The controlled environment of virtual reality is proving ideal for diagnosing and treating traumatic brain injuries. Learn why the Department of Defense is funding trials.
For some people, virtual reality is anything but a game. For some traumatic brain injury patients, it’s a means to living a normal life.
Meet Dr. Denise Krch, a research scientist and one of the leaders in virtual reality (VR) applications for sufferers of traumatic brain injuries (TBI). Krch has won grants from the National Institute on Disability, Independent Living, and Rehabilitation Research and from the Department of Defense (DOD) for her promising research, and works with the DOD to help impaired soldiers.
Krch doesn’t ask a patient to strap on an Oculus Rift or an HTC Vive. In fact, her VR doesn’t use headsets at all. That surround experience is called immersive VR. What Krch uses is non-immersive. Her VR is shown on a computer monitor and is more like a video game in which a player uses a joystick and mouse to manage real-world situations.
For TBI sufferers, distractions and the need to juggle multiple tasks can make the typical workplace impossible to navigate. They find their thoughts batted around by each new interruption, and are unable to focus on one task for long. It’s frustrating and frightening. Krch’s VR applications don’t transport patients to far-off worlds; they put patients in the middle of an office, one that grows more distracting as they progress.
Krch is based in East Hanover, N.J., at a division of the Kessler Foundation, a nonprofit that assists people with physical disabilities, and she is affiliated with Rutgers University’s New Jersey Medical School, but she owes her interest in VR to a guest from the West. Seven years back, Albert “Skip” Rizzo, the director for medical virtual reality at the University of Southern California’s Institute for Creative Technologies, visited the Kessler Foundation to share his research in VR as a treatment Krch was impressed with the role VR can play in rehabilitation and rebuilding cognitive functions that are difficult to improve.
She was so impressed, in fact, that she began working with Sebastian Koenig, then a post doctorate student and researcher in Rizzo’s lab, on a new trial.
Krch’s work deals with the cognitive area called executive function, which includes our ability to organize, plan, and shift attention from one task to another or keep two things in mind at once. Impairments in this area are difficult to measure in neuropsychological assessments. The first challenge Krch and Koenig tried to solve was measuring executive function performance. They wanted to use VR to determine which patients were having trouble multitasking or switching attention in real world situations.
From left to right: Sebastian Koenig, Ph.D., CEO of Katana Simulations; Albert “Skip” Rizzo, Ph.D., director of medical virtual reality, Institute for Creative Technologies; Denise Krch, Ph.D., research scientist in the Traumatic Brain Injury Laboratory at Kessler Foundation Research Center; Nancy Chiaravalloti, Ph.D., director of the Neuropsychology and Neuroscience Laboratory and Traumatic Brain Injury Laboratory at Kessler Foundation Research Center
To do that, they created software that put the test subjects in a virtual environment where they were challenged to perform tasks while distracted or where they were forced to shift focus. The researchers ran their tests with a healthy control population and with patients they suspected of having impairments. Some of these patients had TBI, while others had multiple sclerosis (MS).
The VR environment put subjects in an office where they were seated at a desk and charged to pay attention to different messages coming through their computer. Some messages were spam, which they had to learn to ignore. Other emails required a response. Many included real estate offers, and the subjects had to decide whether to accept offers or decline them.
Besides making financial decisions, subjects had to keep watch on an office projector. That projector wasn’t visible from where they were seated, but was in a nearby conference room. Told that the projector’s light was on the fritz, they needed to turn and check on it frequently while managing their other tasks.
“We found that indeed our patient populations were actually seemingly intact or normal on our traditional neuropsych measures, but they were performing in the very impaired range when we looked at them using VR,” Krch says.
To understand why this video-game-like experience is called VR, it’s necessary to understand “presence”—the feeling of how much believability an immersive situation offers. For a test to be effective, patients need to feel like they’re in a believable scenario. Krch and Koenig’s simulation proved to be extremely believable, stressing out TBI patients in no time with competing stimuli. While creating actual physical spaces could test the same functions, that isn’t practical, and bringing patients into stores or similar real-world locations can lead to safety issues. Using VR better helps researchers control the experience: They can precisely monitor stimuli and responses while generating clinical data.
“In a virtual environment, you have complete control over whether the environment was fairly sterile and limited in distraction. As they were able to build to tolerating more distraction, you could add. So really that’s the biggest advantage of having a virtual environment,” Krch explains.
