CyberTherapy & Rehabilitation Magazine (C&R), the official voice of the International Association of CyberPsychology, Training & Rehabilitation (iACToR - http://www.imi-europe.eu/ - http://iactor.ning.com/). iACToR is an international association that has been created with the goal of disseminating knowledge about exciting new findings being made to transform healthcare through the addition of cutting edge technologies. This publication will serve as a catalyst whereby society may rapidly benefit from the remarkable technological revolution that is occurring, with the ultimate aim of improving the quality of today's healthcare and helping to quickly disseminate research results.
Issue 1 / 2013 and much more... The Official Voice of iACToR ISSN 2031 - 278 FEATURES: It’s All in Your Head: Measuring the Placebo Effect Using fMRI p 15 Can You Enhance Virtual Reality Exposure Therapy Outcome by Adding Pharmaceutical Agents? p 20 ASK THE EXPERT: Mary Baker p 33 COUNTRY FOCUS: Belgium p 40 COVER STORY: Virtual Reality and Pharmaceuticals: Enhanced Synergy to Improve Clinical Care C&R 6(1) June 27_Layout 1 6/27/13 12:23 PM Page 1
Transcript
Issue 1 / 2013
andmuchmore...
T h e O f f i c i a l V o i c e o f i A C To R
ISSN 2031 - 278
FEATURES:It’s All in Your Head: Measuring the Placebo Effect Using fMRI p 15
Can You Enhance Virtual Reality Exposure Therapy Outcome by Adding PharmaceuticalAgents?p 20
ASK THE EXPERT:Mary Bakerp 33
COUNTRY FOCUS:Belgiump 40
COVER STORY:
Virtual Reality andPharmaceuticals: EnhancedSynergy to Improve ClinicalCare
C&R 6(1) June 27_Layout 1 6/27/13 12:23 PM Page 1
UNITED STATES OFFICE9565 Waples Street, Suite 200San Diego, CA 921211-866-822-8762
Letter from the Secretary General and Editor-in-ChiefProfessor Dr. Brenda K. Wiederhold
Dear Reader,
In early 1996 we incorporated the use of real time non-inva-sive physiological monitoring into our clinical practice. For abusy therapist, patient preparation and application of sensorsis relatively simple, and training is available for those who wishto learn to read the signals. For the therapist, the real-time in-formation allows for individualization of therapy protocols, ameans to compare progress over the course of multiple ses-sions, and quantitation of actual emotional reactions to spe-cific cues and stressors. From a reimbursement point of view,the payors receive objective data where the physiology addsa more objective, quantitative component to validate successin the therapeutic intervention. In addition, it is possible tobring a more accurate prediction for the length of therapy andthe associated costs. For patients, it helps them to more eas-ily understand their stress and relaxation levels and results intransitioning of these skills into the real world setting. Empow-ering patients and providing them the opportunity to becomemore active participants in their own health and well-beingbuilds self-efficacy and long-term sustainability of treatmentresults.
In order to overcome a fear or phobia, we must activate thefear structure and provide new information that replaces patho-logical pathways and inefficient thoughts. Physiology shows
both the patient and therapist objectively if the fear structurehas been both accessed and activated. While our initial stud-ies included measurement of real-time non-invasive periph-eral physiology and EEG, in a study conducted by Universityof Basel and Virtual Reality Medical in 2005, we measured cor-tisol levels during the VR exposure experience. We found thata combination of a stimulating and engaging virtual environ-ment with a stressful cognitive task caused an increase in thestress hormone (cortisol) levels, while neither of those condi-tions did so individually. In a more recent study led by LTC Mel-ba Stetz, VR environments were used for flight medic trainingpre-deployment (stress inoculation training), with salivary cor-tisol being measured to ensure elicitation, and the degree, ofarousal during VR tasks.
Moving from measurement of cortisol levels to administra-tion of cortisol, my colleagues and I, led by Dr. de Quervain,introduced 20 mg of oral cortisol given one hour prior to a vir-tual-elevator exposure therapy session. This resulted in a sig-nificantly greater reduction in the patient’s fear of heights incomparison to fear levels of patients given a placebo. Acro-phobia questionnaires, a standard behavioral test used to as-sess fear of heights, and non-invasive physiology confirmedthese results at post-treatment and at follow up one monthafter the treatment ended. Our results, which indicated thatcortisol-enhanced exposure therapy more efficiently reducedacrophobia, are consistent with the idea that glucocorticoidsfacilitate fear extinction.
What is the role of cortisol in fear and its extinction?
Dr. Lang and colleagues first explained the neural foundationsof fear. In our acrophobia scenario, when a person who is afraidof heights recognizes a potentially threatening or fearful sit-uation, his/her brain responds to the stress by initiating a se-ries of hormone secretions that eventually lead to stimulation
“In order to overcome a fear or phobia, we must activatethe fear structure, and provide new information, thatreplaces pathological pathways and inefficient thoughts.Physiology shows both the patient and therapist objectivelyif the fear structure has been both accessed and activated.”
“The cortisol in the bloodstreamthen causes an increase in bloodglucose levels, which can be utilized by the brain and musclesto respond to the stressor.”
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of the adrenal glands for cortisol secretion. The cortisol inthe bloodstream then causes an increase in blood glucoselevels, which can be utilized by the brain and muscles to re-
spond to the stressor.
Researchers have begun using virtual reality scenarios withthe Trier Social Stress Test (TSST) to activate the hypothal-amic-pituitary-adrenal axis described above. A recent studyused a TSST-adapted virtual environment in which a partic-ipant had to deliver a speech. The researchers found that93% of the participants had increased cortisol levels, withthis increase being statistically significant in the momentbefore the speech. Other researchers, using a TSST-adapt-ed virtual reality CAVE™ system with three projected wallsand one floor projection, found that while cortisol increased88% above baseline when a participant was first tasked togive a speech, the rise in cortisol levels was not as dramat-ic in the second session. The authors concluded, “If theseresults can be replicated with larger samples, VR technolo-gy may be used as a simple and standardized tool for socialstress induction in experimental settings.”
What are the next steps?
Additional studies combining VR and pharmacological agentsare being conducted at the Virtual Reality Medical Centerfor the treatment of PTSD, the reduction of avoidance andfear in phobic subjects, and possible reduction of night-
mares in PTSD. As the price of standard VR therapy contin-ues to rapidly decline and the convenience of cloud-basedapplications grows, more widespread use is anticipated.More studies using fMRI and VR-compatible headsets areproviding specific brain pathway activation in response tocues, stimuli and various cognitive tasks. These types ofspecific and well controlled studies bring a new level of pre-cision to our understanding of how best to use these tools.Most importantly, identification of specific targets, whetherthey be receptors, neural pathways, or alterations in physi-ological response, will lead the way to newer and more ef-fective interventions.
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Create your own reality!Brenda Wiederhold
“Additional studies combining VRand pharmacological agents arebeing conducted at the VirtualReality Medical Center for thetreatment of PTSD, the reductionof avoidance and fear in phobicsubjects , and possible reductionof nightmares in PTSD. As theprice of standard VR therapy con-tinues to rapidly decline and theconvenience of cloud-based appli-cations grow, more widespread useis anticipated.”
The accuracy of contents in CyberTherapy & Rehabilitation
Magazine are the responsibility of the author(s) and do not
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CyberTherapy & Rehabilitation Magazine is currently indexed with PsycEXTRA.
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LETTER FROM THE EDITOR-IN-CHIEFB.K. Wiederhold p 1
CONFERENCE HIGHLIGHTSCYBER17 Highlights and Conference Participationp 6
COVER STORYVirtual Reality and Pharmaceuticals: Enhanced Syn-ergy to Improve Clinical CareM.D. Wiederhold, B.K. Wiederhold p 10
FEATURESIt’s All in Your Head: Measuring the PlaceboEffect Using fMRIA. Anderson p 15
D-Cycloserine Augmentation of Cognitive-Behavioral Therapy for Anxiety Disorders C.Sirbu p 16
Can You Enhance Virtual Reality ExposureTherapy Outcome by Adding PharmaceuticalAgents?K Meyerbröker p 20
Modulating the Pain Experience with VirtualReality DistractionS. Sharar, H. Hoffman, D. Patterson p 22
Glucocorticoids Enhance Extinction-basedPsychotherapy in Virtual RealityD. Bentz et al. p 26
Cybertherapy in Medicine: Clinical Application toReduce Pain and AnxietyJ. Mosso et al. p 28
PRODUCT COMPARISON CHARTEnhancing VR with Drugs p 30
ASK THE EXPERTM. Baker p 33
FROM WHERE WE SITG. Riva p 37
COUNTRY FOCUSBelgiumS.Allison p 40
TABLE OF CONTENTS
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Enhancing VR Exposure TherapyOutcomes with PharmaceuticalAgents
The idea is to find out whether or not it is possi-ble to enhance therapy outcomes by giving pa-tients a pill during exposure therapy. This helpspatients learn more easily how to overcome theiranxiety during exposure therapy, making thera-py more efficient in the long run. This idea isbased on a learning paradigm wherein it is as-sumed that a learning process takes place dur-ing exposure.
It’s All in Your Head
A sugar pill can regrow hair in a study on bald-ness; sham knee surgery can reduce paincomparable to real surgery. During World WarII, a nurse injected a wounded soldier withsalt water after heavy casualties depleted mor-phine supplies, giving the soldier enough painrelief to make it through surgery. The place-bo effect describes this remarkable phenom-enon that applying a treatment, any treat-ment, is likely to produce the desired resultsin medicine.
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The 17th Annual CyberPsychology & Cy-berTherapy Conference: Experience theFuture of Health & Well-Being (CY-BER17), the official conference of the In-ternational Association of CyberPsychol-ogy, Training & Rehabilitation (iACTOR)was held September 25-28, 2012 in Brus-sels, Belgium. Prominent academic rep-resentatives from Europe, North Amer-ica, and Asia served as Scientific Chairsand on its Scientific Committee. iAC-ToR’s Secretary General, Professor Bren-da K. Wiederhold was the ConferenceChair.
CYBER17 was truly an international suc-cess with 140 attendees from a multi-tude of disciplines and more than 20countries. By locating the conference inEurope’s capital, CYBER17 provided aunique opportunity to raise the confer-ence’s visibility and highlight the impor-tance of technology and healthcare re-search. The presentations anddiscussions emphasized the need to en-hance public awareness of how technol-ogy can overcome obstacles and increaseaccess to top quality healthcare for allcitizens.
