WEBINAR: Virtual Reality in 2021 for Medicine and Health
PRESENTER: Associate Professor Andrew Campbell
DATE: 27 April 2021




Kate Steinbeck: [00:00:04] Welcome to the WH&Y webinar for the month. I'm Kate Steinbeck and I lead the NHMRC Centre of Research Excellence in Adolescent Health. I would like to acknowledge our partners, who we put up on the screen every time. I'd also like to acknowledge the Traditional Owners of Country throughout Australia and recognise their continuing connection to land, waters and culture. And we pay our respects to elders past, present and emerging. 

Kate Steinbeck: [00:00:51] This is our website in case some of our audience today hasn't visited it yet. It's a great website an, a website that is heavily involved with our WH&Y commission of young people who are helping us in both co-design and co-implementation of research. 

Kate Steinbeck: [00:01:16] Before we introduce our speaker, I just want to let you know of a couple of housekeeping things. First of all, we will mute your microphone, and your video will be switched off while the speaker is talking. You've got two ways of being involved in this. First, you can use the chat button, which is the first one, and type your message in the panel below and hit enter when you've done that. If you have a question for our speaker, there's a second tab which has the question mark, and you can put your question in there and I will ask questions of our speaker at the end of the presentation. 

Kate Steinbeck: [00:02:15] You will be able to watch this webinar and/or read the transcript as Associate Professor Andrew Campbell, who is presenting today, has kindly agreed to have his webinar recorded. And so, if you've missed it or know anyone who missed it, it will be there on our website. 

Kate Steinbeck: [00:02:39] So, it gives me very great pleasure to introduce Andrew Campbell, who is a collaborator of mine. Andrew is chair of Australia's first formal cyber psychology research group that's within the Faculty of Medicine and Health at the University of Sydney. Andrew's really pioneered the use of technologies, including virtual reality, video games, social networking and wearable technology as part of youth mental health research. This is going to be a fabulous talk, so welcome, Andrew. 

Andrew Campbell: [00:03:31] Thank you very much for having me, Kate, and I'd like to acknowledge the Traditional Owners of the land as well, and welcome all of you coming from many different places, I saw someone popping up from Myanmar, so thank you very much for joining in today. 

Andrew Campbell: [00:03:44] I'd like to start off by first recognising some of the early research in this field and then move into the 2021 research in the later part of the talk, because I think it's important to understand that there has been a disconnect or an out of step, if you will, between clinical medicine and the technology used in medicine when it comes to virtual reality. And then bringing the aspects of adolescent health and adolescent medicine, which we'll be talking about sort of more in the middle, and the reason being is because the adolescent aspect of the use of virtual reality and augmented reality, which I'll be talking about as well, really hasn't been a focus group. It's quite surprising, you'd think youth technology would be the driving force behind some of the VR use, but actually it’s been different age groups and different disease groups or chronic health issues.

Andrew Campbell: [00:04:36] So, we're going to start around 2006. I'm giving credit specifically to two pioneers in the field that have done quite a lot of hospital work. And now we're moving as a collaborative group into adolescents and other age groups. So, the people I would like to give a thank you to for sharing their research today as a start of this historical start is Professor Brenda Wiederhold, and Professor Mark Wiederhold both work at the Virtual Reality Medical Center at Scripps Hospital in San Diego. So, a lot of the pictures that you see today are from their studies as well as some of the publications, and then we'll move into the broader aspects. 

Andrew Campbell: [00:05:22] It’s probably good to know where we start with the use of VR, or virtual reality, as a treatment modality or a distraction modality for a particular disorder, and to be honest, it started with pain management. One of the things that was first seen from a psychological point of view was the more we could distract the patient, the easier it might be for them to tolerate procedures. But more importantly, actually return to doing the procedure if it was a very lengthy process. And you'll see one study coming up, I’m sort of pre-empting this, around burns treatment, and it has since been expanded upon quite a lot into adolescent medicine. But I wanted to show off a very simple model at the beginning here, the diversity of pain conditions that require treatment. We've got medical practice, of course, we have cognitive behavioural therapy and positive psychology, which is breathing techniques, mindfulness training, ways to account for preparing yourself going into a procedure and ways to recuperate. So, all of that is very psychological. But now we've got life-changing technologies that help us do both the medical practice side and the psychological side. 

Andrew Campbell: [00:06:35] When we started with VR use quite some time ago for pain distraction -  I want to be very clear, that pain distraction was the goal, not a medication point of view where we're looking to block pain. So, we're trying to use the powers of the brain. You'll notice here from this very simple chart from the American Society of Interventional Pain Physicians, that chronic pain affects more than those people suffering from diabetes, heart disease and cancer combined. So, it was across a broad topic to start with, across conditions. 

