Virtual reality was first experienced as the world’s first flight stimulator Link Trainer by Edwin Link (1929) and later as the interactive theatre ‘Sensorama’ invented by Morton Heilig in 1957. Over time virtual reality has metamorphosed from science fiction to science reality. Today, virtual reality can be experienced in many forms that include not only visual and auditory feedback but also other sensory feedback. Primarily hyped in the entertainment sector, virtual reality also enjoys the application in fields such as simulation-based training and healthcare research. In medicine and medical research, virtual reality allows the opportunity to train, and investigate speculations and behaviors with greater experimental control and without endangering subjects, and at relatively reduced costs.
Traditional methods of practice and research require infrastructure, numerous tools, and apparatuses which all add to the cost and tend to be time-consuming. While animal-based experiments can be performed in laboratory set-ups under different environmental settings, the same is not always possible with human subjects. Further, traditional approaches require maintenance of different environmental parameters and the environments used may not always be ethologically or ecologically satisfactory. Ethical concerns also limit the application scope of traditional methods.
Surgical Training
Though traditional methods have their own strengths, the use of virtual reality (VR) offers far more benefits that improve the quality of medical research and practice. Virtual reality-based surgery training has been shown to have a significant influence on surgery performances when compared to performances of individuals trained only using conventional methods (Palter & Grantcharov, 2014; Seymour et al., 2002). Modern medical VR training systems in addition to providing rich virtual environments (VE) also combine haptic systems that make the experience more realistic such as by allowing the feel of tissue resistance in a simulation. Further, VR can be tailored to individual needs as well as the specific needs of different medical scenarios. Thus, VR is a promising teaching and training tool in medical practices that expand the possibilities of learning as well as reduces variable parameters of training (Samadbeik et al., 2018).
Human Behavior Analysis
Beyond training applications, virtual reality can be effectively utilized in analyzing human behaviors. Often data collection for human behaviors relies on case studies and estimated responses of the participants to hypothetical scenarios. While case studies can involve real-time data collection using behavioral experiments such as the unannounced evacuation of an office building to estimate behaviors during a fire event (Nilsson, Frantzich, & Saunders, 2008), the reliability of such experiments is not high enough. Consider the experiment performed by Kinateder et al. (2014) to assess the effect of social influence on exit choice behaviors of participants in a simulated tunnel fire. The experiment employed a virtual tunnel environment that was equipped with a virtual agent (VA) whose behaviors were varied to simulate different scenarios. Kinatedar et al. observed that when no VA was present, the participants would quickly make the decision to move towards the exit. However, a passive VA resulted in the participants waiting longer to make a move which was in agreement with the findings of Latané, and Darley’s (1968) laboratory experiment on bystander influence on escape behaviors. When provided with an active VA that moved towards the exit, 85% of the participants also went towards the exit as opposed to the 75% in the no VA condition. However, a VA running away from the exit resulted in only 61% of the participants making it to the exit. These behaviors were comparable to the Sydney Harbor Tunnel field experiment results of Burns et al. (2013). As evident from these outcomes, the virtual reality-based experiment was able to provide comparable and reliable results without compromising the participant’s safety.
Animal Model to Human Model Translations
Translation of animal-based models to human models is made easy with virtual reality. Traditional mazes such as the Elevated Plus Maze and the Radial Arm Maze are often used with animals to assess fear, anxiety, learning, and memory and can easily be programmed into VR. Additionally, virtual environments permit the creation of ecologically and ethologically relevant scenarios, such as a city, farmland, or apartment, which can quickly be swapped out without interfering with the task performances. Lee et al. (2014) were able to successfully assess memory impairments in patients with amnestic mild cognitive impairment (aMCI) and Alzheimer’s disease (AD) using a virtual Radial Arm Maze. The use of the virtual maze also allowed differentiation of working memory and reference memory. The aMCI patients were observed to have significantly impaired spatial reference memory, though not working memory, while the AD group showed impairments in both memories. Further, a five-year follow-up analysis by Lee et al. comparing the virtual maze performances revealed that the aMCI converters had made more spatial reference memory errors in the task than the corresponding non converter group. Another study that utilized the virtual Morris Water Maze was able to translate the findings of the differential effect of scopolamine on hippocampal activity in animals to humans (Antonova et al. 2010). Antonova et al.’s combination of fMRI analysis with the virtual task performance revealed a dissociation between hippocampus-based and striatum-based memory system activations following placebo and scopolamine administration. These studies, among many others, show the strong potential of VR in enhancing diagnosis as compared to classic approaches to testing. (See also virtual Elevated Plus Maze and virtual T-Maze).