CYBER17’s theme, Experience the Fu-ture of Health & Well-Being, explored theuses of advanced technologies throughfour main focus areas. First, the impactof technologies as tools being used intraining, therapy, rehabilitation, and ed-ucation for the improvement of the qual-ity and availability of healthcare. Second,the influence of new technologies thatfurthers the investigation into how newtechnologies are influencing behaviourand society through the use of positivetechnology. Third, the imprint of socialnetworking which explores its effects onindividual behaviour and societal rela-tions. Lastly, CYBER17 focused on theintroduction of new technologies andterms on psychological aspects of areasinfluenced by technology such as; cy-berfashion, cyberadvertising, and cyber-stalking.
Under the direction of Workshop ChairStéphane Bouchard, CYBER17 kicked offwith pre-conference workshops on Tues-day, the 25th of September. The work-shops included a wide range of topicssuch as mobile technology for wellbe-ing, VR for mental health and brain com-puter interfaces.
The conference officially began onWednesday, the 26th of September witha keynote address by Robert Madelin,Director-General of the European Com-mission’s Communications Network,Content & Technology Directorate (DGCONNECT) who spoke on “Cyberpsy-chology and Europe’s Digital Futures.”The second keynote speaker was MaryBaker, President of the European BrainCouncil, who gave a presentation on “So-cietal Challenges Facing Europe.“
The first symposium, Digital SocietalPlatforms, was chaired by Ilias Iakovidisand Peter Wintlev-Jensen, ICT for Digi-tal Societal Platforms at the EuropeanCommission. This was followed byHealth and Well-Being presentationswhich were chaired by Peteris Zilgalvisand Terje Peetso from the ICT for Healthand Wellbeing Unit. A PTSD symposiawas chaired by Colonel Carl Castro ofthe U.S. Army Medical Research and Ma-teriel Command.
Day 1 concluded with a poster sessionand Cyberarium. The poster session wasan opportunity for developers and sci-entists to demonstrate their work andconverse, one-on-one, with interestedspectators and colleagues. The Cyberar-
ium dedicated time for researchers topresent their prototypes and for partic-ipants to experience their colleagues’ re-search, generating valuable feedback. Af-ter the scientific program, participantswere invited to a welcome reception atBrussels Town Hall located in the his-toric Grand Place. Other conference high-lights included a Gala Dinner that tookplace at Le Chalet Robinson and anawards ceremony.
Four students were presented with theYoung Minds Research Award; Yoon JungChoi, Haesol Hwang, Elisa Postrach andMaryan Ziekle. The 2012 LifetimeAchievement Award was given to Mari-ano Alcañiz for his outstanding work inthe field. The New Investigator Awardwas given to Pietro Cipresso.
From the full day of pre-conferenceworkshops to the groundbreaking scien-tific program, CYBER17 continued itsrole as the leading conference in design-ing the future of cyberpsychology andhealthcare. It is with sincere apprecia-tion and gratitude that we thank thosewho made this conference possible. CY-BER17’s Scientific Committee Chairs,Professors Rosa Marie Baños, Willem-Paul Brinkman and Giuseppe Riva, wereinstrumental in providing exceptionalscientific and social programs. The con-ference was also graciously sponsoredby institutions and organizations whoseimportant contributions allowed for avibrant conference including BrusselsCapital Region, the European Commis-sion, DG CONNECT, Hanyang Universi-ty, International Association of CyberPsy-chology, Training, & Rehabilitation(iACTOR), Interactive Media Insitute (IMI),INTERSTRESS, ISfTeH, Istituto Auxologi-co Italiano, Mary Ann Liebert, Inc. Pub-lishers, National Institute on Drug Abuse(NIDA), Université du Québec enOutaouais (UQO), the Virtual RealityMedical Center (VRMC), the Virtual Re-ality Medical Institute (VRMI) and VisitBrussels.
“The quality and significance of the work pre-sented at CYBER17 reaffirms that advancedtechnologies are increasingly playing a signifi-cant role in healthcare”
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Highlights of the 17th Annual CyberPsychology &
CyberTherapy Conference
T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
“CYBER17 was trulyan international suc-cess with attendeesfrom more than 20countries.”
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Conference Chair B.K. Wiederhold,Keynote Speaker R. Madelin, &
iACToR President G. Riva
Keynote Speaker MaryBaker, President European
Brain Council
Mariano Alcaniz receiving theLifetime Achievement Award
A happy audience at one of the manySymposiums
Students from Chung-Ang University enjoying
the break
Conference members attendingthe poster session
Participants networking on abreak at the EU Commission VR demo at the Cyberarium
T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
Keynote address by RobertMadelin (DG-CONNECT)
Highlights of the 17th Annual CyberPsychology &
CyberTherapy Conference
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International Association of CyberPsychology, Training & Rehabilitation (iACToR)
Conference Participation Report 2012 / 2013
The Internet of Things EuropeBrussels, Belgium / www.internet-of-things.euNovermber 12-13 2012,
The 4th Annual Internet of Things Europe explored the co-existenceof real and virtual worlds in everyday life within areas such as health,transport and retail.
The Internet of Things Conference (IoT) in Brussels focused on theprinciple that connected devices and objects that are uniquely iden-tifiable, are increasingly becoming reality, with related technologiesrapidly finding their way into everyday life. In order to achieve a sin-gle market for IoT and maximize the advantages that a safe and ad-vanced IoT would bring, policymakers, citizens and industry leaderstogether to collaborate.
The event facilitated debate among stakeholders on how both thepublic and private sectors need to work together to create an envi-ronment for increased innovation, investment and enconomicgrowth.
Under the tag line “Fact not Fiction: The future of eHealthis already here”, the EHTEL Symposium 2012 held in Brus-sels, brought together leaders within the health, telemat-ics and policymaking sectors.
Now that Telehealth is just as integrated in home care astelemedicine is in clinical routines, (e.g. for stroke) every-one in healthcare uses some digital communication. Yetwhile the tools are there, many conceptual, legal, organi-zational and educational challenges remain. Participantsjointly learned and debated about citizen-centric conceptslike the Coproduction of Health and the Digital HealthContinuum. At the same time, the Symposium outlinedthe strategies and tactics that stakeholders can use to facetoday's situation, and to do this in a way that is radicallydifferent from 2-3 years ago. The current fact is the old fic-tion.
Mobile Health (or mHealth) is a term that refers to the provision ofmedical services through the use of portable devices with the capa-bility to create, store, retrieve, and transmit data via mobile commu-nications
European project Movinglife presented and discussed the mHealthroadmap offering stakeholders an opportunity to voice their perspec-tives and opinions on the future deployment and widespread use ofmHealth.
The roadmaps addressed a broad group of fundamental issues suchas: technology options for applications and services; options for newand improved medical guidelines; user empowerment, acceptance,ethics and privacy; socio-economic environments and policy and reg-ulatory frameworks. The combined roadmaps will address a range offundamental issues that are related to the vision of massive deploy-ment and use of mHealth solutions to support lifestyle changes amongcitizens and improve disease management.
Medicine Meets Virtual RealityConference San Diego, California, USA / www.nextmed.comFebruary 21-23 2013,
INTERSTRESS members, Brenda K. Wiederhold (VRMI),Mark Wiederhold (VRMC) and Giuseppe Riva (Auxologi-co) chaired a half day symposium on Rehabilitation Tools/ Psychology & Technology at the MMVR conference 2013.The INTERSTRESS results were discussed.
The 20th anniversary of the MMVR Conference held Feb-ruary of this year in San Diego attracted 288 people fromaround the world.
Three plenary sessions with featured speakers exploredthe forefront of health and medicine, while oral andposter presentations detailed critical developments inthe field. Exhibits and demos provided tactile, one-on-one interaction, the Calit2 tour inspired visitors, andevening activities merged networking and fun.
The next conference MMVR21 will be held at Manhat-tan Beach, Los Angeles, California on February 20 - 22,2014. Mark your calender!!
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International Association of CyberPsychology, Training & Rehabilitation (iACToR)
Conference Participation Report 2012 / 2013
Individual Organization
Europe International Europe International
Online EUR 80 EUR 95 EUR 150 EUR 180
Print
Online EUR 40 EUR 65
C&R 6(1) June 27_Layout 1 6/27/13 12:25 PM Page 11
“The combined use of virtual reality (VR) and medication is an emerging techniquethat has been gaining public notice.”
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Virtual Reality andPharmaceuticals:Enhanced Synergy toImprove Clinical Care
By Mark D. Wiederhold & Brenda K. Wiederhold
The combined use of virtual reality (VR)and medication is an emerging techniquethat has been gaining public notice. Clin-ical psychologists and neuroscientistshave been studying this approach for thetreatment and/or management of vari-ous types of medical conditions. Theseinclude chronic pain management, anx-
iety relief, and trauma recovery. Somestudies have also shown the usefulnessof VR as a tool for information dissemi-nation and for the testing of new phar-maceutical products. Several pharmaceu-tical companies have used VR to educate
individuals about a mental health disor-der, patient’s perspective and state ofmind. These companies then taught par-ticipants how medication may help withalleviating symptoms.
Pain Management
In a study by Schmitt et al. (2011) on us-ing virtual reality exposure therapy (VRET)for analgesia/pain reduction in pediatricpatients who have to undergo physicaltherapy for burn injuries, they found thatthe patients responded positively to VRETfor pain reduction. The patients withVRET during physical therapy had report-ed significantly reduced pain sensationthan the control group (patients who werenot given VRET during physical therapy).Furthermore, both groups showed equiv-alent or comparable increase in range ofmotion, regardless of whether they weretreated with VRET or not. Thus, this showsthat VRET can be used in conjunctionwith physical therapy to relieve pain with-out any detriment to the patients’ phys-ical recovery. Another interesting point inthis study is that the level of analgesia ex-perienced by patients during physicaltherapy with VRET did not diminish over
time. Instead, the pain relief provided byVRET remained constant throughout theentire duration of the study.
Anxiety Relief
VRET has been used to manage anxietydisorders over the last two decades byproviding visual, auditory and kinesthet-ic stimulation. VRET places patients in acomputer-generated world where they"experience" the various stimuli relatedto their fear or phobia. Its effectivenessin the treatment of multiple anxiety dis-orders has been established in controlledstudies which have been replicated by re-searchers worldwide.
