沉浸式医疗虚拟现实：还是一种新奇还是已经是必需品了？

Immersive medical virtual reality: still a novelty or already a necessity?

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Virtual reality (VR) technologies have been explored for medical applications for over half a century. With major tech companies such as Meta (formerly Facebook), HTC and Microsoft investing heavily in the development of VR technologies, significant advancements have recently been made in hardware (eg, standalone headsets), ease of use (eg, gesture tracking) and equipment cost. These advancements helped spur research in the medical field, with over 2700 VR-related articles indexed in PubMed alone in 2022, and the number of VR articles more than tripling in the last 6 years. Recently, the US Food and Drug Administration (FDA) also approved the first VR-based therapy for chronic back pain.1 虚拟现实（VR）技术在医疗领域的应用已经探索了半个多世纪。随着梅塔（前Facebook）、HTC和微软等主要科技公司在VR技术开发上的大量投资，最近在硬件（如独立耳机）、易用性（如手势跟踪）和设备成本方面都取得了重大进展。这些进步有助于刺激医学领域的研究，2022年仅PubMed就收录了2700多篇VR相关文章，VR文章的数量在过去6年中增加了两倍多。最近，美国食品和药物管理局（FDA）也批准了第一个基于VR的慢性背痛疗法。1

Whether the technology has reached a tipping point for its use in medicine is debatable, but it seems timely to provide a brief overview of the current state of immersive VR in neurology and related fields. In this editorial, we will discuss the characteristics of VR that make it a potentially transformative tool in healthcare, review some of the most mature VR solutions for medical use and highlight barriers to implementation that must be addressed before the technology can be widely adopted in healthcare. This editorial will focus solely on immersive VR technology and will not delve into the applications and use cases of augmented or mixed reality. 这项技术是否已经达到了在医学上使用的临界点是有争议的，但现在似乎是时候简要概述一下沉浸式VR在神经学和相关领域的现状了。在这篇社论中，我们将讨论使VR成为医疗保健领域潜在变革工具的特性，回顾一些最成熟的医疗用途VR解决方案，并强调在医疗保健领域广泛采用该技术之前必须解决的实施障碍。这篇社论将只关注沉浸式VR技术，而不会深入研究增强现实或混合现实的应用和用例。

Characteristics of VR VR的特点

VR is a technology that allows users to interact with and experience a simulated environment.2 The technology typically involves the use of a headset or other device that displays a 3D computer-generated environment, as well as sounds and haptic feedback, and input devices to create a fully interactive immersive experience. The immersion establishes a sense of presence3—a user’s subjective feeling that they are actually present in the virtual environment. This subjective sense of presence is modulated by the employed technology4 and is enhanced by the use of head tracking and other technologies that allow the user to move around within the virtual environment. Medical VR applications take advantage of the technology’s ability to elicit emotional responses, convey spatial information and provide a sense of presence in a simulated environment. Typically, the applications use engaging VR experiences while providing a safe and controlled environment for failsafe practice, learning, distraction, relaxing or treatment.5 VR是一种允许用户与模拟环境交互并体验模拟环境的技术。2 该技术通常涉及使用显示3D计算机生成的环境以及声音和触觉反馈的耳机或其他设备，以及输入设备来创建完全交互式沉浸式体验。沉浸感建立了一种存在感 3- 用户实际上存在于虚拟环境中的主观感觉。这种主观的存在感是由所采用的技术调制的 4并且通过使用头部跟踪和允许用户在虚拟环境内四处移动的其它技术来增强。医疗VR应用利用了该技术在模拟环境中引发情感反应、传达空间信息和提供存在感的能力。通常情况下，这些应用程序使用引人入胜的VR体验，同时为故障保护实践，学习，分散注意力，放松或治疗提供安全和受控的环境。