Andrew Campbell: [00:07:17] So, here's some actual study photos from the Wiederhold’s work back in the early 2000s. There a few things I want to point out here is that the technology itself is still quite cumbersome, back in the day. We had the doctor themselves forming an epidural spinal block, lumbar puncture, while we also had in the background, you can only just see their hand, a nurse operator working with the VR equipment with the patient. And this is because the VR equipment itself was very much tethered, you'll see a cable running to the computer, to a very simple video playback device. So, the virtual world, which you can't see on the screen, but I'll show you some pictures in a moment. And this helped the person hopefully begin to immerse into an environment while a procedure was being done to give basic distraction. This was comparable to some things like watching TV or listening to music. The truth is, that we found it in the initial studies to be slightly more immersive than those other distraction tasks. 

Andrew Campbell: [00:08:17] You can see in the early technology, very basic graphics were used to explore a beautiful castle or a mansion. And one of the things that patients referred back was it's great that you're showing this to me and it's helping me to be distracted, but I want to be able to wander around, I want to have control, I don't want the nurse to direct me through it. So that was one of the biggest barriers to patient distraction, allowing them to have control over their immersion and directions of the worlds that they were in. 

Andrew Campbell: [00:08:50] Then, we get to probably the biggest breakthrough at the time, which was Snow World. It was a gamification video or virtual reality that not only helped to block pain in the sense of distraction but actually seemed to work on a sense of concentration that started procedural pain to reduce. So, there was some neurocognitive activity beyond distraction happening here. And here we have a burns patient, it was actually a young soldier who was returning from the Iraq war in the early 2000s who had received burns in combat and had to go through many different procedures here with the ice bath and skin grafts. You'll notice very simply that there was a controlled trial of playing a video game, Nintendo, versus virtual reality. So, playing the game, being just a distraction, was not as effective as the virtual reality of being immersed in a game. And that game, which will come up in a moment, is called Snow World. You'll see here from a very small sample group, so N14, this is really a very early feasibility study, that was starting to show really big reduction in pain and allowed for skin grafting techniques to go longer and for patients not to fear them, to come back in and do them. 

Andrew Campbell: [00:10:18] This is what the person was seeing in the goggles that you saw in the picture. In the first iteration of the Snow World, it really was very clunky in that all the graphics were very simple triangles. You can sort of make that out in the forefront here. And you did get to wander around it with the joystick that you saw. But what was even more entertaining was later on, as you'll see, is the program from Hope Labs, which was updated and given better graphics, more animation like the penguin on the ice blocks and the ability to shoot snowballs at penguins and make them come out of the ice blocks. So, nothing violent, just something that helped you free animals. And that sense of altruism while being engaged and enjoying the environment, and it's cold and you have a lovely wintry-type soundtrack around, gave it a 3D immersion that really helped these procedures to be very successful. 

Andrew Campbell: [00:11:14] During this, it was also very important to monitor quite a number of physiological responses: heart rate being one, breathing, blood pressure and skin temperature. Now, these particular screens that you see here are an old biofeedback program used in the early 2000s. The majority of these types of programs today don't require complicated devices. In fact, most of them now are very good wearable technologies. 

Andrew Campbell: [00:11:45] Moving on, sort of coming into the early teens, we realised that exercise and physiotherapy was becoming a gamified area, meaning that we could do things to help our physical bodies, whether it be reducing weight or giving strength or even rehabilitation from an injury, if we provided what's called haptic equipment. And that's what the person in this picture is wearing, particular gloves, arm sensors and also leg sensors that give the computer a position in space. Now, as we jump forward to 2021, we had a revolution in not having to wear some of these haptics because we had cameras able to follow us and determine it without having position devices on us. So, there was a big technological jump in measuring how we move in virtual reality. And I'll come back to this one because it's a big breakthrough.

Andrew Campbell: [00:12:43] So, what then started happening was that we realised that VR could be used as a distraction for pain management. It could also be used in a lot of psychological areas, such as phobia reduction, fear of spiders was being tested quite a lot in VR or reducing the fear of flight. Some social engagement was starting to happen in VR, but the one-to-one, as in talking to somebody in VR, wasn't very good in the early or mid 2000s. But hospital procedures, medical procedures, dental procedures were starting to be funded, and in this particular study it was funded in the United States. NIDA Scripts Dental Center, a Virtual Reality Medical Center has a dental centre there and they started doing physiological measures, looking at pain reduction for long procedures, such as root canal. And here, the number one thing that we found was an interesting gender difference, in that more men did not want to see the dentist as opposed to women. So, what would get men into the dentist was if we could, one, gamify their distraction and give them a game that they really, really wanted to play, not one that was just off the shelf. So, they got together and they created golf games so you could actually golf while having a dental procedure, and this actually increased a lot of interest in coming to get dental checks and having dental procedures. 

