Michael Aratow is a clinician and health care executive who founded VRecover, which is health care startup making physical rehabilitation exercises more engaging with VR. He says that rehab is like homework, but that sometimes up to 90% of people don’t actually do the exercises. VRecover is betting that gamifying rehab exercises within immersive VR environments will help accelerate the healing process while making it more fun to do.
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Michael says that governments are looking for ways to cut costs and save money, and he sees that improving the rehab process is a simple and easy way to do that. Not only can surgery be avoided all together in some cases, but it can help accelerate the healing process with both rehabilitation and prehabilitation exercises.
VRecover is planning on developing a number of different VR experiences targeting the most popular rehab exercises starting with issues with the back, arms, and legs. For example, in order to increase the range of motion on the arms, they created a VR experiences where you close blast doors on a space ship. There’s an endless number of possibilities for creating experiences that encourage physical motion and have a therapeutic benefit, and they’ll be using a data-driven approach in deciding which rehab exercises that they’ll be initially targeting.
Michael has been involved with medicine in VR for the past 15 years, and he says that there’s over a decade’s worth of research showing how effect VR treatments are. There’s one study in particular that provided bogus range of motion feedback, and was able to show that people were able to have a wider range of motion that went beyond what they were able to do without VR.
VR rehab has the potential to start to gather more specific data on motion than was possible before. Not only could more accurate range of motion measurements be made over time, but it also could open up new metrics that weren’t possible to measure before such as velocity of movement. This could represent a trend towards personalizing rehab exercises beyond the standardized regiment that has been traditionally been given.
Recover is also going to target physical therapy offices directly rather than the general consumer market. The idea would be that the people would have to come into the office to do rehab exercises within a room-scale VR environment. Their initial prototype was using a Kinect to measure the range of motion, but they haven’t settled on a specific technology stack just yet. Perhaps they’ll eventually sell directly to the consumer market once the adoption of consumer VR grows past the point of existing game consoles, but they’re keeping their customer service demand lower by taking a B2B approach.
Finally, Michael sees that VR provides a new gateway into the mind, and that presence from immersive technologies enable a lot of new healing capabilities through enhancing cognition, controlling pain, and being able to manipulate perception for good.
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Rough Transcript
[00:00:05.452] Kent Bye: The Voices of VR Podcast.
[00:00:09.595] Micheal Aratow: Hi, I'm Mike Erato and I'm CEO of VRecover. And we're using immersive virtual reality to help with physical rehabilitation. Right now, there is a crisis in health care, as well as a crisis in rehabilitation. As you know, healthcare is becoming an increasingly larger proportion of GDP, and the government has decided that we have to figure out ways to save money. And it turns out that rehab is a great way to save money. In fact, there's been a lot of studies that show that it can take place of certain things like surgery instead. For example, for back surgery, it's actually more effective. And also, rehabilitation has been shown in the pre-habilitation, before surgery, to actually improve the time that it takes them to recover. And so, we decided to focus on this because it lends itself very well to rehabilitation. Rehabilitation has been a challenge to people, even though it's a very effective modality to use because it's like doing homework. You can go to the physical therapist, they give you homework, and then up to 90% of the time, at times, people don't do that homework. And that's what makes the rehabilitation effective. And so here comes virtual reality, a beautiful way to engage people, to give a sense of presence, and to motivate them. And what we do is we create environments that are gamified, but that actually duplicate a lot of the motions that they need to do in their rehabilitation regimen. And at the same time, we're measuring those, and that way allows the therapist to see objectively how they're doing. Well, right now, they use what's called a goniometer, which is more of a manual measurement, although there's some more sophisticated motion capture things, but we're trying to make this very easy to use and also to integrate well into their workflow and integrate into the electronic health record and into their billing and then their documentation.
[00:02:06.952] Kent Bye: Great, so maybe you could talk a bit about your background and how you got into virtual reality doing this then.
