#488: Managing Pain & Anxiety in Hospitals with AppliedVR

Josh-SackmanThere’s been more than 30 years of research into the medical applications of virtual reality, but it’s not until the recent consumer VR revolution that the technology has been cost-effective enough to use. The research shows that the combination of immersion with interactivity can help to reduce pain up to 70%, and in some studies do as well or better as using morphine. AppliedVR was spun out of Lieberman Research Worldwide, and so they’ve been looking at previous medical VR research, creating new VR experiences, and then doing clinical research studies to prove out the efficacy of using virtual reality to manage pain and anxiety before, during, and after hospital procedures.

I had a chance to catch up with the President of AppliedVR Josh Sackman at the Experiential Technology Conference in May 2016. We talked about how VR can improve the overall patient experience metrics, the clinical metrics that VR could impact, and how VR can create a sense of connectedness, pleasure, and empowerment in patients. We also discuss the future of integrating biometric feedback like heart rate variability as a control input for VR experiences.


I had a chance to try out AppliedVR’s guided meditation application, and I was struck with how engaging they were able to make it. Usually a static VR scene is fairly boring and not very interesting, but AppliedVR was able to change the light throughout the course of a sped-up sunrise scene to show a lot more progress within the scene. Google Earth VR also uses a lot of dynamic light changes throughout their pre-recorded animation sequences to provide a sense of progress and a feeling of a beginning, middle, and end to an individual scene. AppliedVR also uses music from a sound healer and a guided meditation script to help with the pacing and sense of progress within their experience.

Here’s a 360 video with some the Applied VR experiences

The other thing that was really interesting was to hear more about the changes in how hospitals are getting reimbursed with new patient satisfaction and healing efficiency metrics. If medical applications of virtual reality can demonstrate that they have impact on some of the key metrics and potentially even save insurance companies money by reducing the cost from opioid drugs or the length of stay, then VR could be seen as way to increase efficiencies and improve the overall patient experience.

This interview was conducted in May, and in June 2016 AppliedVR announced that they’re using VR technologies in the Spine Center, Department of Surgery, and Orthopaedic Center at Cedars-Sinai Medical Center in Los Angeles.

Here’s a trailer for AppliedVR

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Music: Fatality & Summer Trip

Rough Transcript

[00:00:05.412] Kent Bye: The Voices of VR Podcast. My name is Kent Bye, and welcome to the Voices of VR podcast. So when I was at the Neurogaming and Experiential Technology Conference back in May, there were a lot of companies that were looking at how do you integrate biometric data, either from EEGs or wearable technologies, into different experiences. And one of the companies that was there was AppliedVR, and they were using VR in order to reduce pain and anxiety to patients who were waiting to go through surgery in the hospital. And so I had a chance to talk to the president, Josh Sackman, there, and we talked about how VR can be used as a pain management and anxiety management tool, as well as where they see being able to integrate additional biometric data into VR experiences for medical applications here in the future. So that's what we'll be covering on today's episode of the Voices of VR podcast. But first, a quick word from our sponsor. Today's episode is brought to you by the Voices of VR Patreon campaign. The Voices of VR podcast started as a passion project, but now it's my livelihood. And so, if you're enjoying the content on the Voices of VR podcast, then consider it a service to you and the wider community, and send me a tip. Just a couple of dollars a month makes a huge difference, especially if everybody contributes. So, donate today at patreon.com slash voicesofvr. So this interview with Josh happened at the Neurogaming and Experiential Technology Conference that was happening on May 17th, 18th, 2016 in San Francisco, California. So with that, let's go ahead and dive right in.

[00:01:49.337] Josh Sackman: My name is Josh Sackman, I'm the president of Applied VR, and as patients are going through healthcare, it could be a very unfamiliar, cold experience, filled with a lot of anxiety and uncertainty about what they're going into, and pain associated with the procedures they're going into. And so what we're doing is using VR to help patients manage pain and anxiety before, during, and after procedures. by giving them a tool to empower them to remove that threatening environment around them and displace them into a completely different world. We can transport a patient anywhere in the world, take them cliffside overlooking the water, take them through guided relaxation to help them relax before going into procedure. Our experiences are designed to manage their pain. through distraction by focusing their efforts, instead of on the recovery, onto a game that's meant to be played from a hospital bed by people of all ages, and seeing really promising results at how you can empower people in healthcare environments, at hospitals, surgery centers, and clinics, using VR as a tool that lets people have another alternative to their treatment.