The benefits of pharmaceutical drugssuch as selective serotonin re-uptake in-hibitors (SSRIs), monoamine oxidase in-hibitors (MAOIs), beta-blockers, and oth-er anxiolytic medications for thetreatment of anxiety disorders have longbeen established. However, many recentstudies have shown the increased effec-tiveness of combining medication thera-py with cognitive behavioral therapy (in-cluding VRET) to teach the patient analternative way of managing his or her
COVER STORY
T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
“Studies have alsoshown the usefulnessof VR as a tool forinfromation dissemina-tion and for the testingof new pharmaceuticalproducts”
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symptoms while medication is reduced (orcompletely discontinued). Using VRET isideal for testing the effectiveness of themedication since it allows systematic stim-uli to be administered to the patient in acontrolled clinical setting.
Specific Phobias
In a study published in March 2011 in theProceedings of the National Academy ofSciences (PNAS), de Quervain et al. report-ed on combined VRET and hormonal ther-apy (cortisol) in treating acrophobia (fearof heights). The results indicated that cor-tisol enhanced the effects of the VRET. Thepatients who received cortisol together withVRET showed significantly greater reduc-tion in anxiety and fear compared to pa-tients who received placebo. The overallanxiety and fear reduction was seen bothright after the treatment (post-treatment)and at a follow-up assessment done afterone month of the procedure being con-ducted.
Patients undertaking treatment due to afear of driving or PTSD due to a motor ve-hicle accident have responded positivelyto VR treatments while on medication ther-apy. If patients become nauseous within90 to 120 seconds after the commence-ment of VR treatment, they are referred toa vestibular specialist to determine if thereis a vestibular abnormality. In many in-stances, patients who feel nauseous 90 to120 seconds after VR therapy starts do havevestibular abnormalities. If patients chooseto continue with the VR therapy sessions,they can opt to take anti-nausea drugs suchas dimenhydrinate (Dramamine) or on-dansetron (Zofran) prior to VR therapy with-out diminishing the therapeutic benefitsobtained from the treatment.
Other studies have also documented theuse of beta-blockers and anxiolytic drugsin conjunction with VRET as effective treat-ments/therapies for glossophobia (fear ofpublic speaking), aerophobia (fear of fly-ing), and claustrophobia (fear of closed ornarrow spaces).
Posttraumatic Stress Disorder (PTSD)
Apart from enhancing the effects of cer-
tain medications, the combined use of VRand pharmaceutical drugs has been uti-lized for the treatment of PTSD and so farhas shown no negative effects in the gen-eral well-being of the patients. Veterans ofthe Iraq and Afghanistan wars (sufferingfrom both PTSD and chronic pain) whowere undergoing VRET treatment while onmedication did not manifest any adversereactions after the use of VRET.
In one study, VRET was utilized to reducethe retrieval of aversive memories in PTSD.By administering adrenaline along with glu-cocorticoids, which enhance the formationof new memories for emotionally arousingevents, researchers were able to impair thememory retrieval processes. This seems tobe effective in the reduction of excessiveretrieval of traumatic/aversive memories,and consequently in the reduction of there-experiencing or reliving of traumaticmemories.
In another Virtual Reality Medical Center(VRMC) study conducted at Balboa NavalHospital and Camp Pendleton (both in CA,USA), the VRET for PTSD symptoms provedsuccessful in 80% of participants. Many ofthe individuals treated with VRET requiredmedication in addition to therapy, but themedication did not diminish their abilityto fully engage in and receive therapeuticbenefits from VRET.
Eating Disorders and Obesity
In a preliminary study conducted by Rivaet al. (2001), the researchers assessed thefeasibility of using VR for the treatment ofbody image issues of obese patients andfound that patients who were treated us-ing VR showed better body satisfaction andmotivation for change than patients whowere treated with the cognitive-behavior
approach. While this study spanned only ashort period of time, the promising resultscan be explored further to improve and de-velop VR treatments for the psychologicaland mental state of obese patients who aretrying to become more fit and lose weight.
The FDA has recently approved several newdrugs to combat obesity and eating disor-ders. Many studies have shown that weightloss medication when combined with cog-nitive behavioral therapy-based interven-tions dramatically improves adherence andsuccess. Virtual environments offer an en-hanced venue for the delivery for CBT-basedprotocols and may prove extremely usefulwhen combined with these new pharma-cological agents.
Test bed for New Medications and MedicalTechnologies
VR can also be used to test the effects ofcertain medications prior to release. Thisnascent field is on the rise for increasingthe efficacy of combined treatment. UsingVR, the precise stimulus is isolated. It is rel-atively simple to add physiological moni-toring and analyze the patient’s objectiveresponse as well as asking for their subjec-tive ratings. This technique is a perfect testbed for observing patients’ emotional andphysical state. With the addition of fMRItechnology, we can see the precise effectmedication is having on an individual whilenavigating a stressful, relaxing, or rehabili-tating environment, which will help to bet-ter tailor drug delivery and allow for moreindividualized care.
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COVER STORY
T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
“Apart from enhancing the effects of certain medications, the combined use of VR and pharma-ceutical drugs has been utilized for the treatment ofPTSD and so far has shown no negative effects inthe general well-being of the patients.”
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COVER STORY
Cognitive Effects of Medications Alreadyon the Market
Another use of VR is to test the possibleside effects of medications which have al-ready been released on the market. Whilemanufacturers and physicians generallyadvise patients to avoid certain activities(e.g. driving) while taking specific medica-tions, the actual side effects of these med-ications have not been tested on humans.VR allows testing of these drugs’ effects ina safe and controlled clinical setting.
In recent years, there has been a height-ened interest among researchers and cli-nicians in using VR technology to addressadditional driving-related issues. One studyled by R. Mager evaluated a driving simu-lator using a motorway test-track to inves-tigate the impact of a single oral dose ofthe SSRI sertraline on various cognitivefunctions related to driving tasks and ob-jective driving performance. Resultsshowed no evidence of drug-induced im-pairment of drivability in the simulator.
Another study examined 37 adults withType I diabetes and their ability to drivein VR driving simulation tests. Researchersmanipulated participants’ blood glucoselevels by giving them an intravenous in-
sulin solution containing various amountsof sugar. At all three ranges of hypo-glycemia, driving performance was foundto be significantly impaired. Participantswere more likely to swerve, brake inappro-priately, and speed up in comparison towhen their glucose levels were within nor-mal limits. Even more surprising, less than1/4 of the participants realized that their
driving was impaired, while only 1/3 tookcorrective action by drinking soda or stop-ping driving, and most did not do so un-til their glucose levels were below 50mg/dL. Non-invasive sensors were used tomeasure the patients’ blood glucose lev-els accurately during the task. By provid-ing precise stimuli and measuring the par-ticipants’ reactions, more definitive resultsof the effect of medications were ascer-tained.
In another study, researchers at VRMC inSan Diego enlisted 24 participants to com-pare the effects of three antihistamines:fexofenadine, loratadine, and cetirizine. Atthe beginning of each session, participantswere given either one of the antihista-mines or a sugar pill (placebo) to drink. Af-ter one hour (the time needed for themedications to take effect), the partici-pants carried out a VR test of tracking abil-ity while their heart rates and breathingpatterns were monitored. They were thenasked to fill out questionnaires rating theirmood and sleepiness. After data gather-ing and analysis, the results showed thatloratadine and/or fexofenadine affect driv-ers’ moods and cognition less than ceti-rizine, making loratadine or fexofenadinebetter choices for drivers who need to takeantihistamines.
Educating and Providing Insights on Pa-tient Conditions
A recent demonstration sponsored by Or-tho Biotech Inc., utilized VR to make physi-cians feel what patients suffering from fa-tigue caused by cancer-related anemia felt.They named the simulator Insight to Can-
cer-related Anemia (ICRA). ICRA helpedphysicians really understand their patientsby simulating a home with foot and handcontrols which are designed to mimicand/or induce the fatigue felt by patientsundergoing chemotherapy. Of course, thisevent was also used by the sponsoringpharmaceutical company to inform physi-cians that medications are available forchemotherapy-related anemia. Aside fromthat, this VR simulation did seem to helpin educating physicians because 60% ofthem, after experiencing ICRA, said thatit changed the way they would view andtreat patients suffering from side effectsof ongoing chemotherapy.
Virtual reality has so far shown a lot ofpromise in providing and/or supplement-ing medical treatment for patients. Notonly that, it also helps physicians under-stand their patients by using VR to simu-late patients’ conditions and/or side ef-fects from medical treatments. Indeed, VRis a very promising tool that can help inthe treatment, maintenance, and improve-ment of healthcare.
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[ ]Mark D. Wiederhold, M.D.,Ph.D., FACPVirtual Reality Medical CenterSan Diego, [email protected]
Brenda K. Wiederhold, Ph.D.,MBA, BCIAVirtual Reality Medical InstituteBrussels, [email protected]
“Virtual Reality is a verypromising tool that can help in the treat-ment, maintenance, and improvement ofhealthcare.”
“While manufacturers and physicians generallyadvise patients to avoid certain activities (e.g.driving) while taking specific medications, theactual side effects of these medications have notbeen tested on humans. VR allows testing ofthese drugs’ effects in a safe and controlled clinical setting.”
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A sugar pill can regrow hair in a study onbaldness; sham knee surgery can reducepain comparably to real surgery. DuringWorld War II, a nurse injected a woundedsoldier with salt water after heavy casual-ties depleted morphine supplies, givingthe soldier enough pain relief to make itthrough surgery. The placebo effect de-scribes this remarkable phenomenon thatapplying a treatment, any treatment, islikely to produce the desired results inmedicine.
To test whether a given medication is su-perior to merely giving out optimism, dis-guised as a sugar pill, during drug trialspatients often must either be divided intotwo treatment groups, or tested twice,once on active medicine and once whengiven placebo medications. Although theplacebo effect has known psychologicalcorrelates that make some people reactmore strongly than others, measuring theplacebo effect without actually applyinga placebo treatment has not previouslybeen possible.
Recognizing this, Ariana Anderson andMark Cohen from UCLA at the Laborato-ry of Integrative Neuroscience in the de-partment of Psychiatry have developed a
method of isolating and measuring theplacebo effect in the brain using function-
al MRI. If the placebo has a consistentfootprint its change can be measured dur-ing a trial. More significant “placebo” ac-tivations in the brain correspond to high-er levels of the placebo effect within apatient. This means that the placebo ef-
fect can be quantified indirectly in peo-ple receiving a treatment, opening the
possibility that drug trials may be run withonly half the patients currently needed.With per-drug bench-to-bedside costsmeasured in the hundreds of millions ofdollars, the savings could be dramatic.“Orphan drugs” are those developed for
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It’s All in Your Head:Measuring the PlaceboEffect Using fMRI“During World War II, a nurse injected a wounded soldier with salt water ... giv-ing the soldier enough pain relief to make it through surgery ... this remarkablephenomenon that applying a treatment, any treatment, is likely to produce thedesired results ... the placebo effect ...”
