Virtual reality in healthcare - part 2
Our AI has generated this annotated bibliography from recent randomized controlled trials on the use of VR/AR in healthcare
A study on the effect of a virtual reality (VR) gaming system on anatomy learning in medical students.
Yi-Chun Du et al. (2020) reported on the impact of multi-person virtual reality competitive learning on anatomy education. Anatomy is one of the core subjects in medical education. The current study developed a VR gaming system based on the HTC Vive environment. The VR environment strengthened the spatial-related knowledge of the human body among the VR group students. There were no differences for the participation of SP and MP groups in Game 1. Game 2 helped the participants to learn the correct positions of muscles and bones. Introducing a multi-player competition had more positive effects on learning than playing the game as a single player.
The study involved 25 university students. Discussing possible improvements, “In future research, more female participants should be included,” they acknowledge. They contend that the limitations of the study included the small sample size, which might have diminished the statistical power of the research. Future research should be conducted with a larger sample size. In the future, the inventory should be modified to focus on the process of studying anatomy.
The aim of this study was to investigate whether virtual reality (VR) can improve the learning effectiveness of orthopedic surgery residents during a single training course in Canada.
Simulator use in procedural education of health care professionals is prevalent around the world. Ryan Lohre and colleagues (2020) described the effectiveness of immersive virtual reality on orthopedic surgical skills and knowledge acquisition among senior surgical residents. By means of a randomized, intervention-controlled trial, immersive virtual reality (IVR) was demonstrated to be superior to technical video training for acquisition of procedural knowledge as well as pathology recognition and decision-making. The IVR group had significantly better mean OSATS scores than the control group. The transfer effectiveness ratio of 0.79 substituted for 47.4 minutes of operating room time when IVR was used for 60 minutes.
The research involved 3 expert surgeons. The researchers concede that “The confidence scale used may be too granular for single training sessions given task complexity. IVR provides just in time education that is convenient and portable. We used cadaveric specimens rather than a real operative scenario.” The group contend that further research into the effects of longitudinal IVR learning must be undertaken.
Surgical training has changed dramatically over the past 50 years.
For trainees’ surgical skills, the VAS score has been used to evaluate suturing and knot tying skills. Ewa Jokinen et al. (2019) reported on simulator training and residents’ first laparoscopic hysterectomy. In a recent study, with virtual reality training curriculum for laparoscopic hysterectomy, results showed that the learning curves plateaued after 4–6 training sessions. Using the same score difference between a novice and an intermediate group as in a previous study, and using type 1 error of 0.05, they found a significant increase in OSATS and VAS scores. The residents in the intervention group were more experienced in training at obstetrics and gynecology and had done more laparoscopic procedures. The composite score was higher in the control group in basic task 6 in virtual reality simulator.
20 residents were involved in the study. The authors note that “To conclude, we found a significant increase in OSATS and VAS scores in live laparoscopic hysterectomies. This indicates that skills gained in the virtual reality simulator seems to be transferred into the operating room.” Jokinen and colleagues contend that in addition to OSATS-GRS and VAS scales, they used a procedure-specific form to assess operations more accurately. Full validation and routine use of the form would require further studies with other aspects of validity and cost implications.
The 3DP model is a more effective teaching instrument than the NP model for learning the pathomorphology of CVJ deformities, according to a study in China.
Craniovertebral junction (CVJ) deformity is a life-threatening disorder due to the associated neural compression, vascular compromise and instable cerebrospinal fluid dynamics. Surgical treatment of CVJ anomalies remains a huge challenge for neurosurgeons, and requires accurate and detailed understanding of the anatomy in the CVJ region. Traditional education on CVJ deformities frequently combines textbook learning with the use of physical models of the normal CVJ region. In ‘Effectiveness of three-dimensional printed and virtual reality models in learning the morphology of craniovertebral junction deformities’, Siyi Cai et al. (2020) reported that 3D printed and virtual reality groups had higher correct rates in the identification of anatomical landmarks on radiographs of CVJ deformities than the NP group. They believe that 3DP and VR models are effective in enhancing the understanding of spatial relationships for junior students.