[00:02:45.348] Kent Bye: So what's some of the research behind this that you're building on top of in order to prove out and to show that this is going to be an effective approach to pain management or reducing anxiety?

[00:02:57.422] Josh Sackman: What's really interesting about the space we're going into is there's over 30 years of academic research that shows how VR has been used to reduce pain, reduce anxiety, and help with a lot of issues that are taking place in healthcare. The most classic, going back to Snow World at University of Washington in the early 90s with burn victims, using VR as an alternative or supplement to opioids for helping distract patients by putting their focus on throwing snowballs at snowmen as they're changing bandages. And it had shown in over 100 studies that you could actually reduce pain up to 70%, even outperform opioids in certain studies. But the challenge has been VR has been far from practical. Although VR is a viable tool for helping as a therapeutic aid, it was expensive. It was tethered to a computer. The computer was expensive. It was hard to manage. It was difficult to be able to offer in the more integrated in the workflow. And thanks to consumer technology like Oculus and Samsung, and being able to run VR off cell phones, you're actually able to bring VR to the masses in a scalable form through mobile VR technology. And part of what we're doing is learning from the academic research of what works and translating that into what can actually scale and reach the most amount of people in healthcare.

[00:04:07.698] Kent Bye: And so, yeah, maybe you could tell me a bit about the experiences that you have and what each of the intentions of them are.

[00:04:14.662] Josh Sackman: So we're starting out fairly narrowly in the perioperative space, which just means we're helping people before, during and after procedures. The first two applications is part of this platform that we're launching. It's the Netflix of validated therapeutic content and that we're looking to curate content that helps patients. and everything's been tested for usability and effectiveness, starting with content that we're developing, but looking for partnerships as well to license, acquire, and partner to create the most robust content platform in the medical space. But what we're starting with is one relaxation experience designed for pre-procedural anxiety. So in the preoperative space is a patient's ready to get into a procedure before they see the anesthesiologist and they're given anesthesia. Rather than seeing the machines that are beeping, the nurses that are running through the room, and all the things that can instill anxiety and discomfort, we take them to this cliffside overlooking Big Sur campsite. There's a fire in front of you. You can get into a trance with the flicker of the flames overlooking the water. We take people through a guided relaxation exercise that takes deep breathing, body scanning, and other techniques that are meant to help patients relax before going to procedures. And then after the procedure, while a patient is recovering and in pain or during a procedure, if they're getting an injection, We have an experience, it sounds really silly, but as simple as shooting dodgeballs at little bears in a stylized scene. If it's simple just by turning your head with gaze and comfortable from a hospital bed, just that small cognitive engagement that's comfortable by all ages can actually distract them from the pain they're in and increase the comfort during the recovery.

[00:05:45.630] Kent Bye: So what type of studies have you done so far to kind of prove out what you're doing here?

[00:05:50.150] Josh Sackman: So we haven't started any formal FDA trials, but we do have four clinical studies that we're working with Children's Hospital Los Angeles and Cedars-Sinai. And so what we're doing with Children's Hospital Los Angeles are three different studies to understand how VR could be used to help kids in health care in different environments. So one is about reducing anxiety of kids before they go into procedures. The second study is showing how to distract kids during painful experiences in the emergency department, like the drainage of an abscess. And the third is during phlebotomy of blood draws at kids is a not surprisingly challenging. And so using a distraction like VR that can keep them still focused and comfortable during that process is very helpful and has actually been studied before. And then at Cedars-Sinai, our first test was really just to show that patients will put on goggles if it's offered in healthcare and that the staff will enjoy that process. And we quickly found out that patients enjoyed VR once they put it on their head. And they actually started collecting some information and saw really promising decreases in pain levels as they asked patients who were in pain. And so the next stage of our clinical study is understanding the further impact of VR for pain and anxiety in Cedars-Sinai patients.