[00:02:12.355] Micheal Aratow: So my background is I'm a clinician, practicing emergency physician for over 20 years. I'm also a healthcare executive. I'm chief medical information officer of a public hospital over in the Bay Area. And I've been doing that for nine years. So I've got appreciation of what it takes to bring technology into a healthcare organization and be sensitive to the workflows and to the training that's needed, et cetera, and the economics. I got into virtual reality over 20 years ago. A mentor of mine told me about this great new thing and I looked it up and it just really took over my imagination and I just read everything I could on it. I started going to, back then they weren't called meetups, but little groups that got together to talk about virtual reality. I got involved with a 3D standard over the web, which I've been involved in ever since then to sort of keep the content that's created by developers in an open standard so that they're not locked into any one specific vendor. And so, since that time, I've followed virtual reality for a long time, and I've always gone to the, there's a medicine and virtual reality conference, or VR meets medicine, or medicine meets VR, for like 15 years. And so I've kept within the industry, but it didn't seem to be much in reach. And now, with the inflection point here in the software and hardware capabilities, Now that presence is something that can be bought for less than $500, this is really exciting, and I feel it's the time to jump in. And the economics are there, and the business cases are there to really make a difference.
[00:03:50.571] Kent Bye: And so what are some of these studies that are showing the efficacy of virtual reality when it comes to rehabilitation?
[00:03:58.262] Micheal Aratow: There are decades of research on this. In fact, on our board we have Walter Greenleaf who is one of the pioneers of virtual reality and rehabilitation. You know, they've been doing this for 20 odd years and most of the research up to date has been with what I call fishbowl VR, essentially big screen TV VR and maybe a motion capture. And so only now, when it's a lot cheaper and the abilities of the hardware and software are a lot better, are we starting to see some research dealing with what I call immersive virtual reality or the classic virtual reality with a head-mounted display. And they're starting to show really interesting things. Obviously, when you have a sense of presence, you start forgetting about things like your pain, your discomfort. And there was a great study that was done in South Australia where they took some chronic neck pain patients who had very limited mobility in their necks and they put them in a head-mounted display and they asked them to turn their heads. But what they did was they gave them bogus feedback so if they turn their head like 10 degrees and we only make it look in the virtual world like they turn 5 degrees and so they enabled these people who were range of motion limited to actually turn more than they normally could because they were feeding them bogus information. And that shows the real power of what this can do. So you can imagine with people rehabilitating from either a sports injury or rehabilitating from a total joint replacement, that things that they need to do because they're a little uncomfortable and instructions they need to follow from the physical therapist, if the physical therapist can adjust those things within the virtual environment and we gamify it for them, then we can probably get them to hit those goals much easier than if they were to do it in the traditional way. So the research is showing, even with the big screen VR, that it's as good and trending towards better. I don't think there's enough studies out there to really say with good statistical significance that immersive is better, but that's the leap of faith that we're taking, and I think I'm sure that we're going to find out when we have enough studies out with immersive VR that that's going to be the case.
[00:06:00.927] Kent Bye: And so from a virtual reality design perspective, you're going to be designing these different experiences. They're going to solve specific use cases for different types of injuries or things that people are trying to rehabilitate. And so from your perspective, how many of these different, you know, when you think of the taxonomy or the different numbers of types of experiences, you know, how many of them are there and how many are you, you know, where do you even begin with that?
[00:06:23.877] Micheal Aratow: Yeah, I mean, I think you have to do a data driven approach in this market, and we need to go with what is being treated the most. For example, back pain is a big deal. So that's something that we're looking into. And then the extremities, either the arms or the legs, and the solutions are infinite. It's really what kind of motions you need to do and then how do you take that motion and gamify it. And you can obviously think of multiple ways to gamify just you raising your hand up like to reach for a glass in a shelf, which is what you need to do after, for example, a rotator cuff injury or maybe a shoulder replacement. But you can make that anything in a game. In our game here, the demo we're showing, you're an astronaut, you're outside of the space station, and the power is down, so you have to manually close blast doors over windows so it doesn't get hit by a meteor. And so we're making people reach up in the air and pull it down. But that's just one permutation. You can do all sorts of things. And we're going to make it so that we can set up a library that's sort of driven off of the diagnosis and off of the necessary ranges of motion that need to be done. But the possibilities are limitless.