Examples of more mature VR solutions for medical use 更成熟的医疗VR解决方案示例

The range of trialled medical VR applications is vast and their maturity varies widely, with some still being in the proof-of-concept stage and others having been evaluated in high-quality randomised control studies (RCTs). Some of the strongest evidence for the effectiveness of medical VR is in the areas of mental health interventions, pain management and medical training. 试验的医疗VR应用范围很广，它们的成熟度差异很大，其中一些仍处于概念验证阶段，而另一些则已在高质量的随机对照研究（RCT）中进行了评估。医疗VR有效性的一些最有力的证据是在心理健康干预，疼痛管理和医疗培训领域。

Mental health interventions心理健康干预

VR has been shown to be an effective treatment for various psychological conditions, including phobias,6 Posttraumatic stress disorder (PTSD)7 and anxiety disorders.7 For example, a single-blind RCT in 346 patients with psychosis found significant reductions in agoraphobic avoidance and distress in the VR plus usual care group compared with the usual care group.8 Patients with severe avoidance at baseline demonstrated large VR treatment effects even at the 6-month follow-up.8 A meta-review of 11 meta-analyses on VR therapies for psychiatric disorders found medium-to-large effects for anxiety-related disorders when compared with inactive controls. However, no meaningful differences were found when VR was compared with standard evidence-based interventions.9 The lack of statistically significant differences necessitates thoughts and further research into the best use cases for each intervention. VR已被证明是各种心理状况的有效治疗方法，包括恐惧症， 6 创伤后应激障碍 7和焦虑症。7 例如，在346例精神病患者中进行的一项单盲随机对照试验发现，与常规护理组相比，VR加常规护理组的广场恐惧回避和痛苦显著减少。8 基线时严重回避的患者即使在6个月随访时也表现出较大的VR治疗效果。8 对11项关于VR治疗精神疾病的荟萃分析进行的荟萃审查发现，与非活动对照组相比，VR对焦虑相关疾病的影响为中等至较大。然而，当VR与标准循证干预措施进行比较时，没有发现有意义的差异。9 缺乏统计学上的显著差异需要思考和进一步研究每种干预措施的最佳用例。

Pain management疼痛管理

VR is effective as an intervention to control acute pain during medical procedures.10 11 For example, a randomised, crossover study reported a 39% reduction in opioid medication when using VR during painful medical procedures compared with the non-VR condition.12 While less researched than VR interventions for acute pain,13 there are also promising results for chronic pain management.14 This includes an at-home VR intervention for chronic lower back pain, which produced clinically meaningful symptom reduction in pain intensity and pain-related interference.15 While these findings are encouraging, more rigorous high-quality RCT studies are needed13 and unanswered questions about the optimal frequency and dosage of interventions, as well as the durability of any treatment effects remain. VR是一种有效的干预措施，以控制急性疼痛在医疗程序。10 11例如，一项随机交叉研究报告称，与非VR条件相比，在疼痛的医疗程序中使用VR时阿片类药物减少了39%。12 虽然对急性疼痛的研究比VR干预少，13但对慢性疼痛管理也有很好的结果。14 这包括针对慢性下背痛的家庭VR干预，其在疼痛强度和疼痛相关干扰方面产生了临床上有意义的症状减轻。15 虽然这些发现令人鼓舞，但仍需要更严格的高质量随机对照试验研究13，并且关于干预的最佳频率和剂量以及任何治疗效果的持久性的未回答问题仍然存在。

Medical training医疗培训

There is evidence that VR can be an effective tool for medical training16 in addition to its use with patients. For example, VR simulations can improve surgical skills, especially in comparison to non-VR traditional training.17 A meta-analysis of 15 RCT studies using VR to teach anatomy found moderately improved anatomy test scores compared with other teaching approaches.18 There is also emerging evidence that VR simulations are useful for non-technical skills, such as training empathy,19 that are essential for providing high-quality patient care. 有证据表明，VR可以成为医学培训的有效工具 16除了用于患者之外。例如，VR模拟可以提高手术技能，特别是与非VR传统培训相比。17 对15项使用VR教授解剖学的RCT研究进行的荟萃分析发现，与其他教学方法相比，解剖学考试成绩略有提高。18 还有新的证据表明，VR模拟对非技术技能有用，例如训练同理心， 19 这对于提供高质量的病人护理至关重要。