Andrew Campbell: [00:14:15] Coming back to hospitals though, we realised that having typical surgery that you're awake during, your epidural-type surgery, it was good to talk to the patient, obviously, that was pretty standard. But how do we keep them calm? How do we keep their blood pressure down? How do we keep them engaged through long, very, very complicated procedures and exploration? So laparoscopic surgery with regional anaesthesia was trialled using VR and was found to be highly successful. 

Andrew Campbell: [00:14:47] So, again, early studies in 2007, and I'll try to explain a little bit of the terminology here. You'll see on the left there, the blue bar says HMD, that means head-mounted display, that’s the display that you see over the eyes of the patient lying down, versus no virtual reality, and what they had in that group was looking at a TV, so it wasn't immersive. The patient wellbeing during the procedure was much better under VR, the reported wellbeing on the pain scale or any discomfort during the procedure.  And afterwards we used VR in the home or used VR as a distraction to help with medication use in reducing pain medication? 

Andrew Campbell: [00:15:29] So, this moved into lots of different types of procedures that could be very unpleasant for the patient, but also difficult for the clinician who had to carry out the procedures to get the information they needed to make a diagnosis or a procedural recommendation of what to do for surgery. We had upper gastrointestinal endoscopies done. Now, again, the environments were chosen by the clients. You'll notice here there's a joystick in their hand. It had now got to the point where we realised that, one, the nurse couldn't control the computer and we needed them to work on the clinical aspects. We needed to give more technological control to the client and allow them to explore, and also allow the doctor time to do whatever they needed to do. So, we'd set times for how long a VR would run. So, rather than saying to the patient, this will be a couple of minutes, we will say the VR will run for ten minutes, the patient knows that, and then that allows the 10 minutes for the procedure to be done. 

Andrew Campbell: [00:16:32] Again, when we looked at this, of 115 patients that had upper GI endoscopies, again, the VR was far more successful than no VR at all. And even the respiration rate, the calmness, the mindfulness of patients was quite noticeable. What was also interesting in this study, and it was only very, very small, so keep in mind that this is a feasibility study, was that the physician stress was also reported, saying, you know, how easy it is to work with the person that was less anxious that perhaps wasn't worried about what was going on, I could actually do the job far more accurately. 

Andrew Campbell: [00:17:13] And then the natural progression from that was labour. This one here, sort of late 2000s, early teens, started seeing that patients weren't only just guiding their journey, they were now given a suite of VR experiences, whether they wanted to have a relaxing environment, you can see there in the picture a waterfall environment, or whether or not they wanted something familiar, like looking at photos of family members. They could choose what was best for them. Recovery from post-caesarean section, is very, very successful, very good to keep mobility down, blood pressure down, checks and balance and so on, and it's still used to this day, I believe. 

Andrew Campbell: [00:17:58] Then we move to a big jump around 2010-2012 going into 2014. The military in the US realised that VR had a potential for two particular types of psychological treatment. And with young people in particular being very tech savvy, there wasn't a lot of preparation to be done on how to train them to use the technology. It was a case of, do you game? Yes, let me give you a gaming console, which you'll see in the soldier's hands, put on the headset and they entered into an environment. The environment in this case was actually a predetermined environment of a place of insurgency. So, whether it was Iraq or Afghanistan, the young person was given a virtual world to enter, to prepare them for what they may see. While it was animated, which was perhaps the weakness here, the ability to understand surprise and to be on edge, but at a high state of alertness, helped people manage stress upon deployment, but also allowed them to unpack their thoughts after deployment when they replayed scenarios in a virtual world

Andrew Campbell: [00:19:06] Since then, the military in the US particularly has adopted VR for both training and PTSD, anxiety, depression and also integrated training management. These are just some of the pictures that the Virtual Reality Medical Center in San Diego has generated and worked around with soldiers and airmen, sailors and marines in the United States. 

Andrew Campbell: [00:19:30] But then we hit the years of, I would say, almost a tech slump, where the cost of this technology wasn't coming down at the rate that we needed to apply it. Moreover, procedures that were very clear, apart from psychological procedures on how to roll it out on a mass scale in hospitals, was starting to become problematic. And we had to explain to ethics committees, we had to explain to a lot of large clinician groups how this could be used as a tool that is both behavioural and medical. 