[00:07:02.152] Kent Bye: So what has been shown with some of these studies? What have been some of the results so far?

[00:07:05.596] Josh Sackman: So I can only share preliminary research. We still have some studies that are waiting to be published, but it's really promising results. I can share some studies for some internal research that we did. So we're born out of one of the 25 largest market research firms, and so we have access to research facilities. And our version of user research actually involved dunking people's hands in a freezing cold presser and subjecting them to pain to understand how long they'd keep their hands submerged using RVR experiences versus other distractions. And instilling anxiety by having people do mental math and public speaking exercises to show how we can relax somebody after that stress was engaged. So in those internal studies, the first with pain, I think we had 200 to 300 people we put through the cold presser. And it's circulating water held between 0 and 3 degrees Celsius. It's really painful to stay in there. And using RVR, people stayed in 40 to 50% longer in the cold presser than their first submersion without a distraction. But what's interesting is everybody submerged their hand once in the cold presser without a distraction. And then we had them do a second time with different conditions. So in the control condition, people learn it hurts to keep your hand in there. And they kept their hand in less time in the cold press, or the second version, because they had no incentive to keep their hand in longer than the first. We introduced a Pixar movie to provide a distraction that was watching a nice, engaging movie. I think it was Birds. I forget what the actual video, but it was a short Pixar movie. they stayed in longer than the no condition. In that case, they still didn't last as long as the first submersion, but it was a little better than if they had nothing. And using VR, they stayed in the most amount of time. I forget the exact number, but it was two to three times longer using VR than nothing or the Pixar movie condition. And it really came down to what the research showed us in the academic world, that it's not just about distraction, but you need immersion and interactivity to really create the cognitive engagement that could actually lead to decreased pain levels. And so it was consistent with what academia showed, which made us feel good about the direction as we went into those actual clinical studies with hospitals.

[00:09:12.610] Kent Bye: Yeah, with Snow World you're actually looking around, you're throwing like beach balls at sea otters and engaging interactively in that way. Are you developing experiences that have that interactive component to increase that immersion?

[00:09:23.536] Josh Sackman: It's a similar mechanic since a lot comes out of the same school study in pain distraction in VR. Our particular focus was taking what's been done and being able to deliver it on a mobile device. Mobile VR has a lot of limitations and you have to design based on the GPU and CPU restrictions, based on not having additional inputs like hands. So we had to create a completely gaze-based approach. that was able to use a graphic processing power of a phone to still be able to keep the same level of immersion and maintain a high enough frame rate that you don't make people sick and that would still create enough engagement to decrease pain even though you don't have the luxury of additional inputs.

[00:09:59.353] Kent Bye: And so maybe you could talk a bit about some of the VR design principles that you were trying to really do with this relaxation application where you're sitting on the cliff overlooking Big Sur in front of a campfire.

[00:10:10.144] Josh Sackman: So it was a really interesting exercise because we understood that we wanted to transport somebody somewhere else. And removing the threat of the environment was the first part of the equation. You're sitting in this cold, sterile environment that instills anxiety and kind of perpetuates that emotional state that they're in. So the first part is removing the environment and creating an environment that's pleasant and that can relax a person using principles of mindfulness, guided relaxation, body scanning and other practices outside of VR has been proven to be able to relax and provide therapy to a person. But what was interesting, VR, the natural incarnation, is to look around 360 degrees, engage people from all angles. And we want to take advantage of the immersive nature of VR that they felt like they're somewhere else. Because going back, that first step is removing that threat, removing the environment. But we had to keep enough engagement that if they're seated in a bed, or even supine laying down in a hospital bed, or even a condition when they're awake during a procedure and they have very limited movement, you still would have to create a guided relaxation that still takes advantage of the immersion of VR and is still pleasant, but still keeps them from a user experience in a position that's not compromising to anything attached to their arms like IVs or procedures that are being done in that preoperative or the operational environment. And so that was a big consideration is what position is the user in? Are they seated? Are they laying down? Are they on their side? And you have to create comfort in each of those positions. So a lot of natural inclinations of, VR to have movement and to have things that engage people from other angles, we had to take into consideration of how would a user perceive those from the position they're going to be in a hospital environment. And then we also had to factor in how long they're going to be spending in the process. And some preoperative prep is five minutes and some is 15. And we had to create experiences that would pace well, whether in their two minutes or 20 minutes, and to be able to use things like a sun rising as a way to make them feel as a progressing in a scene. but progress fast enough that they feel progress in the five minute version, but also feel a sense of accomplishment and arrival of towards an end of an experience if they're spending the full time in the experience. And so there are a lot of considerations that we had to factor in and we got a lot of great feedback from users around pacing and experience and making sure they ultimately are comfortable and relaxing before going into a really stressful moment.