Barriers to implementation执行障碍

The accumulated evidence for the effectiveness of at least some medical VR applications will aid in the removal of roadblocks to their implementation. Some of the most significant barriers to broader adoption of medical VR in hospitals, which are not necessarily mutually exclusive, include: 至少一些医疗VR应用的有效性的累积证据将有助于消除其实施的障碍。在医院中更广泛地采用医疗VR的一些最重要的障碍，不一定是相互排斥的，包括：

Content内容

Current medical VR knowledge is primarily based on the evaluation of research prototypes. The heterogeneity of the VR systems (eg, display type, method and amount of interaction) and the content (eg, how the tasks and activities are introduced, presented and measured) impact outcomes. The lack of generalisation, combined with a lack of standardisation, makes demonstrating evidence for specific VR applications time-consuming and costly. As a result, there are currently very few readily available commercial VR applications to choose from that have proven their effectiveness. 目前的医学VR知识主要基于对研究原型的评估。VR系统的异质性（例如，显示类型，方法和交互量）和内容（例如，如何引入，呈现和测量任务和活动）影响结果。缺乏概括性，加上缺乏标准化，使得为特定的VR应用程序展示证据既耗时又昂贵。因此，目前几乎没有现成的商业VR应用程序可供选择，并已证明其有效性。

Data use and regulatory barriers数据使用和监管障碍

Uncertainty around regulations related to data collection, storage, ownership and use are considerable barriers to use of VR. There may be regulatory obstacles to implementing VR technology in hospitals, such as obtaining approval from relevant governing bodies before using the technology. In the USA, for example, the FDA regulates medical devices, including VR technology used in a medical setting. Hospitals may also be required to follow other medical technology-related regulations, such as those governing patient privacy and data security. The parent companies of two leading VR headset manufacturers (Meta and ByteDance) operate social media platforms that collect large amounts of personal data for advertising and other purposes. Good solutions must be found to ensure that the collected data is not misused or disclosed without the individual’s consent. These regulatory requirements can increase the cost and complexity of implementing VR in hospitals, potentially impeding immediate widespread adoption. 与数据收集、存储、所有权和使用相关的法规的不确定性是使用VR的相当大的障碍。在医院实施VR技术可能存在监管障碍，例如在使用该技术之前获得相关管理机构的批准。例如，在美国，FDA监管医疗设备，包括医疗环境中使用的VR技术。医院还可能被要求遵守其他与医疗技术相关的法规，例如管理患者隐私和数据安全的法规。两家领先的VR头显制造商（梅塔和字节跳动）的母公司运营社交媒体平台，这些平台收集大量个人数据用于广告和其他目的。必须找到良好的解决方案，以确保收集的数据不会被滥用或未经个人同意而披露。这些监管要求可能会增加在医院实施VR的成本和复杂性，可能会阻碍VR的立即广泛采用。