Virtual Reality Therapy
The immersive and interactive characteristics of virtual reality are also being explored as a treatment tool in psychiatric diseases and rehabilitation. Virtual Reality Therapy (VRT) or Computerized Cognitive Behavioral Therapy (CCBT) is gaining popularity as psychological or occupational therapy. The use of a range of technology such as gesture-sensing gloves, synthesized sounds, and vibrotactile platforms along with a tailored virtual environment creates a sense of active participation in these virtual tasks. Additionally, the possibility of dynamic interactions in VR wherein responses are generated to participant’s action further improve the feasibility of VR as therapy. Case studies have shown virtual reality-based exposure therapy had a significant impact on the treatment of phobias such as driving (Wald, & Taylor, 2000), flying (Baños et al. 2002), and spider fear (Garcia-Palacios, Hoffman, Carlin, Furness, & Botella, 2002) and even led to reduced anxiety in cases of social phobia (Gebara, Barros-Neto, Gertsenchtein, & Lotufo-Neto, 2015). Apart from phobias, VRT has shown great potential in the treatment of other psychological and psychiatric disorders such as PTSD (Maples-Keller, Yasinski, Manjin, & Rothbaum, 2017), eating disorders (Clus, Larsen, Lemey & Berrouiguet, 2018) and attention deficit hyperactivity disorders (Serra-Pla et al., 2017), among others. The effectiveness of VR in psychiatric treatments can be attributed to the assurance of not having to deal with real situations (North, North, & Coble, 1998) and the protection of confidentiality for the patients. Further, the participants also have the comfort of opting out of the simulation at any time during the task. The use of VRT is also beneficial for patients that have difficulty imagining situations. From the point of view of the healthcare professional, VRT allows for greater control of the environment, reduces additional expenses (such as expenses that arise from accompanying the patient), and reduces unnecessary time wastage such as time spent traveling (North, North, & Coble, 1997; Protivnak, 2005).
Animal-Based Research
Apart from human applications, virtual reality is also being taken advantage of in animal-based studies. The main shortcoming of traditional laboratory experiments is their level of ethological and ecological validity. Since animals are tested under artificial environments, complete analysis of their natural behaviors and responses is not always possible. Further, conventional methods may require the management of experimental parameters or consistent involvement of the experimenter. While the early implementation of VR required tethering of animals, new developments have allowed the creation of VR systems that allow the animal to move within the space freely; Thus, allowing uninhibited sensorimotor experiences for the animal and high-quality behavioral analysis (Stowers et al., 2017). The application of VR is also not just limited to land-based animals such as rats and mice, but can also be successfully used with insects such as Drosophila (Fry, Rohrseitz, Straw, & Dickinson, 2008) and honeybees (Rusch, Roth, Vinauger, & Riffell, 2017) as well as aqua life such as zebrafish (Bianco, Kampff, & Engert, 2011). Regardless of the type of virtual reality systems used, VR provides experimenters with the flexibility of manipulating environmental parameters, ease of data collection, and scope for developing new experimental paradigms (Sawyer, & Gleeson, 2018).
The opportunity to manipulate and tailor the virtual environments also means the requirement of a large amount of storage and processing capabilities. These along with management and security systems in addition to initial set-up cost can result in cost-related issues, which in turn limits its adoption into healthcare practices and research. Further, unfamiliarity with the technology and its implementation may cause hesitance in acceptance by both the implementers and the users. The compatibility of the VR system with other existing systems and devices could also potentially reduce its favorability.
Virtual reality systems that are based on participant movements, as with conventional methods, also have a limitation on the area that the participant can physically traverse. This can, to an extent, be mitigated with the use of omnidirectional treadmills or similar technologies. Given the range of available VR systems, not all systems employ or seamlessly integrate olfactory, haptic, and thermal simulations. Thus, most VR systems are limited to visual and auditory simulations. Limited or no interaction with actual physical objects can also limit the realism of the experience for the participant.
In a treatment set-up, such as a Virtual Reality Therapy, or behavioral testing, the control of the stimuli and virtual environment is in the hands of the healthcare professional or investigator. This control can potentially result in subjecting the participant to experiences too quickly or that are too realistic to handle, which can hinder their progress or affect their performances. Thus, consideration of the participant’s capacity must be paid attention to while employing VRT. Additionally, VR experiences can cause virtual reality sickness possibly resulting from sensory conflict (Fulvio, Ji, & Rokers, 2018) or postural instability (Smart, Stoffregen, & Bardy, 2002). Technical aspects such as mismatched motion, the field of view, motion parallax, and viewing angle in addition to the duration of the experience can also induce sickness. Other factors such as age, gender, motion sickness sensitivity, mental rotation ability, and field dependence/independence can also impact the user experience.
Despite its many advantages, the efficacy and ethological and ecological validity of VR still require further validation. Legal and ethical issues associated with the use of virtual reality systems should also be considered before their employment. The lack of standardization of the virtual environments and protocols across studies and laboratories may also affect the data comparability and inferences.
Virtual environments can be based on augmented reality, virtual reality, or mixed reality. The technologies used to employ virtual reality can range from a simple desktop set-up to a cave automatic virtual environment. The consistent development in the field of virtual reality opens up possibilities for new VR technology that can be applied to meet the different needs of biomedical research and healthcare. Current applications of virtual reality include surgical training, treatment of psychiatric and psychological disorders, rehabilitation, and animal-based experimentations, among others.
The highlight of virtual reality and its growing popularity in the field of healthcare and research is the flexibility of tailoring virtual environments. Virtual reality proves to be a powerful tool that allows consistency in experimentation and replication, and greater control over participants’ safety and the experimental parameters. Despite the initial set-up cost, virtual reality systems tend to be cost-effective and relatively less time-consuming. The VE also offers better ecological and ethological set-ups as opposed to traditional approaches. The use of auditory, tactile, and olfactory systems in combination with VR can further enhance the experiences and realism of the setting.
However, VR systems do require a large amount of storage and processing capacities. Virtual reality experiences can induce sickness similar to motion sickness in the participants. The limited available literature and validation of the efficacy of VR are also of concern in addition to the lack of standardized practices across studies.
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