[00:12:31.228] Kent Bye: Yeah, I thought that was really interesting to see what you were doing with the sun movement because it's a pretty static scene. I've done a lot of different VR, but yet you see all the different light changing as it's essentially like watching a sunrise, but in a time-lapse mode where you're able to see the sun move about 10 or 20 times faster than it normally would because I was just in there for a few minutes and it went from sunrise to like high noon in what felt like just a few minutes. And so it's really interesting to me because with the light changing it felt like this evolution of the scene. So maybe you could talk a bit about like what you were doing there.

[00:13:07.634] Josh Sackman: It was a challenge to be able to create realistic representations and particularly light and transparency naturally propose issues with mobile VR. And so we had to be selective in terms of what are the elements that we're going to let shine. And in the initial versions we had animated trees with leaves falling. We had a lot of movement in water. We had a lot of other elements. At the end, we didn't want to divert focus in a lot of areas because the paradox of choice and adding more options for them to be engaged with naturally can create more anxiety as their attention is being focused in other areas. And from a technical perspective, As we're looking for things that are going to create the most utility, we had to figure what are the elements in the scene that are going to lend best to pacing the experience, to promoting relaxation, and creating comfort in those environments. And so, through kind of natural selection of testing all these elements in the scene, of trees animated, and water moving, and clouds moving in the sky, and light changing the scene, We found light and the pacing of the music and the voiceover with light naturally create the most cohesive experience for taking a person through a meditation. And so what you're seeing is the end result of a lot of refinement based off a lot of research and kind of that natural selection of VR. And that's the great thing about VR. is it's meant to be iterative, that you're never going to get it right the first time. You go understanding that you're going to have to make adjustments. And thanks to Unity and tools that make it easy to iterate, and certainly easier than before, you can come to those conclusions a lot faster. And it's really nice to be in that state of VR where there's a receptivity of people to try the experiences so you can get that user feedback. And tools allow you to have a much more agile framework for that iteration process.

[00:14:44.977] Kent Bye: And so yeah, maybe you could talk a bit about like, why is pacing important? Because you know, as you're moving the sun, that's part of the reason why you're doing that is to create a sense of pacing and progress. But why is pacing important when someone is getting ready for some sort of surgery?

[00:15:00.293] Josh Sackman: What we want to do is take them from this static state where they feel stuck in the hospital environment, overwhelmed with fear and anxiety and fright and negative feelings. We want to take them to a lot more positive place. But because we don't want to physically move them, we need to figure out other things that create that same sense of advancement and movement towards that relaxed state. And so part of using that is a way to create that sense of movement and transformation in a way that's less literal than actually putting them on a rail and taking them to a physical place.

[00:15:31.033] Kent Bye: And are you using any type of binaural audio as well?

[00:15:34.227] Josh Sackman: So we're using a combination of visualization, we're using music from this space called, his name's James Hopkins and he's a sound healer and he uses this concept of Pythagorean harmonics and it's the tuning and it's the structure of the instrumental and he actually uses these really abstract instruments and has patients laying on a bed and plays these series of notes and chords that are meant to promote relaxation and healing and we're really intrigued by the story and so that was the first place we went and kind of VR is all about telling a story and explaining the narrative of why you make decisions and why a music is used and what the visuals are trying to accomplish. And so we look for other compelling stories that integrate into our experience. And so that was one of the sound and music tracks that we played around with in the beginning.

[00:16:20.721] Kent Bye: And so is this an application that consumers are going to be able to buy, or is this something that's being sold directly to hospitals?

