Dec 10, 2021, 09:48 AM

Collaboration yields groundbreaking VR intervention for hemodialysis patients

When Rosalba Hernandez got an idea to turn the web-based positive psychological intervention for hemodialysis patients she helped create into a virtual reality program, she was excited by the potential.

But she wondered how she would bring the idea to fruition.

“I don’t know how to build a VR program,” thought Hernandez, a public health expert, cardiovascular epidemiologist, and associate professor in the School of Social Work at the University of Illinois Urbana-Champaign.

Then her dean told her about the Center for Innovation in Teaching & Learning’s (CITL) Virtual Reality Lab.

After reaching out to CITL, Hernandez teamed up with Digital Art Director Killivalavan Solai and Visual Media Designer Drew Fast, among others, on a study to examine whether the intervention was safe and effective when delivered on a VR platform.

Earlier this year, the pioneering study—“Mindfulness-based Virtual Reality Intervention in Hemodialysis Patients: A Pilot Study on End-user Perceptions and Safety”—was published in the journal Kidney360. Based on the results, the National Institutes of Health (NIH) awarded the team a nearly $1 million grant to further develop the intervention and conduct a larger trial. The Illinois News Bureau previously wrote about this study in this story. 

“CITL saw my vision and offered up their resources … so that it could become a reality,” Hernandez said of the collaboration that produced Joviality^TM, the first VR program to help hemodialysis patients during treatment and in their daily lives.

“Something that could have been too daunting, too stressful (to attempt) … became a joy to work on.”

Located in the Armory Building, CITL’s Innovation Spaces—including the VR Lab, Innovation Studio, and Innovation Classroom—were designed to foster discovery, innovation, and problem-solving across all disciplines on campus and beyond. Students, faculty, and staff can experience VR, AR, 3D scanning, 3D printing, drones, and other emerging technology as well as a one-of-a-kind iFlex classroom and learn how they could use them in their educational pursuits, courses, and research.

“We’re here to provide that initial spark of innovation … and to support innovation,” Director Michel Bellini said. “We want them to drop in; have a hands-on, interactive experience; learn how they can apply that experience to their educational pursuits, teaching, or research; and be inspired.”

The shift to positive psychological intervention, VR

Hernandez’s work on creating positive psychological interventions for patients with chronic diseases—including interventions for Hispanic/Latino patient populations that are delivered in Spanish and culturally appropriate—started nearly a decade ago when she was a post-doctoral fellow at Northwestern University. At the time, she was studying how depression, anxiety, and distress influence diabetes self-care in minority populations.
“There was so much research on the negative impact of depression, anxiety, and distress … and very little on positive psychological assets and resilience,” she said.

After researching correlations between positive emotions and improved health, Hernandez partnered with researchers at Northwestern on a study using a web-based positive psychological intervention—which she called ¡Alegrate! (Get Happy!)—to reduce depression and improve blood pressure control in Spanish-speaking adults with uncontrolled hypertension. Hernandez adapted an existing, five-week curriculum called MARIGOLD, developed by Northwestern medical social sciences Professor Judith T. Moskowitz, by translating it to Spanish and tailoring it to be culturally appropriate for patients.

When Hernandez came to the U of I, she began working with kinesiology and community health Professor Kenneth Wilund, whose research involved dialysis patients. Seeing the potential benefits of the MARIGOLD curriculum with that patient population, they partnered with Moskowitz to create a web-based intervention to reduce depression and alleviate boredom and side effects experienced during dialysis.

“This was our first time using a positive psychology curriculum in dialysis patients and the first time using a web-based delivery format,” Hernandez said.

While researchers saw a significant reduction in depressive symptoms in the trial, they also identified several obstacles with delivering the program via tablet computers.

One of the biggest: During dialysis, patients are attached to a machine via tubes that are inserted into their arm, so that arm must remain immobile during treatment. As a result, some patients had trouble using the tablet with one hand. Researchers also found that some older patients weren’t familiar with tech and didn’t know how to use the tablet and others didn’t like or weren’t able to read the lesson.

Then, the idea to use a VR platform came to her.

“VR seemed to overcome a lot of those barriers,” said Hernandez, who had gotten a VR headset to play escape room games.

While she used a controller to navigate with her system, an engineer friend told her that programs could be designed with a hands-free interface.

“And VR brings things to life, so we don’t have to have text,” Hernandez pointed out. “We can have a virtual human talking to the end-user. We also thought … we could gamify it and create activities that would bring the (positive psychology) messages home.”

Creating Joviality^TM

Hernandez shared her ideas for the VR program with Jim Wentworth, CITL’s Associate Director of Educational Innovation.

“I said, ‘I think this could be very innovative and impactful in helping patients. Would you be willing to partner with me and donate some of your time and the time of your staff to make it happen?’” she recalled, adding both Wentworth and Bellini were supportive and offered CITL’s help.

Wentworth put Hernandez in touch with Solai, who after learning more about her vision, tapped Fast as the tech lead on the program. Fast has a master’s degree in biomedical visualization and had created a VR program explaining the intricacies of the inner ear for medical and biomedical visualization students and was eager to use her expertise to help more patients.

Given their limited resources, team members decided to start by creating one of the intervention’s five modules—a mindfulness/meditation exercise—that was short and would be easier to develop.