By Ariana Anderson
Figure 1: Measuring the placebo effect using neuroimaging would lead to signifi-cantly lower costs in drug development.
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rare diseases. Typical drug trials requirelarge numbers of patients to establish
significance. When diseases affect only afew thousand patients, problems in re-cruiting enough subjects can make ade-quate tests impractical. This, combinedwith the problems of cost, often meansthat potentially effective treatments areabandoned. When patients can serve astheir own “matched control” however,the effect of the drug could be measuredwithin a patient while adjusting for theplacebo effect. Moreover it often is con-sidered unethical to assign a patient whohas a terminal disease to a placebo. Us-ing medical imaging to measure theplacebo effect could promote drug de-velopment for such patient groups withrare, yet lethal, disorders.
This new technology harnesses mathe-matical and statistical methods to learnwhat networks are activated in the brainafter a patient receives either an activeor sham medication, but not before. Byisolating these patterns, changes in this
brain activity can be measured before,during, and after treatment, yielding ameasure of how strongly the placebo isexpected to act in a person, allowing theplacebo effects to be removed from theanalysis. Simulated trial results haveshown up to 40% reduction in patient re-cruitment necessary for drug trials, lead-ing to more efficient and less costly drugdevelopment in the future.
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[ ]Ariana Anderson Ph.D.The Semel Institute UCLALos Angeles, CA
T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
D-Cycloserine Augmentation ofCognitive-Behavioral Therapyfor Anxiety Disorders“In Studies using IVET protocols, DCS has demonstrated efficacy for social anxi-ety disorder, but has yielded mixed results for obsessive compulsive disorder,panic disorder with agoraphobia, and posttraumatic stress disorder.”
Exposure-based interventions are the mosteffective treatments for anxiety disorders;however, their acceptability in the generalpopulation is limited. New translational ap-proaches inspired by basic research in the bi-ological mechanisms of animal extinctionlearning have the potential to increase theefficacy and speed of exposure therapy.
One example of a pharmacological agent withgreat potential is D-Cycloserine (DCS) a par-tial agonist of the N-Methyl-D-Aspartate(NMDA) receptors with demonstrated en-hancement of extinction learning consolida-tion. In this article, we discuss the relevanceof DCS as an enhancer of cognitive-behav-ioral therapy for anxiety disorders, focusingon: pharmacological characterization of DCS,
documented efficacy of DCS for anxiety dis-orders treatment and a brief description ofongoing DCS studies from our group.
Characterization of D-CycloserineDCS was approved by the Food and Drug Ad-ministration in 1965 as a broad spectrum oralantibiotic for tuberculosis. Standard dosesrange from 250-500 mg and some patients
By Cristian Sirbu et al.
“the placebo effect can be quanti-fied indirectly in people receiving atreatment, opening the possibilitythat drug trials may be run withhalf the current patients” ”
“Although the placeboeffect has known psy-chological correlatesthat make some peo-ple react more strong-ly than others, meas-uring the placeboeffect without actuallyapplying a placebotreatment has notpreviously been possi-ble.”
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T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
can reach doses of 1g per day. Adverse sideeffects have been documented with dosesof 1g per day and include headache, psy-chosis, seizures, or somnolence. The maincontraindications are alcohol use, renal fail-ure, epilepsy (increased risk of seizures), orpregnancy. In addition to its use as an an-tituberculotic agent, DCS has been evalu-
ated as a medication for schizophrenia andAlzheimer’s dementia, but with low effica-cy. Pharmacokinetic studies of DCS indicatethat after a single oral dose of 50 mg, thepeak plasma level measured 1-2 hours af-ter administration is 3.7 +1.2 mg/dl, withan estimated 2.9 + 0.96 mg/dl peak cere-brospinal fluid level (80% of the peak plas-ma level).
Efficacy of D-Cycloserine augmentation ofexposure therapy for anxiety disordersIn studies of exposure therapy augmenta-tion, DCS is used at low isolated doses of50-500mg either before or shortly after theexposure therapy session. In most studies,DCS is used in association with In Vivo Ex-posure Therapy (IVET); however, few stud-ies explored the use of Virtual Reality Expo-sure Therapy (VRET) (see below).Virtual Reality Exposure Therapy (VRET)has documented efficacy in the treatmentof specific phobias (acrophobia, flying pho-bia, claustrophobia, driving phobia, arachno-phobia), panic disorder with agoraphobia,social anxiety disorder, and posttraumaticstress disorder.
The mechanisms of exposure therapy in IVand VR involve activation of different phys-iological systems. Thus, IVET produceschanges in heart rate and skin conductance(involving both behavioral activation andinhibition systems) while VRET produces
changes in skin conductance (involving onlythe behavioral inhibition system); there-fore, an important question is what effectdoes DCS have on IVET versus VRET? Instudies to date, DCS was used exclusivelyas an enhancer of either IVET or VRET. Instudies using IVET protocols, DCS hasdemonstrated efficacy for social anxiety dis-order, but has yielded mixed results for ob-sessive-compulsive disorder, panic disorderwith agoraphobia, and posttraumatic stressdisorder.
Surprisingly, the number of studies investi-gating the association of DCS and VRET arelimited. In two published studies, DCS wasused in association with VRET for acropho-bia. Ressler et al., administered 50 mg DCS,500 mg DCS, or placebo two to four hoursbefore two sessions of 30-minute VRET, anddemonstrated higher reduction in acropho-
bic symptoms at one week and threemonths post treatment for DCS conditionscompared with placebo. No difference wasnoted between 50 and 500 mg DCS. In arecent study in acrophobics, Tart et al. useda similar protocol; however, 50 mg DCS wasadministered immediately after the two 30-minute sessions of VRET. No difference wasnoted between the DCS and placebogroups; however, a reanalysis of the data in-dicated that DCS was superior to placeboonly for patients who experienced a suc-cessful exposure session. Contributions from our group
In the past few years, our research on DCShas been focused on two main areas: (1)physicochemical characterization of DCSfor anxiety disorders, and (2) investigationof DCS efficacy in acrophobia and dentalphobia.
1) Physicochemical characterization ofDCS for anxiety disorders
We conducted extensive studies regard-ing stability and characterization of DCSreformulation. Most studies using DCSfor anxiety disorders use 50 mg DCS cap-sules. Those are reformulated from the250 mg Seromycin® capsules. Questionsregarding stability as well as potentialconversion of D-Cycloserine into L-Cy-closerine are important when DCS is re-formulated. Research in our lab hasdemonstrated good stability as well as alack of conversion to L-Cycloserine duringthe reformulation of the 250 mg DCScapsules to 50 mg strength. Further, wehave demonstrated that the DCS under-goes significant degradation at acidic pH.This brings an important question aboutthe amount of DCS reaching the brain,especially at the low doses (50 mg) usedin the treatment of anxiety disorders, con-
sidering degradation at the acidic pH inthe stomach. This issue has stimulatedour interest in identifying new deliverymethods (transdermal and nasal) forDCS.
2) DCS efficacy in acrophobia and dentalphobia.
In one of our current studies, we are com-paring the efficacy of 50 mg DCS to place-bo in acrophobics. The drugs are adminis-tered 30 minutes before a three-hour,one-session treatment with either IVET orVRET. This design will allow the first com-parison of the effect of DCS on IVET versusVRET using self-report, clinical interview, aBehavioral Avoidance Task, and physiolog-ical outcomes (heart rate variability and skinconductance). To date, no side effects havebeen noted in our participants (either place-bo or DCS); data collection is ongoing andno comparison is possible yet since the tri-al is double blinded.
“ The mechanisms of exposure therapy in IV andVR involve activation of different physiological sys-tems .... IVET produces changes in heart rate andskin conductance while VRET produces changes inskin conductance.”
“ DCS has also beenevaluated as a medica-tion for schizophreniaand Alzheimer’sdementia”
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In a second study, we are investigating theefficacy of 50 mg DCS for reducing anxietyduring dental visits and dental avoidance inpatients with dental phobia. DCS is admin-istered immediately prior to two dental vis-its. This ongoing study will provide the firstdemonstration of DCS efficacy in the con-text of a naturalistic exposure conducted inthe dental office by dental professionals (hy-
gienists). Additionally, DNA and RNA analy-sis of blood cells collected at baseline, aftereach treatment session, and at one week fol-low-up will allow investigation of the mod-erating effects of genetic polymorphism on
DCS efficacy, as well as gene expression pro-files, associated with this treatment. In summary, DCS augmentation representsa significant avenue for optimizing the ex-isting exposure therapy protocols for anxi-ety disorders, reducing the duration as wellas the number of sessions. Studies focusingon new clinical conditions (i.e. dental pho-bia) as well as the combination of VRET and
DCS are important and delineation of clin-ical parameters of DCS use in both IVER andVRET are critical steps in understanding theoptimal use of this promising pharmacolog-ical agent.
Cristian Sirbu, Ph.D.Charleston Area Medical CenterHealth Education and ResearchInstituteWest Virginia University Schoolof Medicine Charleston Division Department of Behavioral Medi-cine and Psychiatry
Patrick Kerr, Ph.D.West Virginia University Schoolof Medicine Charleston Division
Daniel W. McNeil, Ph.D.West Virginia University
Andrew W. Goddard, M.D.Indiana University School of Med-icine[ ]
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“DCS augmentation represents a significant avenuefor optimizing the existing exposure therapy proto-cols for anxiety disorders, reducing the duration aswell as the number of sessions.”
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T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
Can you Enhance VirtualReality Exposure TherapyOutcome by addingPharmaceutical Agents?
“a patient recieves a pill during exposure therapy sessions tostimulate their brains, making successful confrontation with
their possible fears.”
Imagine a therapy that is always successful andwould hardly take any time. Instead of goingto therapy once a week for months, your treat-ment would be completed in several weeksand you would be yourself, without your lim-iting fears. Recent research suggests an ap-proach to more successful therapy outcomes.The idea is to find out whether or not it is pos-sible to enhance therapy outcomes by givingpatients a pill during exposure therapy, thushelping patients overcome anxiety during treat-ment. In turn this makes therapy more effi-cient in the long run. This idea is based on alearning paradigm wherein it is assumed thata learning process takes place during exposure.