Andrew Campbell: [00:20:05] So, I want to bring us to the current day, and that is to first give a thank you to WH&Y for collaborating with the Psychology Research Group on an ACI study that they led. Starting in 2019, and with Covid, we had to really be creative and stop it for a while and work on systematic reviews and things like that. By collecting data as a feasibility study with adolescents at the Westmead Children's Hospital emergency department, we achieved 26 completed surveys and interviews with young people in the emergency room who, while there experienced fear, were offered a choice, they could access a Netflix program of choice, most likely a comedy, they could play a game, we did only prescribe one game, which was Tetris, because we didn't want to elevate too much blood pressure or heart rate, and we also didn't want them to move around, so it was more of a cognitive game, or a mindful program like a breathing program or a relaxing meditation program

Andrew Campbell: [00:21:07] This is very hot off the press. We've literally only just finished analysing this data, but the main thing, as a feasibility study for the adolescent group, and keep in mind that adolescents had not been the focus of VR in emergency departments or any part of hospitals really other than maybe cancer treatment, was that we found it was very successful with a 0.001 reduction of distress over the 25 minutes during the time they were in VR. And we also found that their worry about what was going to happen while they're in the emergency department being assessed, came down, that's the negative effects side. The others there, while not significant, were trending. You can see that pretty much everything was working either biologically in the right direction, physiologically and psychologically. So, again, this is probably more of a power size issue, and also, we need to do a breadth of analysis across genders, cultures, age and so on. But this initial grab of the small group really does align with all the literature we found in distraction for pain management or distress in adults for about the last 15 years. 

Andrew Campbell: [00:22:20] Some of the qualitative feedback is really, really good and you often don't get these in publications. I really wish there was more of this because the publications themselves tend to focus more on the technology and the disorder or the clinical treatment that they want to work with, and very seldom look at the user-centred feedback that they get. But we got this from the young people, and you will see their first impressions were overwhelmingly positive. This is probably not remarkable because young people grow up with technology, they're expecting to use it, but virtual reality is still not mainstream, so it probably was seen as a bit of a novelty factor and we did build that into understanding the results. But you can see immediately they could see it was taking away from what was actually happening to them. They did find it distracting. They found it calming, and they preferred using VR to watch Netflix rather than their phone or computer because it was more immersive. When we looked at what their experience was on the immersion level, they all said pretty much they were able to shut out the noise of the emergency department, any concerns of other people in distress around them. They certainly found it better than being on their phone. And that was without us even sort of testing that, they just offered that information. They felt privileged to get this experience in the hospital. And I think that's such a golden nugget there to say we are stepping in the right direction of moving with adolescent needs and adolescent wants with technology in medicine and health, more fun, and something new, it made time fly, and believe me, given waiting times in emergency departments, I think that's a wonderful response. 

Andrew Campbell: [00:24:01] The interview results also showed that there was a vast variety of VR headsets out there, but we chose some very simple ones off the shelf. And the main thing was that most people found them very, very comfortable, some a bit heavy, but even since this study has concluded, there's new headsets coming out, which you'll see at the end of this presentation, that are even more comfortable than what has been on the market even back to the early 2000s. They did note some other things. There is a mark on your face when you have a VR headset on for a long period of time, it does leave what I would call a diver's mask, if you're a scuba diver, it can leave that mask. It does take a while for your eyes to adjust, so a person that has glasses or a person that has eyesight difficulty may have a little bit of adjustment time needed because you have to adjust the width of the lenses inside the VR goggles. Some people do feel dizzy, but this is a side effect that is reducing as the technology has got better, eye a bit itchy, or heavy on the head. But all of these were deemed to be sort of acceptable things, things that didn't dissuade them from using it. 

Andrew Campbell: [00:25:09] The perceived effects were really good as well. Nearly all participants said their body felt relaxed, mind calm, and using the device to them didn't seem at all difficult, they understood, they put it on and once they understood the menu, they were into what they wanted to do reasonably quickly. They found that it was a distraction from reality in the hospital, which I mentioned before. It does take you to a different world and escape the stressful environment. It kept your mind off what you were here for and it was back in your own zone. It felt like you were at home, which is a wonderful thing you want to generate in a strange environment for an adolescent. 

Andrew Campbell: [00:25:44] Those who played the Tetris game felt focused or excited, but Netflix was the main choice. They really wanted to immerse themselves in something that was going to make them feel as though they weren't doing the work. So that was an interesting finding itself, because gamification had been up till now the main thing that we wanted patients to do while going through procedures or distractions. But now it seems that as long as the entertainment value or the immersion value is highly engaging to a personal level, then a passive form, in other words, a non-interactive form of VR, could be the preference for the use of this technology in hospitals. 