[00:07:32.088] Kent Bye: One of the things with VR is that the visual field does tend to dominate. And so you're getting visual input, and it could make you feel or forget the pain that you have. And so it seems like there could also be the risk that they get into VR and kind of overextend themselves or go beyond what they should be doing. And so how do you mitigate against that?
[00:07:50.421] Micheal Aratow: That's funny. Everyone brings this up. So I mean, I think when you're doing something with a physical therapist, they have very specific directions to give the patient. And within this world, they're going to have control of the game in terms of how much movement they're going to have. And we'll make it so that they're not going to want to be able to, like, for example, in these bars, we can set the height. So we're not going to set the height so that they have to reach almost directly over their head. We're going to make it so that when they start off, for example, they're almost reaching sort of straight out in front of them. And so you set up the game mechanics so that this is something that's not desired or wanted. And they wouldn't likely do that even in the real world, you know, if they had to reach for something. So as long as you don't give them the game mechanics and the provocation to do that, I think it's fine. And it's got to be, obviously, monitored by a physical therapist. So what's really important about this is that a physical therapist is looking at their progress, is seeing what range of motion they're making. And we can also, since it's a virtual world, we can do a lot of things. We can, if they start to reach too high, we can set off an alarm. We could actually cut the display. We can do a lot of different things. And I mean, that's something that you have to be seeing what's the best way to do it. But I don't see that as a problem at all. We have a lot of control of the environment and the physical therapists are going to have a lot of control of that environment too.
[00:09:12.370] Kent Bye: I think one of the really interesting things that you mentioned is that you're going to be able to collect some real objective data as to how people are actually doing in their exercises that they're being tasked. And so you mentioned some sort of format. What are the numbers that are being sent back? What are you actually recording and what's being shared back with the doctor?
[00:09:31.138] Micheal Aratow: Yeah, so the best thing is a range of motion. So that's essentially the area in space that your joint is moving. So you can imagine if you hold your arm by your side and you lift it up straight out to your side, that's moving it and it's parallel with the ground that's 90 degrees in a certain axis. And so those are the things that that 90 degrees is the thing that we're going to send to the physical therapists. because that's the world that they work in. Obviously, we can do other things, and I think we're going to find that there are going to be new metrics that are going to be sort of revealed, not that people didn't really know that they existed, but they're so easy to get now, like velocity of movement, that actually can become new metrics for diagnosis and therapy. And so that's what's really exciting, is I think we're going to open up some new metrics here, because we're actually capturing everything, and this is something that's widely available.
[00:10:24.487] Kent Bye: And it seems like the frequency in which they're actually doing the exercises, you know, because imagine they're not, maybe they need to do it every day or twice or three times a day. And maybe they haven't necessarily known for sure what the optimal amount is. So it sounds like there's going to be some feedback loop cycles in terms of this information going back and then trying to figure out what is the optimal way for people to heal.
[00:10:46.384] Micheal Aratow: Yeah, I mean, I think that we have some, there's some set regimens now and some set exercises, and they know how often they should be doing them. But what you're doing now, right, is that the physical therapists will be able to actually see if they do their homework, and then how well they do their homework, and if they're progressing more quickly than someone else. And I think you're going to see a lot of, you know, when we talk about personalized medicine, everyone is pushing on a generic regimen for people. Now, it's definitely there is some feedback loop when the physical therapist sees them, you know, they may see them a few times a week initially, but now that you have some sort of objective criteria to look at, you may be able to tailor regimens more personally to the individual, especially if they're doing much better and if we integrate these things with other sensors like heart rate and look at heart rate variability, etc., things like that. then they can sort of make some judgments of, oh, could we do things better, and maybe faster in this person, or maybe slower in this person, and we have to back off a little bit.
[00:11:47.865] Kent Bye: And so would a system like this be sold directly to the practitioners as something that they would then resell to their clients, or is this something you would go direct to the market for people to come and download this experience and then work with their practitioners who are certified or whatnot?