This paradigm concerns the enhancement ofemotional learning by administering a cogni-tive enhancer as adjunct to (virtual reality) ex-posure therapy. This means that a patient re-ceives a pill during exposure therapy sessionsto stimulate their brains, making successfulconfrontation with their fears possible. Theidea is to augment the emotional learningprocess during therapy by stimulating the no-radrenergic system, which is involved in theprocess of emotional learning. One such cog-
nitive enhancer is Yohimbine hydrochloride(YOH). While a number of experimental labstudies find positive effects of cognitive en-hancers, results of intervention research withpatients suffering from anxiety disorders havebeen less consistent. In a randomized con-trolled trial, Powers et al (2009). had claustro-
phobic participants undergoing exposure invivo in combination with YOH or a non-activeplacebo. The YOH group showed significantlybetter results on anxiety improvement thanthe placebo group. This indicated that admin-istering a pill during exposure therapy mightindeed improve the therapy outcome. A more
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[ ]
recent study consisted of participants witha fear of flying. They were treated with vir-tual reality exposure therapy and no addi-tional benefits of YOH were demonstrated.Patients received four sessions of virtual re-ality exposure therapy for fear of flying, con-sisting of two virtual flights in each expo-sure session. Compared with patients whoreceived the same therapy but a non-activeplacebo pill, patients who received YOH didnot show better therapy outcomes. This wascontrary to the expectation as the dosagewas almost the same from another study.One possible alternative explanation would
be that the effects of a cognitive enhanceras YOH are so small that the powerful in-strument of exposure has overruled them.
Results of research into cognitive enhancershave yielded diverse results. Generally wecan say that the success of such pharmaco-logical agents is based on the interactionwith the mechanism of the psychological
intervention (Vervliet, 2008). But as suggest-ed by Powers et al (2009), the attribution ofan additional medication to exposure ther-
apy can play a crucial role. Therefore it is im-portant to take into account the attributionof the patients themselves.
To sum up, there has been extensive re-search into the learning paradigm with cog-nitive enhancers which has been used withnon-anxious participants. In clinical researchthis does not provide us with sufficient in-
formation about the disorder and its treat-ment possibilities. One important instru-ment for translating this research in the fu-ture is virtual reality exposure therapy. It canprovide an excellent research environmentto further investigate treatment mechanismsand theoretical paradigms. Extensive anddetailed standardization within this treat-ment can provide us with valuable informa-tion about therapeutical processes and itsimplications in clinical populations.
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T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
Katharina Meyerbröker, Ph.D.University of AmserdamDepartment of Clinical PsychologyNetherlands
Figure 2: Patient undergoing Exposure Therapy monitored in the resaech environment.
“One important instru-ment for translating thisresearch in the future isvirtual reality exposuretherapy.”
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Since its inception in 1997, the Virtual Reality Analge-sia Program at the University of Washington (Seattle,WA) has sought to explore and understand the mech-anisms, efficacy, safety and cost-effectiveness of virtu-al reality (VR) applications to the vexing and unsolvedproblem of clinical pain. This commitment to explor-ing nonpharmacologic approaches to pain manage-ment is important because pharmacologic pain med-ications (e.g., opioids/narcotics) alone often fail to controlthe intense acute pain patients experience after injury,after surgery, or during medical procedures. Further-more, such analgesic medications all produce dose-re-lated side effects that limit the quantity of drug thatcan safely be administered – the result often being in-complete pain relief and other discomfort (e.g., nau-sea). Lastly, repeated episodes of excessive pain andthe regular use of large doses of opioid analgesics canhave serious long-term consequences, including in-creased risk of chronic pain and opioid dependence.Our program focuses on VR analgesia applications inclinical pain settings such as medical procedure-asso-ciated pain (e.g., wound care and rehabilitative physi-cal therapy in patients with cutaneous burn injuries[Figure 1]), with a complementary laboratory researchcomponent whose two goals are to better understandthe analgesic mechanisms of VR applications and tooptimize their clinical use. Funding support for theprogram includes awards from the US National Insti-tutes of Health, the Paul G. Allen Family Foundation,the International Anesthesia Research Foundation, theScan-Design Inger/Jens Brun Foundation, and the Gus-tavus/Louise Pfeiffer Research Foundation.The most carefully studied analgesic approach to dateis “VR distraction” – an approach based on the prem-
“By immersing patients in an attention-grabbing, computer-generated, interac-tive virtual world that blocks the sights and sounds of the immediate medicalcare environment, their attention is pulled away from the concurrent painfulstimulus of their injury or a therapeutic medical procedure, resulting in significantly reduced pain experience.”
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T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
FEATURES
Modulating the Pain Experience with Virtual Reality Distraction
By Sam Sharar et al.
Figure 1: Burn-injured patient experiencing immersive virtual reality dis-traction while undergoing wound cleaning partially submerged ina hydrotank. (copyright Hunter Hoffman, University of Washing-ton)
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[ ]T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
ise that the human pain experience re-quires conscious attention toward a painfulstimulus (nociception). By immersing pa-tients in an attention-grabbing, comput-er-generated, interactive virtual world thatblocks the sights and sounds of the im-mediate medical care environment, theirattention is pulled away from the concur-rent painful stimulus of their injury or atherapeutic medical procedure, resultingin significantly reduced pain experience.Our group created an interactive virtualenvironment specifically for this purpose
(SnowWorld® [Figure 2]), and publishedthe first report of VR distraction analgesiain Pain in 2000. Subsequently we have re-ported clinical success with VR distractionanalgesia in various clinical pain settingsincluding patients with cutaneous burninjuries, dental pain, urologic surgery, andpost-operative rehabilitation. Since 2007,our investigations have resulted in 38 peer-reviewed publications in scientific jour-nals, six textbook chapters and review ar-ticles, and one book, as well ascollaborations for both clinical and re-search applications in civilian and militarypatient populations in ten centers in theUS, Europe and the Middle East. Recent-ly we have reported the first successful useof VR technology to facilitate hypnoticanalgesia – inducing a hypnotic state anddelivering hypnotic suggestions for re-duced pain, improved function, and im-proved sleep – in patients with ongoingclinical pain following traumatic injuries.
Complementary laboratory studies allowVR analgesia techniques to be studied in
a controlled setting in healthy volunteersexposed to carefully regulated experimen-tal pain. To better understand the neuro-biology of pain and analgesia, we employtechnically advanced outcome-assessmenttools – for example, functional MRI im-aging of pain-related brain activity and con-nectivity – and novel combinations oftherapies (e.g., VR distraction combinedwith pharmacologic opioid receptor block-ade) that are often not possible to studyin the clinical setting. These investigationsfill gaps in our knowledge of how new VRanalgesic techniques work, and enabletheir exploration and refinement beforethey are introduced to actual clinical care.As a result of such laboratory studies, wehave demonstrated that VR distractionproduces similar reductions in both sub-jective pain reports and pain-related brainactivity as intravenous opioid analgesics.
These studies have also helped identifythe VR hardware and software compo-nents most essential to the user’s senseof presence in the virtual world, and hencethe analgesic success of VR distraction.
Current efforts are exploring the relativeroles of various central pain pathways andneurotransmitter systems, as well as theeffect of user age (e.g., adolescent com-pared to older adults) on VR distractionanalgesia.
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“VR distraction producessimilar reductions inboth subjective painreports and pain-relatedbrain activity as intravenous opioid analgesics”
Figure 2: Screenshot image of the user’s view ofSnowWorld® during immersive virtual reali-ty distraction. Virtual world designed/de-veloped by Hunter Hoffman and David Pat-terson, with software created by FirsthandTechnologies. (copyright Hunter Hoffman,University of Washington)
“we have replorted clini-cal success with VR dis-traction analgesia inpatients with cutaneousburn injuries, dentalpain, urologic surgery,and post-operative rehabilitation.”
Sam R.Sharar, M.D.Harborview Medical CenterDepartment of AnesthesiologySeattle, WAUSA
Hunter G. Hoffman Ph.D.University of WashingtonDavid R. Patterson Ph.D.Harborview Medical Center
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Glucocorticoids Enhance Extinction-based Psychotherapy in Virtual
Reality
Exposure therapy is a state-of-the arttreatment approach for anxiety disorderswith a high success rate. During exposuretherapy, a patient exposes himself sys-tematically to the feared object (e.g. adog) or situation (e.g. a height situation)within a therapeutic context. Apart fromconventional approaches to anxiety dis-order treatment, exposure to real objectsor situations (in-vivo exposure) and men-tal exposure to imagined objects or situ-ations (in-sensu exposure), in virtual re-ality (VR) exposure has become a thirdvaluable variant.
During VR exposure patients are ex-posed to virtual environments, whichcan include any feared stimuli or dis-play any scenario. This approach ben-efits the treatment of patients whosefeared situations are conventionallydifficult to recreate under tradition-al therapeutic conditions.
Despite successes in exposure-basedtreatment approaches, there is stillroom for improvement and a needfor continuous research. Recently, re-searchers in the field have started totranslate neuroscientific findings intonew clinical applications. However, be-fore these approaches can be appliedin daily clinical routine, they have tobe systematically tested in pre-clinicaland clinical studies. Beyond the men-tioned clinical benefit of VR exposure,the VR technique has certain featuresthat make VR ideal for this kind of re-search.
For example, the therapist has the oppor-tunity to expose every patient in an iden-tical, uniform manner within the samesituations as often as needed; which is essential for the standardization of exper-imental protocols as needed in pre-clin-ical and clinical studies. Additionally, thetherapist has better possibilities to con-trol unpredicted events that can occur inreal environments (e.g. other fearful peo-ple) and is able to control the intensity ofexposure better. Therefore, we decided to use the VR tech-
nique in our study. We investigated if thecombination of exposure with cortisol ad-ministration, a steroid hormone natural-ly produced in the human body duringstress, would be beneficial for the treat-ment of patients with height phobia. For
our study we created a semi-structuredexposure regime that was adapted to thesubjective fear of each participant dur-ing each exposure session. Patients withheight phobia were exposed in a virtualheight environment. Half of the partici-pants had taken cortisol before exposure,and the other half a placebo. Our resultsshowed that all patients profited from theVR exposure, but the group that receivedthe combination of cortisol with VR ex-posure had a higher treatment success.Our study not only indicates that corti-
sol has the potential to augment theefficacy of exposure therapy, but alsoshows that the emergence of newtechnologies such as VR is in favorto develop new treatment approach-es.
“All patients profited from the VR Exposure, but the group thatreceived the combination of cortisol with VR exposure had a high-er treatment success.”
By Dorothee Bentz et al.
