History of Virtual Reality in Health Care

Dating back to 2011, researchers noted that virtual reality (VR) was proven an effective methodology for rehabilitative treatment. “In clinical settings and experimental studies, participants immersed in VR experienced reduced levels of pain, less general distress/unpleasantness and report[ed] a desire to use VR again during painful medical procedures.”

In very recent years, VR has gained widespread usage among clinicians. Researchers at Harvard Medical School and many other university medical programs have noted the powerful pain distraction abilities of the immersive VR environment.

“At WakeMed Rehab, we are always working to align the therapy and care we provide with evidence-based interventions,” says Alisa Dunn, the Manager of Therapy Services — who supported formal VR program creation at WakeMed.

Research has shown positive impact of VR use in rehabilitation of neurological diagnoses as well. “Compelling evidence of moderate and high quality of evidence emerged for people with stroke on most outcomes: mobility, balance, upper limb function, and body structure/function and activity.”

How VR Technology Works

VR builds the immersive world through a precise, stereoscopic head-mounted display. This headset is similar to thick goggles that encompass the entire visual scope, blocking out ocular access to the real world. Images in the virtual, three-dimensional (3D) world are provided for each eye.

More expensive and higher quality headsets need to be connected to a computer to run games. Less expensive versions simply involve a smartphone clipped to the front of the headset.

Everything the patient perceives in the environment is artificially constructed utilizing images and sounds, and these computer-generated environments appear real, making patients feel they are immersed in their surroundings. The authentic feel of this environment is possible because the headset typically includes head-motion-tracking sensors. VR headsets need a tracking system and sensor camera to recognise user’s movement and give the best experience of the 3D world. This also allows the view to change as patients turn their heads.

Additionally, devices, such as accelerometers, eye-tracking sensors, gyroscopes, magnetometers or structured light systems enhance the VR experience.

Through a combination of these sophisticated technologies located within the headset, users experience three critical elements to the VR experience:

1. Interactivity — providing mapping, range and speed
2. A sense of movement — making users feel that they are traveling through and engaging with the environment
3. Sensory management — offering direction, movement and vibration

WakeMed Clinical Aide Experiences VR

In December 2020, Joseph (Joe) Jourdain, a clinical aide in WakeMed Rehab, was introduced to VR gaming by a friend. While immersed in the environment, he decided it was not just a fun, leisure, after-work hobby, but it would also be a great addition to WakeMed Rehab’s therapeutic activities.

Joe says, “The reason why I was immediately convinced that VR would be effective for patients is because it tricks the brain into believing that what is happening in the game is real. It immerses patients into a virtual world, so they feel the emotion of the moment. VR also provides an opportunity to escape reality, which during the rehab journey can be painful and challenging. It reduces the patients’ perceptions of pain, building confidence in their abilities, to foster a supportive and fun environment, so patients can experience the full benefits of rehab.”

Joe bought his own VR gaming system and headset. He tested a few games to determine which ones would be most appropriate as participation and motivation enhancements for rehab patients. He then sanitized his system with medical grade infection prevention supplies and sought approval from Rehab Hospital leadership to test usage on patients.

Within months, consent was granted, and WakeMed’s experiential journey into VR began.

How It Started: WakeMed Rehab’s Initial VR Integration in Select Therapy Sessions

August 2021 marks the launch of the first trial usage of VR at WakeMed. The initial user was patient Jacquelyne Simpson-Clarke who had undergone surgery on her leg.

Joe says, “Therapists had been using a standing frame support to help her gain strength in her legs and put weight on her feet. The longest she could handle being upright in the standing frame was five minutes at a time. In getting to know her, I learned that she was a very competitive person and enjoyed working out. I asked her therapist and gained her approval to be our first candidate for VR. During the VR game, her competitive nature took over. She was boxing competitively against artificial intelligence robots and was determined to beat them. When she would get winded, we would lean her back to help her catch her breath while still keeping some pressure on her legs to hold her up. By the time she finished the game, she’d been standing for 24 minutes. Her competitive nature overtook her need to sit. I credit her as the patient who spearheaded the launch of VR for patients. After her amazing experience, she sent the Rehab Hospital Director a very detailed letter regarding her experience and advocated for a formal program. Within months, we purchased equipment for WakeMed and officially launched the VR Rehab program.”

Jacquelyne had been in therapy prior to her introduction to VR, but her therapeutic team did not feel she was progressing as they’d hoped. Loss of full independence had impacted her confidence.

VR came at the right time for her. She was amazed by her VR experience.

Jacquelyne recalls, “From July 2020 to July 2021, I was unable to stand as a result of major surgery on my left leg. After a year of not standing or exercising, my weight was up and my confidence of ever standing or walking again was down. Also, I was weak and had very little range of motion. Yet, Joe wanted me to stand and do battle on a VR game! Besides my physical limitations, I didn’t think I could really get as excited about VR as I had been for the regular rehab gaming system. On this gaming system, I was the reigning champion — ranking across the board as the top player.”

Still, Jacquelyne knew the team would not recommend VR if they thought it wasn’t possible for her. In August 2021, she asked Joe to bring in his VR system, so she could observe him using it.

