29/08/2022 | BlogPost
Chronic pain is a major public health problem. At a population level, in 2019, back pain alone was the leading global cause of prolonged disability, and conservative estimates predict that 20% of people report disability and distress from untreated pain. This population burden is stable across countries and is growing.
There are pharmacological interventions for chronic pain aimed primarily at analgesia, which have had limited success. Psychological interventions aimed at promoting self-management of pain and re-engagement in valued life activities are effective and have been adopted in guidelines as the minimum standard of care, however, their availability is scarce.
Digital therapeutics (DTx) have emerged as a potential solution to the problem of scaling effective psychological interventions for chronic pain management.
Virtual reality (VR) technologies generally offer significant opportunities in psychotherapy and, more profoundly, in pain management and rehabilitation. Virtual reality can enable existing treatments to be offered at scale through automation, but it can also improve the content and impact of both assessment and intervention. Although there are many reports of VR for analgesia and sedation, there are few examples of attempted use in chronic pain.
Orion Corporation wanted to develop a novel virtual reality-based treatment that provides advice and instruction for self-management of adults with chronic back pain who want more valued activity and improved function.
We started the work on this project in 2018. From the beginning, we were helping Orion to design and develop the solution. We followed design thinking principles which began with extended information gathering. We conducted various interviews with pain patients, as well as physiotherapists, gamification experts, and other professionals who could help us build a successful experience.
After the research phase and analyzing results, we began to prototype. We worked our way from paper prototypes through computer mockups to actual virtual reality demos. One of the UK’s leading pain psychologists Christoper Eccleston and professionals from Orion built hours and hours of cognitive behavioral therapy dialogue to support the physiotherapeutic movements in the experience. Slowly but surely the development proceeded, and while testing different versions of the product, we received a growing number of indications that we were building something that works.
The experience we built was becoming an extensive intervention for adults with chronic low back pain and high fear of movement. Finally, in late 2019 the first version of the product was ready, including different activities, three different areas, and six-week-long verbal and written therapy.
In early 2020 Orion started a clinical trial to test the efficacy and safety of the product. In the fully immersive environment, patients were guided by a mentor who provided health information and tasks to perform. Although the mentor was introduced as a person, it lacked an avatar and the therapeutic content was delivered as audio and written text on screen. The trial was a randomized, controlled trial comparing the active virtual reality intervention with a sham placebo comparator as well as a standard care group. The primary aim of this study was to determine any comparative efficacy and report any adverse events.
After the study was ready and the results were analyzed, even we were surprised by the excellent results.
During the six-week-long trial, patients’ fear of movement had reduced significantly, their quality of life had improved, and they perceived these changes were for the better.
The study was peer-reviewed and a research paper was published in 2022 in the PAIN journal.
*The cover for the issue was designed by our very own Art Director Marjo Noukka.
Encouraged by these great results, Orion tasked us with building an even better, commercial version of the experience. For this version, we aimed to improve the mentor function and appearance for adults with chronic low back pain. In particular, we decided that the mentor should appear as a physically animated humanoid rather than text or audio alone. From there, we set out to design this Semi-Autonomous Mentoring Intelligence (SAMI), a non-human agent, scripted to engage with a user and guide them on a pain management intervention. SAMI was semi-autonomous, meaning that she could react to certain situations, but relied on pre-programmed patterns and therapy. SAMI was designed to be as credible, effective, and persuasive as possible.
The new experience also included new and visually upgraded environments, allowing more variability in the activities as well as more credibility and immersion. On top of these improvements, many new functionalities were developed, and we used professional audio engineers to plan the soundscapes for each environment.
Another research article was written and reviewed for the Frontiers publication about SAMI. Even though several people from our team were involved in creating her, especially Marjo Noukka who created her visual look and Lauri Rustanius who made her alive, Joonas Turunen oversaw the design of the virtual reality experience and how SAMI operates. He was thus also involved in writing the publication.
The article reviews evidence of the decisions we took when designing SAMI. It was not intended to be an exhaustive description of how best to design a virtual mentor, but a summary and explanation of some key aspects for researchers and developers to consider when developing virtual mentor interventions, and a springboard for others to build on. The final results of the article describe thorough considerations and recommendations for researchers involved in designing future virtual reality characters.