Andrew Campbell: [00:26:21] When asked if the VR device had any impact on pain or discomfort they were feeling, there was a split response, and I think this is very understandable because we don't know just how much pain they were in coming in. We did ask those questions and looked at pain scales and so on. But looking at the sense of distraction versus plain blocking is a big distinction, and that's something that further studies need to look into. But we did get some positive responses. They didn't think about the injury during the device. They did find playing a game did elevate their adrenaline, and that sort of changed their focus from the pain. During a procedure, say a cannula, we have studies already that show this with adults. They didn't notice the pain of the needle and were distracted at first, but the pain came back, better if you're lying down. Again, I think situational, perhaps looking at what the client was having to deal with at the time. 

Andrew Campbell: [00:27:14] At this point, I'm going to stop talking. I want to show you a video that is going to be played from Kate's end, and that's actually from Cleveland Clinic in 2018. So, a little bit out of date, but keep in mind that this technology is still evolving. HaloLens 2 is now available on the market. It's an expensive technology, but it is being first used for training and treatments in medicine itself and being trialled in medical hospitals. But it is augmented reality, meaning that you can still see the room around you, you're not shut off from reality, you have an overlay on the reality to give you a sense that you can see something you wouldn't normally see in reality, to learn something more or to actually be able to intervene and do something. So, this is a starting point to where this is all moving to. I will hand over now to Kate to play that video. 

Video Recording Starts

Frank Papay, MD, Chairman Dermatology & Plastic Surgery Institute, Cleveland Clinic: [00:28:05] So, the common expression, when people first put HaloLens on, is usually whoa, they can't believe it. 

Shenya Louis, medical student: [00:28:09] In terms of surgery and medical education, I think being able to visualise things in 3D is just so much more than any textbook can offer. 

Frank Papay: [00:28:23] You put it on, and you don't want to take it off. You can see right away all the different opportunities. Virtual reality is when you put on a set of goggles, you can be placed on something like planet Mars. HaloLens is an augmented reality system, you can actually see through the goggles, but then what it has is another set of lenses that project another image, which is the hologram. Right now we use these loops and all they are are magnifying glasses. Really  to augment reality by magnifying it with the HaloLens, it  does the same thing, but to the next degree.

Karl West, MS, Director, Medical Device Development, Cleveland Clinic:[00:29:01] Let's say we have a patient on the table and we want to perform some type of  intervention.  Using augmented reality we can superimpose data onto that patient say their cat scan or MRI.

Frank Papay: [00:29:23] And putting them all together, integrating them to really come up with this virtual 3D see- through model. 

Charles Martin, MD, Interventional Radiologist, Cleveland Clinic: [00:29:23] The technology itself can be pretty game changing. There are a tremendous number of ways that you can actually use augmented reality to help patents.

Karl West: [00:29:31] What we are developing in the lab is microwave ablation of cancerous tumours in the lungs using HaloLens, so a way of guiding the surgeon to the target without using radiation. 

Charles Martin: [00:229:45] If you are able to sink what you are looking at with what's going on in real time you are able to treat different types of tumours.  Larger tumours in more challenging places, you are really able to change the cancer care continuum.

Frank Papay: [00:29:58] The technology in our lab is now at the point of which by the end of this year we will be able to use it in an operating setting, to actually be able to help in a treatment.

Charles Martin: [image on screen of scans] [00:30:07]I Pre-op, post-op. I have no doubt that this technology will be utilised, it’s just a matter of in how many different ways and who is going to be utilising it.

Frank Papay: [00:30:19] Some people like football, some people like golf. I like the sport of bringing innovation together with the engineers and clinicians, thinking beyond what is here now, that is the excitement and I think the magic of the Cleveland Clinic.

Video recording ends

Andrew Campbell: [00:31:21] Here we are in the age of augmented reality now.  We are moving from not just being able to immerse ourselves in different worlds, to blend those worlds with our own reality. Where is it going? Well, at the moment, augmented reality has started where you might think with games, and I'll come back to what it started with a few years ago in a moment. I wanted to jump forward to what's been done in the last four years. And that is the use of exercise. So, we found for young people in particular that the more information they get about their exercise in a day, beyond what they're wearing on their wrist, so pedometers to be honest are very old now, nothing new, and they don't stimulate you to make 10,000 steps a day. It's a case of, it's just information. But being able to have augmented reality where you're blending your reality with goals you're setting yourself during the task. So, in this case, you've got a spin class here and people are trying to reach their own individual heart rates or certain distances or difficulty levels, and they can also see around them who's reaching their goals, which gives group participation a new sort of competition aspect while being static working at a gym is becoming a very big motivator for people to use AR to improve their health. 