The analysis involved 153 participants. The researchers’ findings may confirm prior work in this topic: “The application of lifelike 3DP models dramatically enhances the teaching of spinal fracture anatomy, which is consistent with the results of the present study,” Cai said. Discussing potential shortcomings, “More knowledge and a positive attitude generally facilitates long-term retention of information. Different anatomical landmarks have differing levels of importance in identification of CVJ deformities. The scoring process did not involve weighting of the anatomical landmarks in accordance with their importance,” they acknowledge. The team advocate that previous studies have reported a difference in visuospatial capacity between sexes. All participants in the present study happened to be men coincidentally. This limitation may be solved in further studies by the use of a weighted scoring system. The authors have provided data and code at: http://creativecommons.org/licenses/by-nc/4.0, http://orcid.org/0000-0001-5061-7998.
A study into the feasibility of delivering group social support to people with aphasia via a virtual reality platform.
Aphasia is an impairment of language caused by stroke or other neurological events. A team at the Centre for Language and Communication Science Research led by Jane Marshall (2020) reported on a randomised trial of social support group intervention for people with aphasia. The Study aimed to explore whether EVA Park could successfully host a programme of remote support group intervention. Thirty four people with aphasia were recruited over a period of 13 weeks, out of 67 screened. Of those recruited, 31 began the intervention (91.18%). Twenty nine (85.3%) completed intervention and 27 (79.4%) completed all assessments. Using virtual reality to deliver social support to people with aphasia included one group session per week. The findings indicate that it would be feasible to conduct a larger trial of remote group intervention.
11 volunteers were involved in the research. Some of the researchers’ results potentially strengthen what was previously known about this topic: “Assessment of Living with Aphasia might be considered as a primary outcome measure, given that this has shown treatment effects in a comparable study,” Marshall said. Discussing potential improvements, “Wenke et al assessed the costs of embedding different service delivery models for aphasia treatment. Their per participant costs ranged from AUD3289 to AUD6655, which under current conversion rates equate to £1806 and £3655,” they note. The team contend that a commonly cited difficulty concerned the composition of groups, with respondents reporting that they had too few clients or clients with too disparate needs to form successful groups. Resourcing and logistical barriers included a lack of funding, staffing constraints, and problems with transport.
Virtual reality and wearable haptic devices are a viable alternative to conventional therapy for improving upper limb function in children with Cerebral Palsy and Developmental Dyspraxia.
In ‘Immersive Virtual Environments and Wearable Haptic Devices in rehabilitation of children with neuromotor impairments’, a team led by Ilaria Bortone at the Institute of Clinical Physiology (IFC) (2020) noted that the past decade has seen the emergence of rehabilitation treatments using virtual reality. The aim of the present study was to evaluate the efficacy of a 4-week Virtual Environments and weaRable hAptic (VERA) devices program for rehabilitation program of upper limb in children with Cerebral Palsy (CP) and Developmental Dyspraxia (DD). They found that the use of VR-assisted therapy was not significantly different from conventional training. Both treatments showed a comparable efficacy in improving kinesiological indices of either Linear Path Tracking Task or Reach-To-Grasp Task.
8 children were included in the research. The researchers’ conclusions claim to strengthen previous work in this area: “VR-assisted therapy with VERA system was overall feasible for introduction in a prolonged rehabilitation trial. Further studies should be conducted integrating this analysis with head and trunk position during the task execution,” Bortone suggested. The researchers acknowledge that “The sample size is too small for an in-depth analysis, and therefore, any future work should be planned with larger patient groups according to power analysis. The long-term effects of VERA were not evaluated in this study.” The authors suggest that several design factors should be addressed in future research. They think VR-assisted therapy can increase the motivation of the patients.
Oral implant education can be improved by using virtual reality.
Virtual reality has become especially popular in the dental sciences. In China’s dental implant education system, the simulation laboratory model is an important tools for oral experimental teaching and pre-clinical skills training. However, few applications of virtual simulation technology exist in oral implant surgery training. In ‘Virtual versus jaw simulation in Oral implant education’, a team led by Baoping Zhang of the School of Stomatology Lanzhou University (2020) reported that their research aimed to investigate the evaluation methods of teaching oral implant clinical courses. The results of the study show that a combination of virtual reality simulation and jaw simulation model is better in terms of theory, operation as well as implant accuracy.