[00:16:27.686] Josh Sackman: Our focus currently is on hospitals, surgery centers, and clinics. Until consumer adoption is able to allow this into people's homes at any scale, we want to focus on creating the most impact in people's health using VR. Our mission truly is to use VR to create positive change in people's lives. VR is a powerful tool, and we think the best way of doing that is bring that to where people are congregated who are in need. And hospitals, surgery centers, and clinics are environments where pain and anxiety and other issues aren't managed particularly well. There's a lot of big considerations in the healthcare environment. that are causing healthcare providers to focus on delivering a better patient experience, being more efficient with treatment, and as organizations like the NIH are decreeing publicly the risk of using opioids and the inefficiency for managing pain, healthcare providers are looking for alternative forms of treatment that aren't drug-based. And so the timing's really ripe to bring innovation like VR and other technology into the healthcare systems, and so that naturally was our first place to start. What we're looking at doing is starting in this very focused area of helping patients before, during, and after procedures, but then looking more broadly at what other content is needed to be able to offer patients in different areas. Because ultimately we look at the patient journey from the time they know they're going in for a procedure to the time they're going home. There are a bunch of needs that VR could be used to assist. from educating a patient about what to expect, taking them through a hospital tour, taking them inside the body and providing more engaging education that leads to higher levels of retention, to when they actually get admitted, to helping them pass time and manage their anxiety and pain while they're in the hospital, to the time they go home and they need a certain course of rehabilitation and things that need to be done after they leave healthcare to engage a patient, to what happens after they leave the hospital. There's a huge opportunity of just supporting that patient journey to empower a patient to have tools that help them manage their experience better. And then after that, we look more broadly at how to actually intervene in home and self-management and preventative health to use VR to solve bigger issues like chronic pain and things that are real societal afflictions that ultimately do start in managing people's homes. By the time they hit the hospital, it's often too late. And so we do look more broadly at that place, but a little further once we can prove the viability of VR in this more controlled environment.

[00:18:46.559] Kent Bye: And so it seems like in some of these experiences, you're actually trying to cultivate this either time compression or time expansion. So when people go into the experience, the actual procedure that may be taking a long time, they have this perception that not much time is passing. And so are you deliberately trying to create VR experiences that are impacting these patients' perception of time?

[00:19:06.864] Josh Sackman: There was an interesting study, I think it was out of Japan, for chemotherapy patients that showed how VR could increase the perceived time or how fast they went through the chemotherapy treatment. And so there is some academic precedence that shows VR can actually help pass time. But we're looking at delivering value in a few areas. So one is in the overall patient experience, which goes to how a patient felt that their pain was managed, how much time and how efficiently they were treated in the process. And there's a whole lot of other variables that are actually tied to something called HCAPs. which is all around patient satisfaction metrics that are actually tied to Medicare reimbursements for hospitals for inpatient. So it's a big area of focus of not just time passing, but how well you were treated, how well you were informed, and what your overall experience was. You know, Yelp is not the metric for healthcare, but there are versions of that that are coming around that are actually impacting reimbursements and that have cost and revenue implications for healthcare. And so that got healthcare providers really paying attention. Two is we're trying to demonstrate how VR can impact some real clinical metrics. If we relax a patient before a procedure, can we impact the amount of sedation they're given going into the procedure? If we could relax a patient and manage their pain using VR post-operatively. Can we reduce the morphine equivalent? Can we get a patient ambulatory more quickly? Can we get them off of IV drugs? And can we impact all these drivers that ultimately impact their length of stay or how long they're actually spending in the hospital? And we're pretty confident through our studies we'll be able to demonstrate some real clinical outcomes that VR can impact as we embark these additional clinical studies that we're taking. And then ultimately, just how can you create a more sense of connectedness and pleasure for people as they're going through really tough times? So outside of the healthcare value from a patient, a lot of patients just feel helpless. They don't feel empowered. They don't have a lot of tools except for the morphine drip button that they click at their bedside. And we're really looking at patient empowerment and what do patients need to feel better as they're going through really vulnerable moments in their life.