Andrew Campbell: [00:32:48] Here, we have a very simple one called XAR, which is a game that you can play at home at first on a treadmill, or you can wear the AR headset and go running with it on and look around you, which will actually feed you information on what you see on the screen here, your time of running, distance and heart rate, calories and so on. But if you look at other people that were running a race with you, it also tells you information about them, it tells you how fast they're running. It tells you where they're running to, or where you need to run to if it's a race. So that extra information is like a heads-up display of further motivation to what you need to get done to either beat a person in a race or meet your objectives for physical fitness or many other things. 

Andrew Campbell: [00:33:40] Now, coming back to gamification, this is old news, but the top one is Pokémon Go. Pokémon Go was kind of the first mainstream augmented reality game that young people were taking up. For a while there it was very, very hot to trot around 2016. The novelty of it wore off, but we did find a lot of young people going out and spending a long-time hunting for Pokémon’s and thus getting their steps up and getting environmental change, not being behind a screen and also having fun sharing their accomplishments online, socially, thus motivating other people to be involved in the game. So, there were a lot of social, psychological and physical benefits. However, after a while it was a repetitive game and people thought ,you know, I can only collect so much, and it doesn't have an interest anymore. 

Andrew Campbell: [00:34:32] But where we are moving to is a virtual or augmented reality environment, and you'll hear a term in a moment where I'm finishing up the talk called mixed reality. But the bottom one that you see there is photos of actual people who have turned their photos into avatars. They are then in a virtual place where they can do whatever they want, socialise, play a game, watch a movie together on Netflix in the same room, or they can collaborate on a project. Alternatively, if someone doesn't have that program and they just have Zoom or they have another video chat program, that person can be brought in with their actual picture. What we're seeing here is a cross platform of technologies from Zoom to avatars to virtual worlds to interactive games and augmented reality. This is known as mixed reality, where we're starting to do things together using different platforms based on whatever the person has, so that one person isn't excluded. 

Andrew Campbell: [00:35:33] An example of where this would be quite good with adolescents' use is for those who have long stays in hospital, being able to stay connected to those in the classroom. Those who feel they've missed a social occasion, such as a birthday party, or an event, can be there looking through augmented reality glasses that somebody else is wearing that they can watch on their own phone screen.

Andrew Campbell: [00:35:54] So, I want to conclude this talk on first a note that I don't have up here, but it's probably a really big thing to keep in mind is, one, we are still scratching the surface of this research. Even with 15, 16, nearly 20 years of research of how it could be used in either medicine or health, we still have not seen mainstream adoption of the technology in hospitals or in health care. One answer is because it has been very, very cost ineffective. It was very expensive in the early days. Second one, is that the technology keeps rapidly changing. We kind of need to hit a plateau for a while of what is going to be standard. For example, what is standard now is like phones and tablets. We know that the modality of a phone, how it works and what it looks like, is not going to change between models. Essentially, it's still going to be a flat screen phone that we can carry around. Headsets need to go the same way and there getting there, getting there quite quickly. Thirdly, right now in 2021, the average headset for, say, virtual reality, could be anywhere from $200-$400. That is a big change from when headsets cost around $1,000-$2,000 nearly 15 years ago. 

Andrew Campbell: [00:37:11] So VR and AR are becoming mainstream devices. It is predicted at the rate that they are developing for off-the-shelf consumerism that they will be mainstreamed within the next 10 years. In fact, there are now predictions, given the fact that we had the 2020's Covid pandemic and how quickly we had to revert to working at home or working by distance modalities, that VR has expedited its development.

Andrew Campbell: [00:37:39] MX and XR is the next step. MX is mixed reality, where we blend whatever we have that's a visual technology, whether it be 2D, like me on this video conference, or a headset or an augmented glass-wearing headset so that we can all interact together. XR is where we can do things in those environments, actually interact with each other, whether it be working on files, videos, working on 3D graphics together, studying together and working together. Extended reality is what we're moving towards. 

Andrew Campbell: [00:38:14] I wanted to conclude by showing that the World Health Organization and UNICEF wrote a paper in the Lancet Commission on Child and Adolescent Health in the Digital Age. The full text link is here. It's a very simple statement and the statement is that, one, we need to involve young people in its development. And so far it has been very tech driven or clinician driven. Very seldom have we been able to get the research at a level of intensity, both with sample size and follow up on how to refine technology for a particular use. The only organisation that's been doing this for quite some time has been Hope Labs, who have worked with adolescents in the United States since 2006 on gamification for helping them to deal with cancer treatments. And they developed two very successful games called Remission. But even they have got to the point where that is not a priority, and most research funding has gone towards traditional medicine, which is very needed, I'm not taking away from that, but we need to blend traditional with the new technology as well, of different approaches that are client centred. 