80 second- and third-year undergraduates were involved in the analysis. Some of the researchers’ results may support what was previously known about this field: “Virtual and augmented reality technologies can promote enjoyment in learning and the acquisition of operational skills. Especially, virtual simulation systems exhibit great potential in dentistry teaching,” Zhang claimed. However, “There are some limitations to this study, such as the training time was too short. Future studies should examine the long-term application effect of the virtual simulation system, especially its optimal application period in the teaching process, as these questions remain unclear, but significant,” acknowledge the investigators. They suggest that future studies should examine the long-term application effect of the virtual simulation system, especially its optimal application period in the teaching process. It is of great importance to develop more realistic virtual simulation equipment.
A study comparing a conventional CPR training with a Virtual Reality (VR) training aims to demonstrate: (a) non-inferiority of the VR intervention in respect of no flow time and (b) superiority in terms of subjective learning gain.
The most important determinant of survival from sudden cardiac arrest is the presence of a trained lay rescuer. Malte Issleib et al. (2021) described virtual reality as a teaching method for resuscitation training in undergraduate first year medical students. The study compares a conventional cardiopulmonary resuscitation (CPR) training with a Virtual Reality (VR) training. The intervention group went through the Basic Life Support course in virtual reality. The control group took part in the standard training. There were no significant differences between the two groups in respect of age, sex and previous experience with cardiopulmonary resuscitation and Virtual Reality. They found that VR training is superior to the classic training in most items in a comparative self-assessment. The intervention group showed a significant greater learning gain in 6 out of 11 items. The no flow time was significantly shorter in the control group. Overall learning gain was higher with VR. CPR training using VR is a feasible and effective training method. However, for teaching technical skills, a classic training is still superior to a VR training, they argue.
The research involved 56 participants. Discussing potential improvements, “The secondary outcome parameter was the learning gain evaluated with the comparative self-assessment. Around 10% of participants will not have a learning gain per definition, so no conclusion can be drawn on how this group profited from the VR or the classic training in this study,” they concede.
An experimental approach combined with virtual reality appears to be more effective for improving the perceived health-related quality of life in stroke survivors, according to a Spanish study.
Stroke is one of the world’s leading health problems and a major cause of acquired disability in adults. Motor and sensory deficits are common in stroke patients, producing disorders of motor control, balance, and gait. An estimated 80% of the survivors present motor difficulties in the upper extremities. In ‘Effects of Virtual Reality-Based Therapy on Quality of Life of Patients with Subacute Stroke’, Marta Rodríguez-Hernández and colleagues (2021) compared conventional rehabilitation of physical therapy and occupational therapy and the combination of conventional rehabilitation with the use of virtual reality technology. Results show that the use of a virtual reality program combined with conventional therapy produces significant changes in HQRoL in stroke survivors in the subacute phase. Virtual reality as complement to conventional rehabilitation treatment is associated with a perceived increase of health-related quality of life in stroke survivors. Three months after finishing the treatment, the effect of the combined intervention is reduced, especially in the dimensions of pain, anxiety, and depression. The conventional rehabilitative approach combined with virtual reality would appear to be more effective than conventional treatment alone.
There were 43 participants with subacute stroke included in the study. Discussing possible improvements, “A long-term follow-up has not been possible due to the start of the COVID-19 pandemic in Spain. The study was limited to a single center which could increase the effect of treatment, compared to other multicenter randomized controlled trial designs,” they observe.
Cognitive training using virtual reality (VR) may improve the attention ability and cognitive flexibility of patients recovering from alcohol use disorder.
A group from the School of Psychology and Life Sciences led by Pedro Gamito (2020) described virtual reality cognitive training among individuals with alcohol use disorder undergoing residential treatment. They found significant differences in cognitive performance between pre- and posttreatment for both groups in attention and cognitive flexibility. This shows evidence of the positive effects of the residential treatment plan and alcohol abstinence. They found that the use of virtual reality tasks for computerized cognitive training is better suited to promote the transfer of skills to everyday living. These tasks are closer to real-life activities than most of the exercises used in classic cognitive training.