[00:12:02.068] Micheal Aratow: Yeah, what's interesting, the physical therapy market is really disaggregated, I call it. It's split up in multiple ways. One is there's no major players, like the top 25 only take 5% of the market or something like that. And also, physical therapy, about a third of its physical therapy offices, a third of its SNFs, skilled nursing facilities, and about a sixth is hospitals. So, there's different ways to sell into those organizations and those service lines, but the core principle for us is that it's going to be a subscription-based model. And so, whether we sell direct to consumers, which I think requires a larger workforce, or we sell sort of B2B, it's going to be subscription-based, and I think it remains to be seen the best way to do it, but it really depends on the funding and the resources we have.
[00:12:51.529] Kent Bye: And it seems like this is something where you'd really want motion controls, like either the Vive or Oculus Touch, or perhaps you've looked into Leap Motion, but it seems like you really want specific, accurate data. So what type of motion controls are people going to be using in these experiences?
[00:13:06.845] Micheal Aratow: Well, you said what's sort of out there now and other than the Connect, which is what we're using. I mean, we haven't settled on a hardware platform and I'm not really sure if we want to. It would be nice to be device agnostic and vendor agnostic so that whatever the person has in their home or whether if the physical therapy office bought something from some other vendor that we would be able to support it. I think it's just a matter of understanding the device and I think OSVR is a good approach where you're sort of taking a unified interface to all devices and that way it makes it easier to build the interfaces to all of them and to understand the calibrations and the inner eccentricities of each device. But yeah, whatever it's going to be, we're going to need motion capture. That has to happen. We need to do that because that's really the core part of our business here is to capture motion to quantify it, to feed it back to the patient, to feed it back to the physical therapist.
[00:14:01.360] Kent Bye: And do you foresee that this would be something like if somebody has an injury then they would have to go spend $1,200 on a virtual reality gear or is this something where they would go into a place and just do it every day in the hospital or something where they would go in and kind of have a scheduled time to come do their rehabilitation?
[00:14:18.989] Micheal Aratow: Well, I think that's talking about, I mean, we're in a very early period of the second coming of virtual reality. And so in the early part of the market, I think you're going to go to a place, right? Because not everyone's going to have VR. It's going to be still sort of niche-y. But as it, of course, gaming really democratizes a lot of technology. And it's being pushed out, you know, that's the major driver for VR right now. So it's going to push the price down. It's going to make it really plug and play. And I think that, well, how many people have Xboxes, right, at home? So, I think eventually that's going to be how many people have head-mounted displays at home. I think that's going to be the same number. And then, so, it won't be such a leap to have them buy this type of equipment. But, like, in the early days, like right now, I think we're going to have to start off with going to the physical therapy offices and more not in the home because it's not fully plug-and-play yet. We're still working out the bugs. I mean, Oculus is changing their versions and Abandoning a Mac temporarily, abandoning laptops now. I mean, I can't even check my demos now on my laptop, which I used to. Now I have to build a machine to do that, which sort of is a bummer. So, yeah, I think it's a matter of evolution. Eventually you'll be able to do it in your home.
[00:15:31.665] Kent Bye: And what do you think is the ultimate potential of virtual reality and what it might be able to enable?
[00:15:38.021] Micheal Aratow: I think, you know, I just was at a talk with Dr. Tom Furness, who is one of the pioneers, in fact, one of the pioneers of virtual reality, along with Evans and Sutherland, but, and he's really right, it's really a gateway into the mind, and we have a really direct connection there with virtual reality, and when you achieve presence, you can do a lot of things. What we're doing here is we're motivating people, maybe distract them a little bit from their discomfort so they can do their exercises and to be compliant. But there's lots of other things that are going to come of virtual reality in terms of enhancing cognition. Obviously, there's slipstreams doing pain control, which is, you know, chronic pain is a big deal in our country. And I just think that the potential to enhance cognition and to manipulate perception in a good way is really the exciting part. This flip side of that is that it can be used just as effectively for bad things. And I wouldn't be surprised if using this for torture and things like that. I mean, it's so provocative, it's so engaging, and it can be used in good ways and bad ways.
[00:16:43.073] Kent Bye: Okay, great. Well, thank you. Thank you. And thank you for listening! If you'd like to support the Voices of VR podcast, then please consider becoming a patron at patreon.com slash voicesofvr.
