benefits, but for some groups of people, meeting in person and sharing experiences is difficult for a variety of reasons. Virtual reality can be a useful full-featured alternative to connect people with poorer mobility, over long distances, or through the use of avatars anonymously, which is very welcome when addressing addictions or mental health disorders, for example."
Virtual reality treatment: from rehabilitation to coping with addictions and phobias
There are many possible uses of virtual reality in medicine and healthcare, from teaching and training students or health professionals to practice difficult or crisis situations, to rehabilitation, treating neuropsychiatric diseases, pain management, and preventing mental and physical illness.
"Many aspects of mental healthcare rely on self-reported mood states or cognitive ability – to date, these assessments have been based on subjective measurements. Virtual reality brings a standardized environment and allows control over what the user experiences. The intensity of the experience – the dosage in some cases – can be changed or repeated and compared," Greenleaf says.
As an example, he cites the treatment of post-traumatic stress disorder in soldiers returning from Iraq or Afghanistan. "This approach is based on gradual and controlled exposure to situations that cause difficulties. In the presence of a physician, patients relive traumatic events and learn to respond differently, to alleviate unpleasant manifestations." Exposure therapy is a commonly used method in clinical practice, but until now, doctors have not had a method to provide a controlled and measured amount of exposure to the traumatic experience, and thus had to rely on the patients' imaginations – a problematic approach when fear and trauma is involved. "With virtual reality, the intensity of the experience can be controlled and gradually increased. Combined with vibrations and shocks reminiscent of driving a military vehicle or the smell of ammunition, blood, or the scent of a country's typical spices, we can enhance cognitive engagement and the overall experience and thus provide successful treatment."
Similarly, virtual reality is being used to help patients overcome various phobias, such as fear of flying or public speaking. Through simulations that cause realistic physiological responses, patients learn anxiety management skills, gain situational confidence, and can effectively learn from positive experiences how to manage their fears and anxiety.
Another major area of use of virtual reality in healthcare is to facilitate and improve physical and neurological rehabilitation after injuries and strokes, or the early diagnosis of neurodegenerative diseases such as Alzheimer's, for example. Such research is also being carried out at the University Hospital in Motol in Prague.
Underestimated prevention and experiential education
"Why is virtual reality effective in healthcare, especially in the fields of psychiatry and psychology? Because it is very engaging, and a well-designed Virtual Reality experience activates the reward system in our brains," explains Greenleaf. "In everyday life, we only observe the results of our daily decisions after a long time. If you light up another cigarette today or have cake and ice cream instead of a walk, the negative consequences of your behavior may not become apparent until much later. But if you see your avatar in virtual reality changing before your eyes based on your choices, it has an enormous effect."
So today, virtual stores and restaurants are being used where people learn to choose healthier food alternatives, or bars, for example, where they can train their willpower and strategies to resist temptation or peer pressure while quitting smoking or other addictions. "Virtual reality and personalized avatars allow us to really change attitudes and behaviors after you 'become' your future self."
Virtual reality can also transport us into new situations that we experience through someone else's eyes. This gives us empathy and greater tolerance as we experience the impact our behavior has on those around us. VR also helps in the fields of mental health, psychology, and psychiatry, where we can experience first-hand what our loved ones are going through and better understand their needs there. Or conversely, for example, VR systems can be used to help those on the autism spectrum improve their emotional recognition skills by exaggerating nonverbal signals in others – such as facial expressions – to help practice and learn in simulated social or work-related interactions.
Finally, we are entering the era of virtual reality, but beware
"I was optimistic in my predictions, as was everyone twenty years ago. We thought that the use of VR in practice would be faster. In the end, it took much longer for VR technology to become good enough and affordable enough to allow for its widespread adoption outside of research labs, into practice. But now that time is finally here," says Greenleaf, who sees a huge future in the use of virtual reality and other advanced technologies in medicine.
But you also need to consider the risks early on. "As with any new technology, we need to be careful and set up the system of use well. Privacy and protection of health information are absolutely crucial. In clinical practice, we have developed systems to ensure data privacy. However, outside of the medical environment, we do not see the same safeguards. For example, the use of virtual reality systems and the related clinical scoring algorithms in online gaming environments produce a large amount of sensitive data about mood and cognitive function specific to the players. This data could be inappropriately used and analyzed to determine overall mood regulation skills and cognitive function by a potential employer to determine if you are depressed or whether you could be potentially suicidal, for example. In that manner the information gathered could be misused to discriminate unfairly regarding hiring decisions," warns the behavioral neuroscientist.
"The benefits of using virtual reality in clinical practice and as a way to promote health and wellness are enormous. Numerous VR medical systems are already in use and are producing impressive results. Furthermore, studies show that people are not afraid of the technology and are happy to recommend it further after experiencing it personally. Doctors do not need to be afraid either – technology will not replace them, they will still be needed, and they will gain new ways to help their patients. I believe that virtual reality and other technologies can bring about a real revolution in the quality and accessibility of medical care, even in remote regions," says Greenleaf, who will lecture on the use of virtual reality as a transformation of healthcare at this year's Academia Film Olomouc (AFO) festival.