[00:21:05.963] Kent Bye: Yeah, in talking to Walter Greenleaf, he was talking about how he really sees that there's this digital health revolution that's happening right now. All these different trends of needing more objective measurements of the results that are actually being derived from these different treatments. So from your perspective, how does what you're doing with these medical applications fit into this larger context of this digital health revolution?

[00:21:30.348] Josh Sackman: People aren't going to spend every moment of their life in VR. So it's really about integrating different types of technology that can add supplemental value. And so we see integrating wearables as a way both while you're in VR to control the experience. If you could use heart rate variability and sense when a person is getting anxious and provide feedback to relax by focusing on aspects of the VR environment. Or actually allow their relaxation to control aspects of the scene and use your own body as a controller in a scene. You could build off of this amazing development in the wearable space and take real-time data from these sensors and integrate it into VR. After you leave VR, how can you use eHealth applications as boosters to keep yourself relaxed and continue engaging, whether it's through education or additional therapeutic value? Once the goggles are taken off, how can you continue the therapy by using these other technologies? And so we're really looking as we create partnerships of how does this fit in with this ecosystem that ranges from devices that you wear, to applications that you interface with, to other touch points that patients have and people have as they worry about wellness, health, fitness, and other things that ultimately impact people's health.

[00:22:40.419] Kent Bye: And so what other kind of biometric sensors are you trying to integrate within these different VR applications? And in talking to some people, there seems to be some issues with getting EEG mixed with some virtual reality headsets, unless it's already built in, like a device like MindMaze. But you're focusing on mobile VR, the Gear VR. And so it's something that is portable and easy. And so what other type of peripherals are you looking at in order to potentially get more data as to what's actually happening

[00:23:10.150] Josh Sackman: Within the body of these patients and be able to adapt the content based upon that I was blown away at CES this year at how many Bluetooth wearables can provide real-time data It's really incredible how far along the wearable spaces come that with nothing more than a finger cuff pulse oximeter that you can collect blood saturation and heart rate just by clipping a device on the finger that connects via Bluetooth to a phone. And between all the different watches and devices and sensors, between galvanic skin response and heart rate variability, there's a lot of data that healthcare is naturally collecting. the blood pressure, the heart rate, that you can actually use to inform VR experiences. EEG is an area we're fascinated by. To your point, there's a logistical challenge of fitting an HMD on top of an EEG sensor. But I imagine over time, there'll be more integrations at a hardware level that incorporate things like eye tracking, EEG, into the actual headset. And so I imagine time will solve that problem, but that is a consideration. Because as great as a piece of content is, if it's not usable or not practical, it won't be touched or utilized in the healthcare system. And so that's a real focus of ours, of creating content and systems that are easy to adopt and integrate with workflows that add value, but not too much complexity.

[00:24:28.112] Kent Bye: And so, what's next for Applied VR?

[00:24:30.849] Josh Sackman: We're currently part of the Techstars Healthcare Accelerator in partnership with Cedars-Sinai. We're in the process of launching a bunch of commercial tests within Cedars-Sinai, within Children's Hospital Los Angeles, within a lot of different hospitals and surgery centers and clinics across different parts of the country. And we're also looking at building out our content platform. by developing partnerships with other content creators, looking for opportunities, knowing that at the end of the day, not any one content creator can create all the content to solve all the needs in healthcare. And also, people have preferences when it comes to any media, so it's not one size fits all. And so it really is being able to target the right content based on the needs and the interests of the patient. And so we're looking to develop some real strong content partnerships as we continue to develop our own content and then supplement that with licensing, acquisition, partnership, to build a real robust VR ecosystem of content that's been tested, that healthcare providers trust is going to be effective, comfortable, and usable in their environment. And then to continue testing to understand what patient populations and what use cases are most appropriate as we roll this out more broadly in the market.

[00:25:42.257] Kent Bye: Do you have any stories or anecdotes of people that have been using some of your applied VR experiences?