Proof of cost-effectiveness成本效益证明

The cost-effectiveness of VR technology in hospitals has not yet been well established. One study found that VR therapy for pain management saved US$5.39 per patient, compared with usual care, due to lower opioid use and hospital length of stay.20 A randomised clinical trial in senior orthopaedic surgery residents found that not only was VR training superior to technical video training for the acquisition of procedural knowledge and decision-making, but it was also 34.1 times more cost-effective than the control group training.21 A return on investment analysis for a US$300 000 VR delivery (including staff, equipment, software and consumables) revealed a loss of US$38 and cost savings of US$6.79, with 5000 and 20 000 hospital admissions, respectively.20 The analysis, done with the assumption of a 19.3% eligibility and acceptance rate for VR pain interventions, nicely demonstrates the importance of scale. VR技术在医院的成本效益尚未得到很好的确立。一项研究发现，与常规护理相比，用于疼痛管理的VR疗法为每位患者节省了5.39美元，这是由于阿片类药物的使用和住院时间较低。20 一项在骨科住院医师中进行的随机临床试验发现，VR培训不仅在获取程序知识和决策方面上级技术视频培训，而且其成本效益也是对照组培训的34.1倍。21 对价值300，000美元的虚拟现实交付项目（包括人员、设备、软件和耗材）的投资回报分析显示，分别有5，000和20，000名住院患者损失了38美元，节省了6.79美元。20 该分析假设VR疼痛干预的合格率和接受率为19.3%，很好地证明了规模的重要性。

Competency development能力发展

Lack of training and familiarity is a major barrier to the adoption of VR technology. Technological competence, knowledge of the safe use of VR (eg, monitoring for cybersickness, infection control, mitigating the risk of physical hazards such as falls) and the selection of appropriate VR content for a specific patient are required. Many healthcare professionals will lack the necessary skills to use VR effectively. The issue of competency development is amplified by the rapid pace of hardware and VR application developments, with new versions being introduced constantly and headsets becoming outdated within years. The rapidly evolving medical VR field poses significant challenges for developing and sustaining staff competency. A lack of competency undermines not only the acceptability to use the technology, but also impedes buy-in from all stakeholders, including clinicians, senior administrators and IT professionals. 缺乏培训和熟悉是采用VR技术的主要障碍。需要技术能力、安全使用VR的知识（例如，监测电脑病、感染控制、减轻福尔斯等身体危害的风险）以及为特定患者选择适当的VR内容。许多医疗保健专业人员将缺乏有效使用VR的必要技能。硬件和VR应用程序的快速发展加剧了能力发展的问题，新版本不断推出，耳机在几年内就会过时。快速发展的医疗VR领域对开发和维持员工能力提出了重大挑战。缺乏能力不仅破坏了使用该技术的可接受性，而且还阻碍了所有利益相关者（包括临床医生，高级管理人员和IT专业人员）的认可。

Conclusions结论

Advances in VR technology and the accumulating evidence for the effectiveness of VR for some medical applications in the last decade are promising. They provide critical stepping stones towards the wider adoption of medical VR. Further evidence demonstrated in high-quality trials,10–13 linking applications to theoretical frameworks,13 shedding light on mediating outcome factors (eg, content, dosage, frequency, patient characteristics), improving ease of use, and evidence for VR’s cost-effectiveness are required for broader acceptance and medical VR uptake. 在过去的十年中，VR技术的进步和VR在某些医疗应用中的有效性的积累证据是有希望的。它们为更广泛地采用医疗VR提供了关键的垫脚石。高质量试验中证明的进一步证据，10-13将应用与理论框架联系起来，13阐明介导结果因素（例如，内容，剂量，频率，患者特征），提高易用性，以及VR成本效益的证据，都需要更广泛的接受和医疗VR吸收。

The high level of academic research activity, combined with massive investments from established companies such as Meta, and the rise of numerous start-up companies in the field provide an ecosystem that has the potential to drive the growth and adoption of medical VR. However, moving from development and pilot evaluation activities to commercially available and evidence-based VR applications will take time and a widespread use in the medical field is still years away. While VR is undeniably a promising technology, it still has a long way to go before becoming a necessity and to live up to its potential to transform healthcare. 高水平的学术研究活动，加上梅塔等老牌公司的大量投资，以及该领域众多初创公司的崛起，提供了一个有可能推动医疗VR增长和采用的生态系统。然而，从开发和试点评估活动转向商业化和基于证据的VR应用需要时间，并且在医疗领域的广泛使用仍然需要几年时间。虽然VR无疑是一项很有前途的技术，但在成为必需品并实现其改变医疗保健的潜力之前，它还有很长的路要走。

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