Andrew Campbell: [00:39:25] The Lancet article states very clearly that technology such as AR and the introduction of artificial intelligence is not going away. It is something that has been there for some decades and is being refined, and it is now the right time to involve children strongly in medical and health research, particularly adolescents who are going to then take this into their long-term care for health and wellness. 

Andrew Campbell: [00:39:51] That's my talk ladies and gentlemen, I would love to go a little bit more, but the truth is, is that there's so much in this field. I'm trying to keep it focused on adolescent use, but I'm really happy to take your questions. Thank you. 

Kate Steinbeck: [00:40:08] Thank you, Andrew, for a stimulating talk. We've got some questions coming through. And I've got a few, too, if we've got time. The first question was, “thank you for a very interesting presentation. Do you find that clinical staff like to use VR with their patients? Does it ever interfere with their clinical procedure?” 

Andrew Campbell: [00:40:46] The answer, and I'm drawing on the literature for the past 15 years, is that, no, they don't. They don't because they're very busy, they have to learn something that can be complicated, particularly in the earlier versions, as you saw a laptop tethered to a headset with a joystick and a mouse and so on. And if you're overly focused on that, you're not doing what the client needs. The technology itself is becoming so simplified that we believe, particularly with the ACI study, that if it's a case of here's a headset, here's a joystick, there's is a menu and a tutorial, follow it, put it on, and then the nurse or the carer can go straight to work on what they have to do. But essentially, they have handed them an aide. And that to me is where I think we're headed. I think it's strongly what we need to promote, we don't want them to be digital experts necessarily, but to be digital appreciators, that this is a tool that can help them do their job. I'm going to finish off that by saying when medical doctors were saying it's allowing me to do my procedure more effectively because the patient is calm, that is where I think we need to take it for clinicians to say, how does this help you do your job rather than this is something you do in your job. 

Kate Steinbeck: [00:42:06] The next question coming up is: "it would be good to hear what you think, Andrew, about where the biggest opportunities lie with these technologies. Will the greatest gains be on the patient, that is actually treatment, or clinician with simulation and training?" We could probably give an hour's talk on that. But you've got a few minutes so off you go. 

Andrew Campbell: [00:42:40] Right now, in the School of Medical Sciences at the University of Sydney, Martin Brown, who was a presenter earlier in the WH&Y series [March 2021], is a collaborator in developing what's called SoMS (School of Medical Sciences) Media Lab  and its focus is around education. So, the short answer is that we're looking heavily towards education of clinicians using the technology at the moment, as you saw in the video with Cleveland Clinic. Having said that, the demand by clients is high. The gap is that clients don't yet know what it can do. So, we need to work on that as well. 

Kate Steinbeck: [00:43:19] Next question, they're still coming. "Interested to know what impact Covid has had on VR in a health context." 

Andrew Campbell: [00:43:34] I can only give you a technical as in the tech sector answer rather than the medical or health answer. And that is that there has been mass injection of funding from governments and start-ups receiving grants from governments, and that we are seeing evolutions now. I think this is the simplest way to answer it, actually. If you remember back to video recorders in the 1980s, we don't use VHS videotapes anymore, but back then there was a big war between Beta and VHS, and VHS won out. We're kind of getting that way with the headsets now. The headsets are soon going to be very, very standard and in a lot of ways, they're not going to be very different between each other, they're all going to be, well this is just a headset, just like this is a TV. With that happening, content is getting ramped up. More production of VR environments, games, social interaction, and VR data is being produced. So, with that, to answer the question, around Covid, it was like we jumped five years in funding during Covid around the world for the tech sectors. Samsung, Sony, HP, Google, Facebook, all of them are throwing billions of dollars into the sector. 

Kate Steinbeck: [00:45:04] And you see that as a good thing? Do you think there will be a sort of an improvement in what we can do medically because of these groups that perhaps are more interested in the entertainment? 

Andrew Campbell: [00:45:21] Absolutely. I consult with one of the tech companies right now. I can't name them, but I can tell you that their focus is tech for wellbeing because they don't want it to be a case of come and keep buying hardware. Hardware is expensive to make. They want you to buy hardware once in a while, but they want you to use their content. So, essentially, they want content to be tailored to medical and health areas because they know that that is a ready-to-go industry, just as engineering has been a ready-to-go industry. And the other one that is hot to trot, is education.

Kate Steinbeck: [00:45:58] The next question is "just wondering if you know of patients or clinicians who have had negative experiences with VR. While most research seems to be positive, for example with PTSD, could it not be harmful rather than helpful?"And I'm pleased somebody asked that question because that was bothering me as well. 