Dorothee Bentz Ph.DMt. Sinai School of MedicineNew York, NYDominique de Quervain Ph.D.Olivia C. Bolt Ph.DUniversity of BaselFrank H. Wilhelm Ph.D.University of SalzburgTanja Michael Ph.D.Universitat des SaarlandesBrenda K. Wiederhold Ph.D., MBA,BCIAVirtual Reality Medical InstituteJurgen Margraf Ph.D.Ruhr-Universitat Bochum
Figure 1: Virtual Reality environment for height simulation [ ]
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From the beginning of the 21st century,many authors have analysed and pub-lished reports on the benefits of apply-ing virtual reality to medicine within clin-ical procedures. Whether it is fortraumatic head injuries, burn wound care,lumbar punctures, or during chemother-apy treatment for children, virtual reali-ty has many applications. The first pub-lished case report relating to the use ofvirtual reality within an invasive medical
procedure was in 2004 by our group, be-ginning with upper gastrointestinal en-doscopies and so on, until the introduc-tion of virtual reality (VR) in apostoperative care unit of cardiac surgery.The end goal of this project is to demon-strate that virtual reality is a complemen-tary tool to reduce pain and anxiety inhospitals during medical procedures in-cluding surgical procedures.
There are many reasons and justificationsto use VR in hospitals. In Neonatology (0-28 days old) there are newborns who canstay in care units for days, weeks and evenmonths, growing without contact fromthe outside world apart from a few hoursa day where parents can visit their chil-dren. The psychological impact in growthand development during childhood is in-credibly strong; this is where neurostim-ulation in a closed environment is a use-ful alternative. In infants, virtual realityhas been a good resource to reduce painand anxiety in oncology. Hunter Hoffmanhas also demonstrated the benefits of us-ing virtual reality during medical rehabil-itation for child burn victims. It can alsobe applied for postoperative cardiac sur-gery patients whose rehabilitation con-sists of mainly staying in bed under seda-tives and other treatments. Theapplication of VR not only helps psycho-logically, due to their severely limitedmovement, but also helps improvebreathing. In ambulatory surgery too, vir-
Cybertherapy in Medicine - Clinical Applications to Reduce
Pain and Anxiety“Whether it is for traumatic head injuries, burn wound care, lumbar punctures or during chemotherapy treatment for children,virtual reality has many applications.”
FEATURES
T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
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By José Luis Mosso Vázques et al.
Figure 1: Care Unit of Cardiac Surgery
“...to demonstrate thatvirtual reality is a com-plementary tool toreduce pain and anxietyin hospitals durin med-ical procedures...”
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tual reality cannot only help reduce painand anxiety for the patients during the op-eration, but also during their recovery. Thereare, of course, many more areas of medi-cine where virtual reality can be applied;gynecology and obstetrics, gastrointestinalendoscopy, pediatrics and epidural andspinal block anesthesia.
While all patients were affiliated with Insti-tuto Mexicano del Seguro Social (IMSS) andInstituto de Seguridad y Servicios Socialespara los Trabajadores del Estado (ISSSTE),the subjects were of different gender andage, and were mostly undergoing different
types of medical procedures. Despite this,the techniques used in order to measurethe success of the application of virtual re-ality to patients remained the same. Thenecessary virtual reality equipment wouldbe mounted which was followed by a nursemeasuring blood pressure, heart rate andbreath rate before, during and after the pro-cedure. Next, the physicians would ask theirpatients on a scale of 0-10 whether or notthey were feeling anxiety or pain which
would occur multiple times during a pro-cedure.
The strongest re-sults were seen inthe three main rep-resentative groupswhere pain andanxiety were high-est; colposcopy, am-bulatory surgeryand postoperativecare unit of cardiacsurgery. While thecomparative meas-ure of pain wasmade before, dur-ing and after eachprocedure, the sta-tistical method tomeasure pain wasused with a scale of0-10 (zero is nopain and 10 is ahigh level of pain).In the colposcopygroup that used VR, the mean pain beforethe procedure was 7.5 and 5.35 during. Af-terwards, the difference was of 2.15, corre-sponding to a 28,66% in the reduction ofpain. In the colposcopy group that didn’tuse VR, the mean pain before was 6.43 be-fore and 6.78 during which is a differenceof 0.35, an increase of pain of 5.44% Inpostoperative cardiac surgery patients, areduction of pain and anxiety by 54.5% wasseen, despite the mean pain at the begin-ning of the procedure being 8. Despite thelower mean, 5.57, of pain for the surgicalgroup who did not use virtual reality, a re-duction of pain and anxiety at the end ofthe procedure was only 36.80%. With theseresults we can appreciate the impact thedistraction of virtual reality provides thepatient in order to reduce anxiety and sub-sequently, visceral and somatic pains thatregional anesthesia can induce.
While results varied depending on age, gen-der, procedures, culture, diagnosis and prog-nosis, all in all the data showed that the re-duction of pain and anxiety, the latter inparticular, was prominent (the variancewithin these groups is due to the two dif-ferent pathways with which pain is trans-ferred; somatic and visceral, as well as thepatient's psyche). Patients between the agesof 5-14 were found to enjoy virtual scenar-ios more than any other; older patientsmainly demonstrating curiosity for the new
technology at hand. The main benefit ofapplying virtual reality is that, due to thereduction of pain and anxiety and its non-invasive method, it allows for reduction ofmedication, bed days and, especially, an in-crease in the wellbeing of patients.
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29
Figure 2: Woman using VR in the Labor Room
“While results varieddepending on age, gen-der, procedures, culture,diagnosis and prognosis,all in all the datashowed that the reduc-tion of pain and anxiety,the latter in particularwas prominent.”
[ ]José Luis Mosso Vázques, M.D. School of MedicineUniversidad PanamericanaMexico
Jean-Baptiste GolsongVirtual Reality Medical Institute
Mark D. Wiederhold, M.D., Ph.D.,FACPVirtual Reality Medical Center
“The main benefit of applying virtual reality isthat, due to the reduction of painand anxiety andits non-invasive method, it allows for reduction inmedication, bed days and, especially, an increasein the well-being of patients.”
T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
C&R 6(1) June 27_Layout 1 6/27/13 12:26 PM Page 31
VR THERAPY IT COULD ENHANCE
- VR public speaking
- VR combat training
-VR driving
-VR combat training
-PTSD[prevention]
-Any phobia that can be treated with
VR exposure therapy
-Any phobia that can be treated with
VR exposure therapy
-VR driving
-VR combat training
-VR public speaking
-VR combat training
-Any phobia that can be treated with
VR exposure therapy
-Any phobia that can be treated with
VR exposure therapy
-VR public speaking
-VR combat training
-Any phobia that can be treated with
VR exposure therapy
-VR public speaking
-VR combat training
-VR combat training
-VR with PTSD
-Any phobia that can be treated with
VR exposure therapy
-VR with PTSD
-VR driving
-VR combat training
-VR with PTSD
-Any phobia that can be treated with
VR exposure therapy
DRUG
Adderall
Amphetamines
Cannabinoid CB1 receptor antagonist AM
-251 (at a dose of 1.0mg/kg or higher)
Cortisone/Cortisol
D-cycloserine (DCS)
Dextroamphetamine (D-amphetamine /
Dexedrine)
Donepezil (Aricept)
Dopamine D2-like receptor antagonist
sulpiride
Endogenous Cannabinoid (eCB) break-
down and reuptake inhibitor AM404
and other eCB modulators
Ephedra/ephedrine
L-type voltage-gated calcium channel
agonist BayK8644
Methylphenidate (Ritalin)
Modafinil (Provigil)
Propranolol Hydrochloride
Protein synthesis inhibitor anisomycin
(ANISO) injections [under research,
tested only in animals]
Sertraline (Zoloft)
Transcription factor cAMP-response-
element-binding protein (CREB) in-
hibitors [still in research]
Yohimbine
HOW IT COULD HELP
Increases concentration on outside tasks, where it
reduces self-awareness, and combat training.
Enhance motor skills needed to learn how to drive and
for combat training.
May be useful in the control of nightmares and night
terrors
Decreases fear as the user undergoes exposure
therapy
Decreases fear as the user undergoes exposure therapy
Can enhance moter skills needed to learn how to drive,
increase concentration for combat training / other
outside tasks.
Abiltiy to boost learning for combat training
Decreases fear as the user undergoes exposure therapy
Decreases fear as the user undergoes exposure therapy
Increases concentration on outside tasks, where it
reduces self-awareness, and combat training
Decreases fear as the user undergoes exposure therapy
Increase ability for concentration on an outside task
that is needed in combat training
Increases alertness for combat training
Decreases fear on past negative memories
Decreases fear as the user undergoes exposure therapy
and decreases past negative memories
Improves reaction time and alertness, which are useful
skills for driving and combat training
Decreases fear on past negative memories
Decreases fear as the user undergoes exposure therapy
Editor-in-Chief Brenda K. Wiederhold, PhD, MBA, BCIA
Impact Factor: 1.591* 2009 Journal Citation Reports® published by Thomson Reuters, 2010
Frequency: Monthly
Legacy Content
ISSN Online ISSN
In-depth Coverage of the Psychology of Internet,Multimedia, and Social Networking on Behavior and Society
SUBSCRIBE TODAY
www.liebertpub.com
www.liebertpub.com/cyber
Key Benefi ts
Global Visibility and Reach:
The Experts Say“Cyberpsychology, Behavior, and Social Networking
—Paul M.G. Emmelkamp, Academy ProfessorRoyal Netherlands Academy of Arts and Sciences
C&R 6(1) June 27_Layout 1 6/27/13 12:26 PM Page 32
Editor-in-Chief Brenda K. Wiederhold, PhD, MBA, BCIA
Impact Factor: 1.591* 2009 Journal Citation Reports® published by Thomson Reuters, 2010
Frequency: Monthly
Legacy Content
ISSN Online ISSN
In-depth Coverage of the Psychology of Internet,Multimedia, and Social Networking on Behavior and Society
SUBSCRIBE TODAY
www.liebertpub.com
www.liebertpub.com/cyber
Key Benefi ts
Global Visibility and Reach:
The Experts Say“Cyberpsychology, Behavior, and Social Networking
—Paul M.G. Emmelkamp, Academy ProfessorRoyal Netherlands Academy of Arts and Sciences
University of Amsterdam
Indexed in
Manuscript Submission
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C&R 6(1) June 27_Layout 1 6/27/13 12:26 PM Page 33
C&R 6(1) June 27_Layout 1 6/27/13 12:26 PM Page 34
Ask the Expert:Mary Baker
33
PresidentEuropean Brain Council
&
“ You can only make the journey with the knowledge ofpeople you meet on the journey. There are designatedcorridors and they don’t all meet in a square ... the neu-rologists have societies for neurology, the psychiatristshave it for psychiatry ... there is no cross-fertilization. Thisis what drove me to set up the European Brain Council.”