[00:25:48.823] Josh Sackman: That's really what motivates us. So when Cedars had an NBC piece that covered VR and healthcare, They were surprised at how many views on Facebook. I think it was like 3 million views in the first 48 or 72 hours. And they were really surprised at how much attention they could get at the power of using VR in their healthcare system. They had this young patient named James who got in a car accident. He lost most of his teeth. He fractured most of his body, including his ribs and his hip. He was in real disarray and in a lot of pain. And he saw that NBC piece that saw that Cedars-Sinai was offering VR to patients to help manage pain while in the hospital. And so he wrote to the Cedars research team and his family wrote to them and said, my son James has been in this horrible accident and he saw VR and he would really like to try it. And so of course the team rushed over with the VR headset and he wrote the most touching note with a follow-up note from his family saying, this VR experience was single-handedly the most transformative experience for pain management of his time in healthcare. It decreased his pain level and he was so appreciative of that opportunity that was provided and would be very happy to have that opportunity in the future. And although we're doing all this clinical research and we're trying to get all this fancy data being collected, when you can put the names and the faces like James Story to the impact VR can actually make when people are in these really challenging times, it makes us really feel good about where this could go and the opportunity VR really has, not just to entertain or provide gaming, but to really actually affect people's lives in some real meaningful ways.

[00:27:21.442] Kent Bye: And finally, what do you see as kind of the ultimate potential of virtual reality and what it might be able to enable?

[00:27:27.491] Josh Sackman: VR is at an interesting state, and we're going to see this transformation where it goes from novelty to utility, where people see past the bells and whistles and the hype. at where VR can actually deliver the most value. And so there's a lot of interesting applications in education, and training, and healthcare, and a lot of other areas that there's a lot of need of reform, there's a lot of receptivity to new innovation, and VR has been demonstrated over a lot of research in the past. to be able to provide value in those areas. And so I think we're going to see a lot of VR taking place and getting acceptance in areas we didn't really think of beyond the typical gaming and entertainment areas. And don't get me wrong, VR and entertainment gaming is fantastic, and I'm a huge consumer of those areas as well, but I think there's such greater opportunity to use VR as a transformational tool that can actually impact people's behavior, attitudes, and health. And I think we'll see that evolve a lot over the next year or two. Awesome. Well, thank you so much. Yeah. Thanks so much for your time. I really enjoyed talking to you, Kent.