That trial successfully tested for a variety of impairments in attention and executive function. It showed impairments in the ability “to remember to remember,” called prospective memory, in turning to check the projector. Responding to emails tested selective attention where the subject chooses to focus on one thing and not another. Determining whether or not to accept the real estate offers tested problem solving. TBI and MS patients who didn’t show problems on standard neuropsych tests showed problems across the board when using VR.
Testing showed subjects had the biggest problem with interruptions. The biggest stressor in the experience was a phone ringing in the background. Hearing an unanswered phone ring over and over really derailed people’s thoughts. Krch and Koenig used their data to come up with rehabilitation programs that also use VR, and then to write a grant proposal to fund new software that can improve problems with divided attention (multitasking) and set shifting (switching between tasks). Funding by the National Institute of Disability, Independent Living, and Rehabilitation Research led to 3 years of development work with clinicians and TBI patients, and the recent start of randomized clinical trials. Testing involves eight treatments conducted over 4 weeks. The 15 subjects are being tested before and after treatments to monitor progress. Krch began the trial the week before this interview, so she didn’t yet have data.
In this testing, Krch and Koenig’s VR office software has gotten an upgrade. Now the subject works at a corporation that makes a toy animal called the Wonderkin. While there’s plenty of usual office chores, such as sitting at a desk and making decisions about emails coming in, the toy animals add a little fun. One treatment module is set in a laboratory where subjects have to check whether or not toys are broken. Toy horses, goats, and pigs jump around, while subjects make sure they aren’t breaking. The idea in this and other modules is to create a game-like treatment where patients have fun while improving attention skills. As subjects improve, the difficulty rises.
Since this is a clinical treatment and not an evaluation tool, a clinician works with each subject to keep him or her on course. If the subject starts to feel overwhelmed by distractions, the clinician starts the patient on something simpler and helps the person build up.
Krch has a second grant-funded trial going, also continuing work started in Skip Rizzo’s USC–ICT lab. Funded through multiple Department of Defense studies, this treatment seeks to improve balance.
“The DOD has tremendous interest in finding treatments that help rehabilitate individuals with traumatic brain injuries,” Krch says. “As a matter of fact, now having been DOD funded and involved within the DOD system and learning about the DOD system, they actually fund a wide range of things from cerebral palsy research to cancer research to things that seemingly you wouldn’t think the military would care about. But the military serves not just the people who are serving directly, but their families.”
With many soldiers coming back from combat with concussions and TBIs, the DOD has funded a good deal of research in the area, especially studies that use tech simulations. Rizzo is also developing military-funded treatments for veterans, using VR to treat post-traumatic stress disorder.
Sebastian Koenig, Ph.D., and Denise Krch, Ph.D., with the VR simulation they use to help patients with traumatic brain injury overcome distractions typical in workplace environments
Krch’s randomized clinical trials on balance use VR software displayed on a large wall-mounted monitor. An infrared beam detects the subject’s body and the screen shows an avatar in a virtual environment. Testing with active duty personnel is done at Fort Belvoir Community Hospital in Fort Belvoir, Va. Krch’s VR balance treatments don’t currently use headsets, but that’s changing. Patients are more prone to fall when wearing a headset, and the immersive experience can lead to “simulator sickness,” which is becoming less of a problem as VR hardware improves. Krch’s team is adapting a VR program called the Fruit Toss to headsets. In it, fruits fly at the test subject, who has to either catch or kick them. Krch hopes to have it completed by the end of the year. Her team is currently collecting data and feedback on immersive VR tests, which they’ll use as pilot data for an immersive technology grant proposal.
“Our lives are full of distractions. You’ve got a kid in one hand and you’re closing the door. You’re helping a child with homework and you’re cooking, or you are on the phone with your health insurance company and you’re balancing your checkbook. The demands of our lives constantly require us to switch our attention a lot and to do more than one thing at a time,” Krch says. And that’s true in the office, as well: “Most job scenarios nowadays expect you to be able to multitask and to do it in the presence of many, many distractors.” With help from treatments like those Krch is creating, TBI patients are able to return to the workforce sooner and MS patients are able to stay at their jobs longer. That means a better social environment and better quality of life.
The virtual reality environment might still feel like a game, but the results of Krch’s work are a better payoff than any high score.
[This article appears in the September 2017 issue of Streaming Media Magazine as “Virtual Reality, Real Medical Carea.”]
Source: Virtual Reality, Real Medicine: Treating Brain Injuries With VR – Streaming Media Magazine