Using Technology and Virtual Reality to Improve Outcomes, Quality of Life

New technologies that can monitor sleep, track itching patterns, or assist with pain are improving outcomes and quality of life for patients with rheumatologic conditions, according to panelists at the American College of Rheumatology’s annual meeting.

Some technologies are those that people are familiar with, such as pedometers, but others are less well known, such as skin tattoos that can measure body chemistries or that have a microphone that can placed near the throat, explained Jeffrey R. Curtis, MD, MS, MPH, professor of medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham.

There are technologies that digitally monitor bodily fluids so patients don’t need to go to an office for a blood test; for instance, a mouth guard can measure uric acid.

“[Wearable technologies] also have cautions, because sometimes these are incredibly overhyped,” Curtis said. He pointed to the shelved collaboration between Verily and Novartis to create a smart contact lens that would measure glucose levels in patients with diabetes.

Clinicians and researchers are so excited about the opportunities of sensors and wearables because they reduce the burden on patients, thus increasing patient adherence, and they provide quantitative, reproducible measures.

Specifically, in rheumatology, some of the devices that Curtis highlighted were:

• Bluetooth scales to help track weight loss
• Shoe inserts that can look at gait
• Devices that measure ultraviolet exposure for patients with lupus skin disease
• Sleep monitors that measure heart rate and snoring
• Fitbits or other watches that can be used to measure scratching behaviors in patients with psoriasis

However, these devices only work if patients are willing to use them or use them correctly. For instance, monitors worn on the hip or ankle are more accurate, but patients prefer to wear them on their wrists. In addition, the quantified self, which is the act of using personal data to improve quality of life, does not appeal to every patient. Instead, it might be more successful to appeal to the idea of democratizing information—that if the patient shares information, the physician can take better care of them.

“The idea that I’m going to share information in a secure way with my healthcare team, that notion has much broader appeal to patients than only the quantified self,” Curtis said.

There are also challenges with interpreting the data. With the amount of data that can be collected through wearable devices, clinicians and researchers can now compare the person to themselves, rather than to other people. As a result, doing well might mean different things to different people. For instance, in one patient, a reduction in disease activity meant that physical activity decreased, because this specific patient was a writer, and as they felt better, they spent more time sitting at the computer and working.

As a result, during trials with patients, Curtis and his team now asks what the patient’s occupation is. A long-haul trucker will have different sleep patterns than someone from the general population, for example.

“I think we want the ability to do remote monitoring—not in a creepy Big Brother way, but to help people and provide better care,” Curtis said. “We want to know what to do and then what happened. And I think this is kind of the care traffic controller so that we can triage people.”

Another technology being used in new and surprising ways in healthcare is virtual reality (VR). Most people think of VR as a gaming platform, “but what we’ve been exploring is: how do we use virtual reality to really impact patient outcomes—pain in particular, but there are many other outcomes, as well,” said Brennan Spiegel, MD, MSHS, director of health services research at Cedars-Sinai Medical Center.

Spiegel explained that VR can be so immersive when done correctly by showing a video of him trying VR for the first time a few years ago. The video of his view inside the VR machine showed him standing on a lift hanging off the side of a skyscraper. The lift slowly climbed upwards as he looked around and down at all the details, then at the top, the bar in front of him fell away. As someone with a fear of heights, he said he instinctively pressed himself backwards in real life. Then he was asked to step off the lift, which he refused to do. He colleague in the room pointed out that he knew his feet were on the carpet back in his office. His response? “Well, my feet might not be, but my brain doesn’t know that. My brain thinks that I’m going to die.”

Eventually, he did step off, and that was the first time he died in VR.

“And I thought, ‘Oh my God, if we can use this for evil, maybe we can use it for good,” Spiegel said.

The second time he died in VR was just a few months ago, when he had another experience, this time with sensors on his body. In real life, he would be able to move his limbs, and the legs he saw in the VR space would mimic his movements. As little balls fell down from the ceiling in the VR space, the sensors on his body vibrated as if they were hitting him in real life. Then, slowly, he began to float out of the VR body.

Studies have shown that people who have a VR experience are less afraid of death, and researchers are trying to see if there is a role for VR in addressing existential anxiety.

In rheumatology, VR can help with pain and with quality of life. For instance, in a study of 50 patients who were in the hospital for pain of any sort, 10 minutes of a VR distraction experience reduced pain from a 5.4 average score on a pain scale (0-10, with 0 being no pain) to 4.1. In patients who only had a 2D experience, pain dropped from 5.4 to 4.8. In addition, the number needed to treat was only 4 compared with opioids, which has a number needed to treat of closer to 10.

In another study from Spiegel and his colleagues, some patients received a VR experience to manage their pain and some just watched TV. All patients had their pain drop over the course of the hospital stay, but there was a larger drop among the patients who had the VR experience compared with the TV experience (—1.72 vs –0.46). But perhaps more importantly, patients with more pain (>7 score) had a larger drop than patients with a lower score (–3.04 vs –0.93).

He did note that while VR works for all types of pain, that doesn’t mean it works for everyone or all the time.

“If we’re really going to help our patients with pain, we need to think about the nociceptive experience of pain, but also the emotional experience of pain,” Spiegel said. “And it appears that VR seems to help with both of them.”