36 individuals were included in the analysis. The results potentially substantiate earlier work in this field: “RCTs are the emerging gold standard for unbiased testing of treatments and have been lacking from this area of research. Results found in this study converge with previous research in which patients with AUD who underwent cognitive training showed greater cognitive improvements,” Gamito suggested. However, “One main limitation of this study was the small dose of the intervention. Given the time of stay for rehabilitation in residential treatment at the partner institution, it was not possible to extend rehabilitation over a longer intervention period. Training intensity was inferior to most studies with cognitive rehabilitation,” acknowledge the authors. The group contend that the use of a passive control group consisting of treatment as usual, but without virtual training, precluded the use of blinding procedures to both patients and evaluators. Further studies have an independent evaluator blinded to patient assignment. Future studies should focus on more general outcomes related to functionality, well-being, or quality of life.
pilot study in Portugal has shown that virtual reality can improve the cognitive function of people with mild-to-moderate dementia caused by Alzheimer’s disease.
Jorge Oliveira and colleagues (2021) studied virtual reality-based cognitive stimulation on people with mild to moderate dementia due to Alzheimer’s disease (AD). Given the lack of consistent data on virtual reality-based cognitive stimulation (CS) in dementia, this study aims to report the impact of CS using the Systemic Lisbon Battery. They aimed to explore the effects of this intervention in these patients to understand whether it is possible to improve cognition in AD using an ecologically oriented approach to daily living activities in virtual reality. However, the results did not show improvements in the executive functions, but a significant effect was found in the global cognition.
17 patients were involved in the study. Aspects of the conclusions appear to challenge earlier findings in this field: “The outcomes on the executive functions from the TMT revealed that four patients who received interventions showed positive differences, improving from the baseline to the post-treatment assessment. The results are different from those indicated by other studies, which points to improvements at the level of TMT part B,” Oliveira argued. Discussing potential improvements, “Another limitation was related to the lack of an active control group, i.e., a group of participants with characteristics similar to the experimental group but were provided with a “placebo” program of activities. The inclusion of a placebo control group is an important goal for testing this approach in future definitive trials,” they acknowledge. They contend that despite the difficulties in measuring cognitive reserve (CR), this variable would be helpful to differentiate individual performances and contribute with an explanation for intra- and interindividual differences. Future studies in this topic control for CR to provide a more comprehensive understanding of the impact of CS in executive and cognitive outcomes.
A study on the effectiveness of virtual reality-based serious gaming on the learning outcomes of medical students.
Meysam Mansoory et al. (2021) noted that providing pedagogical and technological infrastructures in medical universities is essential for implementing new approaches to e-learning, such as the use of virtual reality technology and serious game. The purpose of this study was to compare the effectiveness of lecture method and virtual reality-based serious gaming (VRBSG) method on students learning outcomes about the approach to coma. This study was performed using a randomized trial pretest-posttest design with a control group in Kermanshah, Iran in 2019. Students’ learning outcomes in the VRBSG group in the test approach to coma were significantly better than the lecture group. The study showed that VRBSG, as a complementary teaching method, is an effective method to increase students’ learning.
50 medical students were involved in the study. However, “Students participating in this study were working in different wards of the hospital, so they participated in the study process for less than an hour in each session. Another limitation was the challenge of financing as virtual reality software and related technologies in Iran are very expensive,” note the authors. The authors argue that the use of virtual reality technology and serious play in medical education is a new approach. It is necessary to conduct further studies to accurately identify its educational applications, how to integrate it in the teaching-learning process.
A game-based virtual reality (VR) rehabilitation program is more effective than conventional physical therapy alone for improving upper limb function, the performance of activities of daily living, and rehabilitation participation in acute phase stroke patients.
Yun-Sang Park and colleagues (2021) examined the effects of a game-based rehabilitation program using a wearable device in acute phase stroke patients on hand grip and function. Neither the experimental group nor the control group showed significant differences across all pre-intervention homogeneity tests. Conventional therapy is a helpful intervention for improving upper limb function and the performance of activities of daily living in acute phase stroke patients. The authors found that the rehabilitation program using a wearable device could promote functional recovery to a greater degree. Previous studies focused on the use of a conventional game device.
There were 44 patients included in the research. The group advocate that the detailed subjective quality of life in acute phase stroke patients based on the enhanced upper limb function and rehabilitation participation could not be estimated. Further studies should recruit patients with more diverse clinical features.