INTERVIEW
Brenda K. Wiederhold: As the presi-dent of the European Brain Council,as well as past President of the Euro-pean Federation of Neurological As-sociations and consultant to theWorld of Heath Organization, youhave a strong history of supportingthe advancement of healthcare re-search. Can you please discuss howyou became interested in this area?
Mary Baker: Once I left university Ibecame a social worker working in ahospital in London. I was always in-trigued how patients who have thesame diagnosis react very differentlyin their coping mechanisms and howtheir family reacts. When I becameinvolved with the local patient groupsagain, I found a tremendous varietyof reactions to the illness. Some peo-ple were determined to find a cure.Others were determined to not let itinterfere with their life. And somehad no regard for their medication ortreatment and they would carry on asnormal. I later became involved with
the Parkinson’s Disease Society forthe UK and became their welfare di-rector. And again, I observed the samething. A lot of people with the samediagnosis had completely differentreactions. And then of course be-cause of my background in sociologyand political theory, I always had anunderstanding of health economicsand I gradually learned the cost to the(British) National Health Servicewhich was partly due to the differentattitudes people had to their illness.I was concerned that there was verylittle done for prevention and thatthere was a tremendous waste in thesystem when some people were nottaking responsibility. Neuroscientists,clinicians, psychiatrists, nurses, vol-unteers were working as hard as theycan but there was very little inter-change of information. The biggestdriver for me is trying to see how wecan break down barriers and how wecan improve the quality of life of peo-ple living with an illness.
You can only make the journey withthe knowledge of people you meeton the journey. The neurologists havesocieties for neurology, the psychia-trists have it for psychiatry, the neu-roscientists have it for neuroscience.There is no cross-fertilization.
BKW: How would you implement aunity between patients, scientists andpolicymakers for the cause of braindiseases and the betterment of re-ducing such diseases?
MB: I have tried hard to break downthe silos and bring people togetheracross a horizontal axis. Diseases arealways treated along a vertical access.Everything is focused on the disease.Take Parkinson’s for example. The dis-ease is the glue that brings neurosci-entists, psychiatrists, nurses, healthcare professionals, patients, carersand industry together. But youachieve much more if you go alongthe horizontal axis. When I was theChief Executive for Parkinson’s Dis-
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ease UK, we formed the EuropeanParkinson’s Disease Association thatbrought together nine Europeancountries and currently has 45 mem-bers. The first step was to bring to-gether with the common disease; theglue. The European Commissiondoesn’t want to talk about a singledisease. They do not want to speakabout Parkinson’s because it is partof Brain Disease. So it seemed logi-cal to bring all the brain diseases to-gether. That was the Federation of theNeurological Associations which start-ed to work well with the EuropeanCommission as it dealt with one or-gan over a disease. But that does notsatisfy everyone. Now we created theEuropean Brain Council (EBC), which
includes patients living with neuro-logical disorders, patients living withmental illness, neuroscientists, neu-rosurgery, biotech, clinicians, patients,neurologists, patients mental illness,pharmacology, biotech, health insur-ance and a group of MEPs who are in-terested in the area. It starts to bringa whole sector together all pushingfor increasing money for brain re-search, listening on how to deal withregulators and how you deal with thepayers. The patient groups have nowbecome a sector of society. Patientsare not a group; society is what webelong to. This is a society who hap-pens to be living and involved withthe brain. We have progressed muchfurther in dealing with the EuropeanCommission and we are now a con-sultant for DG Research and with theupcoming Horizon 2020 program. It’slike building a choir. You cannot havea choir of all sopranos. With one
voice, you will get a lot further.
BKW: How can we ensure brain re-search receives the attention and fi-nancial support it deserves?
MB: This is where we have to collectthe data as no one fully understandsthe costs of the disease. The WorldHealth Organization and the UnitedNations has designated four diseasesto receive the top priority: cancer, car-diovascular, COPD and diabetes. Butthere is no mention of the brain. Butbrain should be running the manage-ment of those four diseases. How canI prevent this? Should I do some re-habilitation? When should I take mymedication? The brain was totally left
out. The EBC gathered data in 2004and again in 2010 data and launchedits results in the European Parliamentin October 2011. The cost of braindiseases across Europe is just under800 billion Euros. This is more thancancer, diabetes and cardiovasculardiseases combined. This is becausethose diseases kill whereas brain dis-eases go on and on. I have tried to ar-gue that the organizations measurethe importance of illness by deathrate but this totally leaves out thecosts of the illnesses and by far thebiggest drain of resources is the braindiseases. I am not arguing that theyare more important but that they aremore costly. If you don’t attend tothese costs, they will drain resourcesfrom everything else. The cost ofdeath is 0 but what is the cost of 30years living with Parkinson’s and oth-er long-term illnesses?
BKW: For those who have suffered abrain injury, what isn't currently be-ing done that needs to be done?
MB: Prevention. Why are we not tak-ing care of the brain? Why are chil-dren still on bicycles without hel-mets? Why are we neglectful of theimpact on alcohol on brain? Why arethe universities, who are treasuringour brightest who may one day be-come our neuroscientists, encourag-ing students with Fresher’s weekwhere they drink and drink anddrink? We don’t do enough aboutprevention. It all relates to social be-havior. We know alcohol is harmfuland statistics show that it is respon-sible for 10% of road accidents and25% of murders. We need to raiseawareness amongst society of the im-portance of adopting healthylifestyles.
BKW: Do you have any predictions onnew trends for healthcare and tech-nology for the next decade?
MB: Data analysis used to take forev-er and now there is technology whereit can be used so swiftly. DNA se-quencing, for example, used to takea very long time but now it has beenmade much faster because of tech-nology. Technology will help us havea better understanding of the organswhich will help speed the progress ofhealth care.
BKW: Anything else you would like toadd?
MB: Don’t believe however clever youare that one specialty or person hasthe definitive answer. If we come to-gether, share ideas and be willing tobreak barriers with the confidence ofother disciplines, we will start tomove forward.
34
ASK THE EXPERTMary Baker
“Don’t believe however clever you are that onespecialty or person has the definitive answer. Ifwe come together, share ideas and are willing tobreak barriers with the confidence of other disci-plines, we will start to move forward.”
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In this and in thelast issues we re-viewed in thisjournal differentapplications ofvirtual reality(VR) in medicine.All of these re-searchers share acommon vision
of what virtual reality is: a collection oftechnologies that allow people to inter-act efficiently with 3D computerizeddatabases in real time using their nat-ural senses and skills (2). This definitionlacks any reference to head mounteddisplays and instrumented clothingsuch as gloves or suits. In fact, less than10% of VR health care applications inmedicine are actually using any immer-
sive equipment. However, if we focus our attention onbehavioral sciences, where immersionis used by more than 50% of the appli-cations, VR is described as an advancedform of human-computer interface thatallows the user to interact with and be-come immersed in a computer-gener-
ated environment in a naturalistic fash-ion.
These two definitions underline two dif-ferent visions of VR.
Clinical psychologistsand rehabilitators useVR to provide a new hu-man-computer interac-tion paradigm in whichusers are no longer sim-ply external observersof images on a comput-er screen but are activeparticipants within acomputer- generatedthree-dimensional vir-tual world. The keycharacteristics of virtu-al environments forthese professionals areboth the high level of interaction con-
trol using thetool withoutthe constraintsusually foundin other com-puter systems,and the en-riched experi-ence providedto the patient.
For physicians,and surgeons,the ultimategoal of VR isthe presenta-tion of virtualobjects to all ofthe humansenses identicalto their natural
counterpart. As more and more medicaltechnologies become informationbased, it will be possible to represent apatient with higher fidelity to a pointthat the image may become a surrogatefor the patient – the medical avatar. Inthis sense, an effective VR systemshould offer real-like body parts or
avatars that interact with external de-vices (e.g. surgical tools) and drugs asnear as possible to their real models.
Using medical avatars, the researchershope to predict the biological effects ofthe various drugs in the hope of fine-tuning their components and, ideally,eliminating the costs of unsuccessfultrials before they are even synthesized. Although these efforts are still in thereinfancy, both commercial and academ-ic research is continuing to make im-provements in simulation tools and ourunderstanding of how the body worksuntil we reach the point where our med-ical avatar can be as effective as a realhuman in predicting the positive andnegative effects of drugs.
Giuseppe Riva, Ph.D.Istituto Auxlogico ItalianoItaly
FROM WHERE WE SIT:The Two Sides of Virtual Reality in Medicine
By Giuseppe Riva
“However, if we focus our attention onbehavioral sciences, where immersion isused by more than 50% of the applica-tions, VR is described as an advanced formof human-computer interface that allowsthe user to interact with and becomeimmersed in a computer-generated envi-ronment in a naturalistic fashion.”
“Using medical avatars, theresearchers hope to predict the bio-logical effects of the various drugs inthe hope of finetuning their components and ideally, eliminatingthe costs of unsuccessful trialsbefore they are even synthesized.”
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elgium, like many Northern Eu-ropean Countries, is regarded ashaving a very high standard of
living. Belgium has a complex history as arelatively new country with three definedcommunities; the Flemish region in thenorth (Dutch speaking), the Walloon re-gion in the south (French and Germanspeaking) and the Brussels region (bilin-gual). These three communities, definedby their language, have political powersover areas in education, culture and ‘so-cial matters’ such as families and health-care. With its capital Brussels, also the cap-ital of the European Union, there arenumerous policymakers, funding agencies,and research projects for the healthcaresector on an international scale.
Brussels Life Science Incubator (BLSI)
The new era in medicine has arrived andthe empowered patient is born. This pa-tient is someone who is increasingly in-volved in his or her own treatment, assist-ing the physician with medical care.“Tomorrow’s World” is now becoming thepresent with developments in technolo-gies such as Smartphones, tablets andcloud computing. Advanced Technology
Healthcare (ATH) is seen as the way for-ward to improve patient treatments andto reduced costs on the increasingly de-manding health sector.