She says, “I saw him play, but noted that Joe was much younger and healthier than I.”

Despite her reservations, Jacquelyne agreed to try it because she realized it took significant effort to obtain approvals and set the game up for patient usage.

“My first two VR games started off slowly. Then he turned on a ninja game — which he’d initially recommended. The ninjas had my attention, and I thought, “Okay, not bad.” He asked if I wanted to kick it up? I consented. Joe being Joe, and Joe knowing me realized I was going for it though my legs were tired. When Joe eventually took the head gear off, we had the attention of the entire gym — probably from Coach Joe making so much noise.

“Once the game ended, I caught my breath, had some water and realized my entire body felt differently. In order to survive in the game, I had to twist, bend, reach, slice, stab and listen to Joe’s coaching. I had to reach far left, far right, above my head and behind me on both sides! The game felt real, so my body kicked into survival mode, forgetting I usually didn’t make those moves since I had been sitting in my wheelchair for more than 365 days.”

She was exhilarated and impressed.

“In my opinion,” explains Jacquelyne, “three key factors determine the success of a rehab session. The first is reasonable goals, the second is motivation to focus and the third is fun. Thanks to Joe and others willing to adjust my PT and OT, I had the opportunity to explore new activities that brought back to life dormant areas in my body I’d not used in years. My outlook improved and my attitude changed toward becoming more active, which, in turn, benefited my overall health.”

In April 2022, WakeMed purchased and approved use of a VR system and headset to formally start the program, spearheaded by Joe. VR has been a game-changing tool in WakeMed’s therapeutic repertoire ever since.

Qualifications for VR Therapy at WakeMed

Patients with vision deficits, vestibular issues or other impairments may not be appropriate candidates for VR. Patients are carefully screened and approved by therapists for engagement in physical or occupational therapy sessions using the VR modality.

Many different types of patients benefit from VR therapy at WakeMed, including adults and children with a range of conditions:

• Spinal cord injury
• Traumatic brain injury (TBI)
• Stroke
• Pediatric injury
• Amputation
• Guillain-Barré syndrome
• As well as patients with general debility who need individualized strength and endurance interventions to regain independence and return to their life roles

VR Therapies Currently Available at WakeMed

VR has a wide variety of uses in occupational, physical and recreational therapies.

Joe says, “Several activities are provided through VR, including cardio, strength training, range of motion, weight bearing, gait, balance and fine motor. The games that help patients immerse in these exercises are very fun.

“We try to keep our therapeutic approach light from the beginning, and we will move up through the advancements based on how the patient is progressing and if the therapist approves.”

Specific body parts or functional movements can be targeted effectively using VR. A variety of skills can be refined through the approach of overlaying the VR tool on skilled, goal-directed physical or occupational therapy provision. These include the following:

Neuro Skills

• Gross motor coordination
• Fine motor coordination
• In-hand manipulation
• Bimanual integration
• Sustained right and left hemisphere awareness/attention
• Task initiation
• Task sequencing
• Motor planning
• Environmental/safety awareness

Musculoskeletal/Sensorimotor Skills

• Dynamic sitting or standing balance
• Activity tolerance
• Cervical and trunk mobility
• Improved posture
• Midline re-orientation
• Core strengthening
• Upper body strengthening
• Weight shifting

The Future of VR in WakeMed Rehab

By 2025, WakeMed Rehab hopes to attain funding for an advanced treadmill system C-Mill VR+ by Motek that includes body-weight support, gait pattern analysis software and integrated VR. This will be visible in front of the patient as well as projected onto the treadmill surface. The treadmill system will allow simulation of walking on different surfaces as well as focus on obstacle avoidance in order to target desirable therapeutic movements, skills and strengthening in a safe and motivating setting.

An Exciting Road to Recovery

Joe believes VR is on a growth trajectory in scope of care because efficacy of the intervention continues long after the patient has discontinued VR therapy.

Joe recalls, “I had a male patient with a spinal cord injury who was experiencing severe back pain. He came in and was at an eight out of 10 on the pain scale. He decided to try VR. This patient was a big Star Wars guy. I put him in a lightsaber dojo VR game. About ten minutes in, I asked him how his back was doing since he was moving quite a bit. He responded that he felt no pain at all at the time and wanted to keep playing.

“When the immersive aspect of VR aligns with what a patient is motivated to do, the brain adjusts its focus to make it possible. Once this patient ended the game, he said his pain was at a level three. In all, his pain came down five levels.”

In remembering our initial VR user, she, too, has experienced long-term results. Today, Jacquelyne continues to improve in her mobility and credits VR with helping her realize that her body could progress and get stronger with the right resources and equipment.

She reflects, “I cannot stress enough the physical and psychological impact I believe VR has on rehab patients. I’m thrilled and excited for patients who, like me, are committed to improving their quality of life.”

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WakeMed Rehab Hospital

Our flagship Rehab Hospital is a 103-bed inpatient rehab facility (IRF) with four units and gyms for adult and children recovering from stroke, limb loss, spinal cord injury, brain injury or other injury or diseases impacting their functional independence. These units are equipped with highly advanced technology to address the specific needs of adults and children in recovery.

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