Andrew Campbell: [00:46:30] Look, to be honest, yes, there's always some negatives. It's not for everybody. I'll give you the simple answer first, and that is vertigo. Vertigo and epilepsy are the two biggest concerns for VR, even though the refresh rate in the lenses, that's how many times the screen refreshes itself, is much better now than back in the 2000s, thus reducing risk of headaches and seizures, vertigo is still there for some patients. But the way you can use it now can be very personalised to how you see the horizon, what mobility you have, if you would prefer to be seated rather than standing, and so on. So, there are far more personalisations to reduce those things. The other question, though, about can it be harmful, and I'll use the PTSD study. Yes, absolutely it can be. The truth of the matter is that with the PTSD research using VR, you have to be very individualised. It's not one size fits all, particularly in a lot of things to do with psychology we find that if you're doing a greater exposure therapy with say a fear of heights or spiders or in the case of combat, you have to do it very, very slowly and work with the client. So, it's not a case of set and walk away. It's very much a symbiotic relationship in some cases, and if we don’t, there are issues. 

Kate Steinbeck: [00:47:52] I was certainly wondering about and just thinking, would you ever get a study like that through the ethics committee in the first place, I think it could be quite challenging

Andrew Campbell: [00:48:05] It can be challenging, but you remember for our one Kate, it took a long time to explain the nitty gritty of what we were doing. 

Kate Steinbeck: [00:48:13] It's interesting because I think you've made the point that we're not keeping up in our medical education with the technology. And so, it will be interesting to see how actual medical schools start looking at this. Do you think that's going to be in the curriculum soon? 

Andrew Campbell: [00:48:42]  The discipline that I work in right now is called biomedical informatics and digital health, and one of the key goals that we've been given from the Faculty of Medicine and Health, Robyn Ward, is to embed literacy experience and hopefully stimulate innovation of medical education using technology. So, the answer is an overwhelming yes. The institutions of training and the accrediting body, accrediting bodies such as the AMA, have to walk lockstep and that's difficult. These are long conversations to get individuals to understand what we're trying to do, how it works, experience themselves and then see the benefits for the greater system. So, we're really still at the early stages of trying to embed curriculum with technology. But it is happening, and I think now it's a case of looking at areas, so pain is one area that we need to perhaps embed a bit more of VR in, whereas it may not be suitable in other areas. So, I think it's not a case at all of all medicine but certainly in areas. 

Kate Steinbeck: [00:49:48] Now there is another question from one of our CRE team, Pip Collins. "Thank you, Andrew, very encouraging results on the use of VR in ED. Digital inclusion remains an issue also highlighted by Covid lockdowns with many families and young people without the access to be digitally first with learning and health. This is a big question. How can we all share the benefits of this tech to those young people who stand to gain the most from a health and social perspective? 

Andrew Campbell: [00:50:34] I couldn't agree more with the direction of that question. Digital inclusivity is a big problem. The short answer again is that we do need to work with the local community council. We need to look at what we can do to supply ready-to-access headsets, and I think we also need to look at what we can provide. Involving councils within the local health services to provide hardware tech libraries to borrow equipment, I think is a very important thing. It has worked in many different countries. We don't do it very often in Australia, in fact I've only seen two regional areas do it. And to be honest, it's inexpensive because if you have technology that is updated every two years it doesn't mean that the last lot of technology is out of date, it just means that it's not the newest. So, recycling the technology for community use would be an excellent way to start propping up that problem. 

Kate Steinbeck: [00:52:04] We're getting close to the end of our time. I did have a question. It was interesting to me about the athletes who could actually monitor where they were and how they were doing in comparison to others. And obviously some athletes use this a lot. For instance, Formula One race drivers are being talked at the whole time they're moving around the track. Do you think this sort of augmented reality might become an issue for Olympic competitions? 

Andrew Campbell: [00:52:47] Oh, absolutely. There are already discussions around it right now, whether or not it would be an advantage or a hindrance. The advantage is obvious as automation creates high level motivation or a strategy for how to perform. The hindrance could be cognitive overload while trying to do what you need to do. So, it's really a blended thing again, I think personal preference. Some athletes would want lots of information. Others may not want much at all. When you see long-distance pilots training, a lot of them just simply want to hear music they don't want to hear you've run X amount of miles at this speed. 

Kate Steinbeck: [00:53:24] Well, Andrew, I think we've come to the end of our time and also to the end of our questions. I'm going to thank everyone who took part, but most of all, I am going thank you for taking time out to come and talk to us. And I think we'll be asking you to come back and talk to us again, because I'm sure in 12 month’s time you’ll have something fantastic to show us. Thank you again.

Andrew Campbell: [00:53:50] I hope so. Thank you so much.