In the beta program, when patients don the VR headset—anywhere from 30 minutes after starting dialysis to an hour before it ends—they’re transported to a virtual living room, where they find themselves sitting in a chair in front of a crackling flame in a fireplace. Next, Hernandez appears on a flatscreen TV above the fireplace and delivers the mindful awareness lesson and how they can apply the principles in their everyday lives to improve their emotional wellbeing.

Then, patients are transported to a surreal garden where Hernandez’s voice guides them through meditation exercises and teaches them how to be present in the moment. The program lasts about 25 minutes.

“We thought this was perfect for dialysis patients,” Hernandez said of the peaceful setting.
An optional beach scene for the meditation exercises has since been added.

Patients must undergo three- to four-hour-long dialysis sessions three times a week, Hernandez said.

“Many can’t travel because they have to adhere to their dialysis regimen. So, we wanted to take them out of that clinic setting for even 20 minutes a session.”

Development on Joviality^TM began with brainstorming sessions to decide what the patients would experience, what the virtual environment would look like, and what 2D graphic design, 3D modeling, video, and audio elements would be needed.

Then, the team created storyboards for every scene; created the environment and the related assets; and created the first prototype with basic programming for proof of concept/early testing.

After working with an independent programming studio but not being satisfied with the results, the team hired David Tamayo, then a student programmer at Illinois, to create a more sophisticated user experience for patients.

Solai and Fast had special considerations such as ensuring that participants could navigate the virtual world with the gaze of the eye or nod of the head due to their limited arm movement. They also had to ensure the experience didn’t cause patients any feelings of motion sickness or disorientation that VR can sometimes cause.

“It was an iterative process that took six months to a year to create,” Fast said, adding the team tested pilot versions on CITL colleagues “to get a feel for how things were going.”

“It was a lot of back and forth, but I loved that. It was truly a cross-disciplinary process … and I learned so much,” Hernandez said, adding that Solai did an “amazing” job of helping her identify the many pieces that would be needed and various personnel that would be involved and “laid everything out in a linear and understandable way.

“All three of us had the same goal—to make this software that dialysis patients could use and benefit from—and we were able to work on all of the steps as a team,” she said.

The pilot trial was conducted with 20 participants, ranging from 34 to 84, in Chicago and Urbana-Champaign area clinics with each participant receiving the 25-minute intervention twice in one week. Researchers were on hand if they needed assistance.

Hernandez was moved when she saw a dialysis patient wearing a VR headset on for the first time—and heard them say they enjoyed the experience.

“Many times, you approach them for a research study, and they’re feeling down, or they’re tired, and they just want to sleep and not be bothered,” she said. “When they saw that (the study) was VR, they were like, ‘I’ve never tried that before.’”

The participants filled out questionnaires about their experience before and after the intervention. The results also showed that the program was safe and helped alleviate depressive symptoms.

“We had some really good results,” Solai said. “Based on those results, we submitted a huge grant request with the NIH. Moving forward, we’ll be developing the rest of the modules …in a similar fashion.”

What’s next

Since receiving the three-year NIH grant, the team has been tweaking the first module based on participant feedback, including stylizing the virtual world to look less sci-fi and more realistic. Hernandez also recorded the lesson and guided meditation for the mindfulness module in Spanish.

The team will also create the remaining modules, which will take about a year. Other modules include Positive Events and Capitalizing, Gratitude, Positive Reappraisal, Focusing on Personal Strengths, Attainable Goals, and Acts of Kindness.

Each module will include an activity, putting the lesson into practice. For example, after learning how to notice positive events, “We’re going to take them outdoors for an interactive I Spy game where they will need to find different objects, including a bird or butterfly,” Hernandez said. “We want to build these new skills and make it even more interactive, so they get to play.”

Hernandez said the team is also planning to add new technical elements, including creating a virtual avatar to deliver the curriculum and recording some scenes with a 360-degree camera with live actors to make the virtual environment look and feel more realistic. Tamayo, who has since graduated, has since been hired as an external contractor to lead the programming.

When the entire Joviality^TM software is ready, researchers will roll it out in a randomized controlled trial with close to 100 patients. Unlike the pilot, this clinical trial will have a control group.

“Half of the group will use the VR program, and the other half will play video games on VR, and we’ll compare the different outcomes,” she said.

The study will also examine the effects on the participants’ emotional wellbeing, morbidity, longevity, self-care, etc., Hernandez said. Two nephrologists—Drs. Natalia O. Litbarg and James P. Lash—from the U of I College of Medicine Chicago—will also be involved.

Given the promising results of the smaller study, the researchers are hopeful that this study will show that Joviality^TM can help in the treatment of hemodialysis patients and that VR can be a safe and effective tool for delivering therapy to increase wellbeing and healing with other diseases and health conditions.

“The possibilities are endless,” said Hernandez, who is also partnering with the Grainger College of Engineering to develop a 3D program set in a grocery store to teach patients about nutrition and healthy eating and would like to see other cross-disciplinary projects as well.

“I feel like so much money and resources go into building things for entertainment and games,” she continued. “Hopefully, we will be at the forefront of harnessing some of those resources to build something educational—both in the delivery of psychotherapy interventions and making them high quality like these video games. I think that would be a game-changer.”

Are you interested in learning more about CITL’s Innovation Spaces? Contact us at citl-info@illinois.edu.