[00:28:28.803] Kent Bye: So that was Josh Sackman. He's the president of Applied VR, and they're using VR to be able to reduce pain and anxiety in hospital patients. So I have a number of different takeaways about this interview is that first of all, there's been a lot of research over 30 years about using VR within a medical context. And it's not until just recently that some of those applications have been commercially viable for startups like Applied VR to come in and start to create experiences and to actually bring them into hospitals. And so to me, it was really interesting that the cultural DNA of applied VR is coming from the Lieberman Research Worldwide, which conducts a lot of clinical research already. And so they are able to use their skills of being able to essentially prove out the efficacy of VR to get that data and to actually be able to potentially get FDA approval and to then essentially validate a number of different experiences in terms of their efficacy and then have this Netflix type platform that has validated content that they're able to distribute out to lots of different hospitals, surgery centers, and clinics. And I actually got a chance to see their guided meditation experience and the thing that was really striking to me is that I've been in a lot of different experiences that are just kind of a static scene, and you get kind of bored after a little bit. You just put it on for maybe 20 seconds, and you're like, okay, I get it, and you take it off, because there's actually nothing really happening within the scene. But the thing that was really interesting about their guided meditation experience was that they had this sunrise, and so as the sun was rising, the light was actually changing within the scene, and it was dynamic and changing enough that it actually made it really interesting and compelling to see that progress happening. That was some of the big points I was trying to bring out with Josh was the way that they were designing this so that they have both the music as well as the guided meditation as well as the visuals are kind of very dynamic and changing over time such that when you put it on you just completely get transported to this other world. So he was really focusing on the importance of progress and pacing. So, I think that this is applicable to just about any VR experience, is to have some sort of dynamic progress that's happening that is telling some story where you have a beginning, middle, or end, or you have some sort of change that's happening from the beginning of the scene to the ending of the scene. The applied VR meditation experience, I think, does an amazing job of that. And Josh said that he experimented with a number of different variables, whether it was like the trees moving, the clouds moving, but the thing that had the most impact was the light changing. And since I've seen this applied VR experience, I've noticed that there has been other experiences that do this as well in terms of having the light change throughout the scene. And to me, it's just really fascinating that you're able to use VR to be able to manage pain. And what Josh was saying was that the research was saying that there's two major components. One is the immersion, so you're completely immersed within a virtual reality experience. But also that there's some sort of interactivity, that you're able to express your agency within the world in some way. And that interactivity actually increases the cognitive load. and in turn helps distract you from paying attention to the pain that you might be experiencing. And so there's been a number of different studies over the years, but they've shown that they can essentially reduce pain up to 70%, and sometimes just not even use the morphine. It could be as effective as the morphine, and in some instances, even better than morphine drip. And with the NIH coming out and saying, hey, we shouldn't really actually be using morphine. There's a lot of risks for addiction. So there's pressures there to find alternatives for pain management. But also there's these other pressures that are coming on into these hospitals in terms of being able to measure the efficacy of their treatments, but also paying more attention into the patient experience. And so having the patient experience and You know, like Josh said, there's kind of like the Yelp reviews of hospitals and that in some ways, some of these reviews are having some sort of impact and actual reimbursement. And so there's a financial incentive to actually be paying more attention into the overall patient experience and. I think that's where VR is going to start to really come in, is that it could actually create a better patient experience. But also, there's a lot of just hard and fast numbers in terms of what applied VR is trying to prove out in terms of how VR could actually impact some real clinical metrics. For example, some of the things he mentioned that they're looking at is, could you reduce the amount of morphine that you're using? Is the patient able to get ambulatory more quickly? Can you get them off of IV drugs? And can you impact the overall length of stay? So Josh actually mentioned SnowWorld, which is one of the first VR experiences that were really tested and used to demonstrate the impact of how you could create an interactive scene to be able to reduce pain. And I actually had a chance to talk to Howard Rose and DeepStreamVR back in episode 180. So go check out that interview to hear from one of the pioneers of pain management and virtual reality. And I think in the future, looking forward, because this was happening at the Experiential Technology Conference, there was a lot of implication that in the future you could start to integrate a lot more biofeedback within the experience and so Josh was saying that you could potentially use things like heart rate variability to be able to measure the level of someone's anxiety and to be able to use that specific metric to be able to control the experience so that depending on how anxious you were that you'd be able to get some direct biofeedback and and to be able to dynamically modulate your experience internally that you're having, but also to be able to use that to be able to control the external stimulus that you're getting from the virtual reality experience. One thing that I did ask around a lot at the Neural Gaming and Experiential Technology Conference was whether or not you could take a lot of these commercial off-the-shelf EEGs and be able to use them in collaboration with the virtual reality headsets and unfortunately the answer is no not really because there's a lot of critical spots on the scalp that you need to be able to touch and that the virtual reality headset actually occludes a lot of those spots with the straps and so there is mind maze vr which is going to be able to create an eeg sensor directly built into the hmd apparatus and so i think that is a company to look out for to look at the more specific applications that are using eeg in coordination to medical vr applications And that perhaps eventually we'll have something like the OpenBCI, which is kind of like an open source platform. And I talked to one of the founders, Connor Russomano, back in episode 365. So perhaps there'll be a way to use some of the EEG platforms that are out there to be able to integrate them within virtual reality. Based upon the interview that I had with Connor in episode 365, he didn't sound very optimistic of being able to use brain control interfaces as a direct real-time interaction within virtual reality. Because at this point, the EEG signals aren't specific enough to be able to do real-time interactions. So go listen to episode 365 to dive into a lot more details into that. But because there has been so much research that has been done within the applications of virtual reality within medical contexts, I think that it's a matter of being able to both prove out the content and the latest systems and maybe a clinical study to be able to then deploy systems out into actual hospitals and to get access to patients who could use some of these different applications. So because of that, I expect that the medical applications of VR are going to be one of the really clear wins of virtual reality technologies. So that's all that I have for today. I just wanted to thank you for listening to the Voices of VR podcast. And if you enjoy the podcast, then please do tell your friends, spread the word, and become a donor to the Patreon. Just a couple of dollars a month makes a huge difference. So you can go to patreon.com slash Voices of VR. Thanks for listening.

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