Du, Y.-C., Fan, S.-C., & Yang, L.-C. (2020). The impact of multi-person virtual reality competitive learning on anatomy education: a randomized controlled study. BMC Medical Education, 20(1). doi:10.1186/s12909-020-02155-9 [Link]
Lohre, R., Bois, A. J., Pollock, J. W., Lapner, P., McIlquham, K., Athwal, G. S., & Goel, D. P. (2020). Effectiveness of Immersive Virtual Reality on Orthopedic Surgical Skills and Knowledge Acquisition Among Senior Surgical Residents. JAMA Network Open, 3(12), e2031217. doi:10.1001/jamanetworkopen.2020.31217 [Link]
Cai, S., He, Y., Cui, H., Zhou, X., Zhou, D., Wang, F., & Tian, Y. (2020). Effectiveness of three-dimensional printed and virtual reality models in learning the morphology of craniovertebral junction deformities: a multicentre, randomised controlled study. BMJ Open, 10(9), e036853. doi:10.1136/bmjopen-2020-036853 [Link]
Jokinen, E., Mikkola, T. S., & Härkki, P. (2019). Simulator training and residents’ first laparoscopic hysterectomy: a randomized controlled trial. Surgical Endoscopy, 34(11), 4874–4882. doi:10.1007/s00464-019-07270-3 [Link]
Marshall, J., Devane, N., Talbot, R., Caute, A., Cruice, M., Hilari, K., … Wilson, S. (2020). A randomised trial of social support group intervention for people with aphasia: A Novel application of virtual reality. PLOS ONE, 15(9), e0239715. doi:10.1371/journal.pone.0239715 [Link]
Bortone, I., Barsotti, M., Leonardis, D., Crecchi, A., Tozzini, A., Bonfiglio, L., & Frisoli, A. (2020). Immersive Virtual Environments and Wearable Haptic Devices in rehabilitation of children with neuromotor impairments: a single-blind randomized controlled crossover pilot study. Journal of NeuroEngineering and Rehabilitation, 17(1). doi:10.1186/s12984-020-00771-6 [Link]
Zhang, B., Li, S., Gao, S., Hou, M., Chen, H., He, L., … Zhang, K. (2020). Virtual versus jaw simulation in Oral implant education: a randomized controlled trial. BMC Medical Education, 20(1). doi:10.1186/s12909-020-02152-y [Link]
Issleib, M., Kromer, A., Pinnschmidt, H. O., Süss-Havemann, C., & Kubitz, J. C. (2021). Virtual reality as a teaching method for resuscitation training in undergraduate first year medical students: a randomized controlled trial. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 29(1). doi:10.1186/s13049-021-00836-y [Link]
Rodríguez-Hernández, M., Criado-Álvarez, J.-J., Corregidor-Sánchez, A.-I., Martín-Conty, J. L., Mohedano-Moriano, A., & Polonio-López, B. (2021). Effects of Virtual Reality-Based Therapy on Quality of Life of Patients with Subacute Stroke: A Three-Month Follow-Up Randomized Controlled Trial. International Journal of Environmental Research and Public Health, 18(6), 2810. doi:10.3390/ijerph18062810 [Link]
Gamito, P., Oliveira, J., Matias, M., Cunha, E., Brito, R., Lopes, P. F., & Deus, A. (2021). Virtual Reality Cognitive Training Among Individuals With Alcohol Use Disorder Undergoing Residential Treatment: Pilot Randomized Controlled Trial. Journal of Medical Internet Research, 23(1), e18482. doi:10.2196/18482 [Link]
Oliveira, J., Gamito, P., Souto, T., Conde, R., Ferreira, M., Corotnean, T., … Neto, T. (2021). Virtual Reality-Based Cognitive Stimulation on People with Mild to Moderate Dementia due to Alzheimer’s Disease: A Pilot Randomized Controlled Trial. International Journal of Environmental Research and Public Health, 18(10), 5290. doi:10.3390/ijerph18105290 [Link]
Mansoory, M. S., Khazaei, M. R., Azizi, S. M., & Niromand, E. (2021). Comparison of the effectiveness of lecture instruction and virtual reality-based serious gaming instruction on the medical students’ learning outcome about approach to coma. BMC Medical Education, 21(1). doi:10.1186/s12909-021-02771-z [Link]
Park, Y.-S., An, C.-S., & Lim, C.-G. (2021). Effects of a Rehabilitation Program Using a Wearable Device on the Upper Limb Function, Performance of Activities of Daily Living, and Rehabilitation Participation in Patients with Acute Stroke. International Journal of Environmental Research and Public Health, 18(11), 5524. doi:10.3390/ijerph18115524 [Link]