Brussels, Europe's capital, has increasing-ly focused on ATH, locally and globally. TheEuropean Commission sees SMEs as driv-ers of new innovation and growth of theATH sector and has set out policies to as-sist SMEs in their growth and develop-ment. On the Woluwe Saint Lambert cam-
pus of the Université Catholique deLouvain (UCL), the Brussels Life ScienceIncubator (BLSI) opened in December2011, to provide a dynamic environmentfor start-up SMEs and business leaders ac-tive in the field of biotechnology, medicaldevices, and IT solutions for the Health
Sector. BLSI helps start-ups and SMEs todevelop new activities by providing theright environment and personalized sup-port services. Two such Advanced Techno-logical Healthcare SMEs housed in BLSIare Esperity and Virtual Reality MedicalInstitute (VRMI).(http://www.blsincubator.com)
Virtual Reality Medical Institute (VRMI)
One of the first companies selected for in-clusion in the incubator was Virtual Real-ity Medical Institute (VRMI). VRMI is a Bel-gian SME with expertise in simulationtechnologies in three main areas: 1) treat-ing patients with stress, anxiety, and trau-ma, 2) training for military medical andcivilian first responder populations, and 3)enhancing medical educational programs.A relatively new start-up, VRMI has estab-lished affiliates in both China and the U.S.
The connectivity of Brussels, the capital ofthe EU, makes location at BLSI even moreimportant. This SME envisages the goalsof the EU in developing the healthcare ofthe future. VRMI serves on EU grants asboth a Dissemination and ExploitationWorkpackage Leader and a Clinical Part-
“Brussels, Europe’s capital, has developed a focus toenhance advanced technological healthcare, locallyand globally. The European Commission envisagesSMEs as drivers of new innovation and growth withinthis sector and have thereby set out policies to helpSMEs to develop and grow.”
[ ]C&R in Belgium
B
> COUNTRY FOCUS
T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
“The new era in medicine has arrivedand the empoweredpatient is born.”
C&R 6(1) June 27_Layout 1 6/27/13 12:28 PM Page 42
41
> COUNTRY FOCUS
ner, using a Combined CommunicationsPlatform of an annual international confer-ence, specialized workshops, clinician train-ing courses, a peer-reviewed scientific jour-nal, a quarterly magazine, and a websiteinformation portal as tools to inform andeducate the general public, policymakers,funding agents, industry and academia. Inaddition, VRMI has a private clinic at BLSIfor patient care to transition protocols andclinical products developed in the laborato-ry setting into actual clinical use. Havingbeen involved in R&D projects in Europe,Asia, and the U.S. for the past 25 years, theprincipals of VRMI have won over 50 com-petitive government contracts and are nowactively involved in marketing the developedproducts and protocols.
VRMI is currently involved with a particular-ly high profile project funded by DG-CON-NECT entitled INTERSTRESS. INTERSTRESSis working with a new e-Health conceptcalled Interreality and is porting physiologyand virtual reality to mobile platforms toprovide easier access to stress preventionand stress management tools for individualcitizens. Selected as a 2012 winner for theWorld Summit Award on mHealth, INTER-STRESS will complete its clinical and mar-keting trials in December 2013. (http://www.vrphobia.eu)
Esperity
Esperity, also based at the BLSI, is a new start-up SME providing a platform for cancer pa-tients to report their treatment outcomesand to connect with other patients similarto themselves. It is the aim of Esperity to diginto this data to find correlations betweeninfluencing variables on cancer treatmentoutcome. Patients all over the world can en-ter data such as cancer type, cancer subtype,treatment, medical history, medicationschemes, side effects and quality of life in-dicators. With the use of Microsoft cloud
technology, patients’ data can be scaled andrelocated depending on their location. Byanalyzing the data of the users, certain pat-terns will become visible. For example, pa-tients with a specific type of breast cancertaking an anti-diabetic drug might reporttotally different side effects and quality oflife indicators compared to patients takingan anti-hypertension drug. Being based atBLSI provides the environment and locationto develop the SME to a wider market.
Esperity, together with major pharmaceuti-cal players, plan to trial patients with the op-timal uptake of medication and the use ofthe online platform. The focus for the fu-ture is to maximize the use of advancedtechnology healthcare in the treatment,training and data management of the pa-tients. (http://esperity.com)
There is a technological shift taking placewithin healthcare and technology, and thisis increasingly becoming accepted by main-stream patients. Together with the increasedpossibilities that modern technology offers,a huge boom of medical data is to be ex-pected. Interpretation of all this informationis key, together with using this informationfor feedback to patients to maximize the ef-fectiveness of technology. The ‘ease-of-use’of future technologies is vitally important
C&R in Belgium
T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n
10.77
77/83
2.1%
41
0.5
97%
653
38,290
10.7%
4,119
0.83
14.1%
540.77
17
Population (Million)
Life Expectancy (Male/Female)
Fertility Rate
Population Median Age (Years)
Annual Population Growth (%)
Percentage of Urban Population
Hospital Beds per 100,000
Gross National Income Per Capita ($)
Total Expenditure on Health (% GDP)
Total Expenditure on Health Per Capita ($)
Mental Health Outpatient Facilities per
100,000 (2011)
Major Depression in general population in a
lifetime
Admissions to Mental Hospital per 100,000
Suicide Rate per 100,000 (2009)
“The EU is beginning tofocus on the involvementof SMEs in the valoriza-tion of research potentialwith international cross-sectional collaboration,making Belgium anattractive place for hightech medical SMEs.”
C&R 6(1) June 27_Layout 1 6/27/13 12:28 PM Page 43
to meet the requirements of the con-sumers. Cloud computing will hopefullybridge the gap in access to new technolo-gies whilst reducing investment costsmaking a more accessible entry point.
Centre of the EU
With Belgium being situated at the heartof Western Europe and Brussels its Cap-ital, the main European institutions, ma-jor companies and research institutes allover the world have delegates in andaround Brussels. One group with head-quarters in Brussels is the InternationalAssociation of CyberPsychology, Training,& Rehabilitation (iACTOR), which is amembers-based international non-prof-it association incorporated in Belgium.iACToR is designed to promote VirtualReality and other advanced technologiesas adjuncts to more traditional forms oftherapy, training, education, and rehabil-itation. It also investigates how new so-cial networking tools are impacting (pos-itively and negatively) individual behavior,interpersonal relationships and society.iACToR members are working to devel-op a “roadmap” for the future of this rap-idly growing area and participate in an-nual conferences and online forums toshare ideas and consolidate experiences.(http://iactor.ning.com)
Being located in Belgium gives institu-tions the benefit of easier access to aninternational stage. Projects are not lim-ited to which country they are located inand can find the best researchers with-
in the EU rather than their home state. Increasing demands on healthcare havecreated a need for an overall shift frominstitutional healthcare settings to every-day environments, and from treatmentto a preventive approach based on newpersonalized healthcare technologies.Using new technologies will help thetreatment of patients as well as cuttingever increasing costs. One area that hasempowered the patient is Virtual Reali-ty, which is increasingly being researchedand applied within the healthcare field.
The Strategic Approach for the EU for2008-2013 stated that ‘health is the great-est wealth’ and that ‘health is importantfor the wellbeing of individuals and so-ciety, but a healthy population is also aprerequisite for economic productivityand prosperity’. Esperity and VRMI, bothlocated at the Brussels Life Science Incu-bator (BLSI), have the benefits of beingclosely linked to UCL, as well as outstand-ing research facilities throughout Bel-gium. Networking events organized byBLSI also help SMEs establish access tofunding agencies such as Innoviris andIWT that promote collaboration betweenthese research facilities and SME’s.
Having access to the European Commis-sion and EU funds enables SMEs to pushforward research for Advanced Technol-ogy Healthcare as well as providing thebasis for international collaborations.These technologies enable treatmentsusing Virtual Reality, the Internet, andCloud Computing to be accessible when-
ever and wherever, creating a greater linkbetween patient and physician.
Moving Forward
As Europe is already pushing for strongercollaboration between academic / re-search institutes and SMEs in its Horizon2020 framework, many hope the fruitsof this initiative will be harvested soon,with a positive effect on the Europeaneconomy. Being based at the Brussels LifeScience Incubator optimizes SMEs abili-ties to collaborate with high quality re-search facilities locally and internation-ally with enhanced access to relevantEuropean departments and Commis-sions. Designed to help new startups withsome of the most difficult issues theyface by providing workspace, supportservices, and networking opportunities,entrepreneurs have more time availableto focus on their subject matter expert-ise and the enthusiasm needed to growtheir businesses. Europe, as does the U.S., agrees thatsmall business innovation remains oneof the keys to moving our countries for-ward.
42
> COUNTRY FOCUS
Sources:
Personal communication withMitchell Silva, World Health Organ-iszation (WHO), Brussels Life SciencesIncubator (BLSI) and Europa.eu
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INJURY CREATION SCIENCEThe Next Generation of Injury Simulation Today
Prosthetic tissue, wounds, and life saving skills training devices used in the training of medical professionals • Cricothyrotomy Skills Trainer • Needle Decompression Skills Trainer • Bleeding Wound Skills Trainer • Amputation Skills Trainer • Burn Wound Skills Trainer • Odor Wound Skills TrainerMerging latest special effects technology with medical and material sciences research to replace live tissue and training.Physiologically based research and development program focused on providing enhanced training capabilities for medical professionals to include: • Basic Life Support • Patient Assessment • Hemorrhage Control • Fracture Management • Shock Prevention & Treatment
Cricothyrotomy Skills Trainer
Needle Decompression Skills Trainer
Bleeding Wound Skills Trainer
Severe Amputation Skills Trainer
Odor Simulation Wound Kit
Simulated Burn Wound Package
FOR MORE INFORMATION, CONTACT:Mark D. Wiederhold, M.D., Ph.D. FACP
INJURY CREATION SCIENCEThe Next Generation of Injury Simulation Today
Prosthetic tissue, wounds, and life saving skills training devices used in the training of medical professionals • Cricothyrotomy Skills Trainer • Needle Decompression Skills Trainer • Bleeding Wound Skills Trainer • Amputation Skills Trainer • Burn Wound Skills Trainer • Odor Wound Skills TrainerMerging latest special effects technology with medical and material sciences research to replace live tissue and training.Physiologically based research and development program focused on providing enhanced training capabilities for medical professionals to include: • Basic Life Support • Patient Assessment • Hemorrhage Control • Fracture Management • Shock Prevention & Treatment
Cricothyrotomy Skills Trainer
Needle Decompression Skills Trainer
Bleeding Wound Skills Trainer
Visually Realistic - Comfortable - Easy to Use
Severe Amputation Skills Trainer
Severe Amputation Odor Simulation Wound Kit
Simulated Burn Wound Package
Visually Realistic - Comfortable - Easy to UseVisually Realistic - Comfortable - Easy to Use
FOR MORE INFORMATION, CONTACT:Mark D. Wiederhold, M.D., Ph.D. FACP
