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I | Acknowledgement

First of all, to Allah, who made all things possible. Al'hamdhulillah.

A special thank goes to my helpful Research methodology module facilitator, Miss. Nur Leila
Khalid. The supervision and support that she gave truly helped with the progression and
smoothness of the research. Her guidance to produce a proper report and keen interest in
understanding our problems throughout the semester was a comforting blanket which
minimized the stress load and her co-operation is much appreciated.

My grateful thanks go to the participant of the interview discussed in this report. Dr.
Bertalan Meskó, MD, University of Debrecen, Medical School and Health Science Center for
the timeless effort and instant interest to participate in the interview. Great deals of
appreciation go to the participants of the questionnaire. Even some of them being outside
the country and answering through email, helped a lot in collecting valid and saturated
information.

I would like to thank all my friends, classmates especially those who work together in solving
conflicts, discussions and reviewing.

Another vote of admiration goes to my family for their never ending support in my studies
and my mom and dad , Ms. Aminath Ibrahim and Mr. Ibrahim Ali and of course my dear
siblings, more than ever my sister, Mausoodha Ibrahim.

Lastly For his endless care and love, I thank my best friend Abdollah Kheitan.

Thank you!
Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

II | Table of Contents

Table of Contents

1. Introduction of Research ................................................................................................................... 2
2. Objectives .......................................................................................................................................... 4
3. Findings .............................................................................................................................................. 5
3.1 Introduction .................................................................................................................................. 5
3.2 Target Audience ............................................................................................................................ 6
3.3 Primary Research .......................................................................................................................... 7
3.3.1 Interview Feedback Summery .......................................................................................... 7

3.3.2 Questionnaire Feedback Summery ................................................................................. 12

3.3.3 Self Observation Survey .................................................................................................. 27

3.3.4 Public Observation Survey .............................................................................................. 33

3.4 Secondary Research .................................................................................................................... 36
3.4.1 Literature Review. ........................................................................................................... 36
4. Conclusion ........................................................................................................................................ 47

5. Reference List .................................................................................................................................. 49

6. Bibliography ..................................................................................................................................... 54

7. Appendix .......................................................................................................................................... 55

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

1. Introduction to Research

Today, the world has come to a saturation point where multimedia technology has the
monopoly over various aspects of our life, may it be beneficial and in some other cases,
even destructive. Likewise, branching from the creative multimedia portal, emerges the so
powerful animation, both 2D and 3D, which easily plays with human emotions and interacts
with our social behavior directly or indirectly. In a higher class practical, when animation is
applied to submerge in reality and idealism it is then called Virtual Reality. Bringing the
attention of the public to virtual reality and increasing the awareness of the technology is
crucial at such a time where time flies by to produce industrial revolutions.

Virtual reality (VR) can be applied in a variety of ways. In scientific and engineering research,
virtual environments are used to visually explore whatever physical world phenomenon is
under study. Training personnel for work in dangerous environments or with expensive
equipment is best done through simulation. Airplane pilots, for example, train in flight
simulators. VR can enable medical personnel to practice new surgical procedures on
simulated individuals. As a form of entertainment, VR is a highly engaging way to experience
imaginary worlds and to play games. Virtual reality also provides a way to experiment with
prototype designs for new products.

While its use is still not widespread, Virtual Reality is finding its way into the training of
health care professionals. Use (Delingette 2009) ranges from anatomy instruction to
surgery simulation. Annual conferences are held to examine the latest research in utilizing
virtual reality in the medical fields such as to find cures for diseases, finding vaccines,
applicable therapies and how this empowered technology can perform medical procedures
that are so complicated (referred to as micro surgery) with precise percussion. Research
field for the use of Virtual Reality is Physical Medicine and Rehabilitation and Occupational
Therapy.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

Using virtual reality in conjunction with traditional therapy for burn patients has proved to
be very effective in relieving pain during wound care, bandage changing, or staple removal.
Pain perception is in part psychological and needs focus, when patients are introduced to
virtual reality the attention is focused on the artificial environment so the pain signals can
be interpreted as painful or not.

These VR simulations can benefit the medical community in many ways. For example, they
can lower the cost of training doctors by providing reusable patients that can be operated
on repeatedly. They can provide assistance to doctors in performing difficult or complex
procedures. They can reduce the need for animal experimentation, and make medical
information more accessible for remote consultations.

The 3-D display technology used in virtual reality is also constantly being improved, as is the
processing capability of the computers used to render the VR data. As they create truly
realistic VR, researchers are even taking the sense of smell into account. Smell can be an
important part of diagnostics. Chapman (2009) highlights that these projects are in relatively
early stages of development, and completion will require a great deal of work in business
terms. Although these virtual hospitals are not yet a reality, the popularity of medical VR as
a research subject promises that advances in the technology will continue, and such
futuristic applications may soon be realized.

_____________________

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

2. Objectives

The author has some important research objectives and are the main base by which the
author would carry out the procedures of analysis. Below are the objectives of this research
report.

• To learn the possibilities of applying virtual reality and animation in medical
procedures.
• To evaluate and find the usefulness of VR in medical studies.
• To discover the challenges faced current Virtual reality systems and its pros and
cons.
• To know what is there in the Virtual reality market in the upcoming future.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

3. Findings
3.1 Introduction

Research methodology and analysis were done in three ways. Firstly, a questionnaire was
prepared with questions regarding the understanding and its application in medicine to
evaluate the knowledge base of the public. It was hard to finalize general theme questions
for the questionnaire because the author had a difficulty in introducing the whole concept
of virtual reality with relation to medicine and animation. Therefore the questions were long
and had to be designed in such a way with examples of virtual reality so that the respondent
can visualize what they have been asked for. The answers were later analyzed to extract
information. The results were compiled as pie charts and percentages along with brief
explanation and comments from the author, to make it easier to compare the
understanding levels of respondents. Few respondents had some difficulty in answering but
most were surprised and eager to know more of virtual reality once they had completed
answering the questions. It was an opportunity to comprehend how most people would
react given that they have chance for virtual reality experiences for granted.

Interviews were also done with people who were working in the field of Virtual reality. The
author presented questions which he wanted to clarify about. It was a hindrance to get in
touch with people in medical field, get an approval from them for interview invitation
because their schedules where busy. Other than that, the interviews had to be made
through online contact since there were no hospitals or institutions practicing VR in the
country where the author resided. However this was an opportunity to get information from
professionals who have a broad background information on what they are doing. The major
ideas and information derived are analyzed and summarized in the Interview feedback
summery of the report.

Finally, the author himself made observations. Self observations were carried out and as
researcher, participated in the applications of virtual reality and evaluated the reactions he

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

got when he experienced the VR. Another observation was made on public, to study how
they react, and as a researcher, author did not get concerned in the applications but
remained a passive observer, watching and listening to the reactions of participants and
drawing conclusions from this of the group being observed in the same manner as its
members, with or without their knowing that they are being observed. Due to restrictions of
VR simulators, videos about it were shown to people. Some of them became too mechanical
on realizing that they are being watched. Negative and positive effects were easy to
comprehend from these observations. The analysis report is included in the observation
section of primary research content of the report.

3.2 Target Audience

This research is for individuals and groups who are in the medical field and animation field
combined. The report would especially help doctors, medical students, animators who are
making the virtual reality environments, and people who are producing, designing and
engineering the hardware and software for VR, patients who are undergoing or people who
want to understand the impact and implications of VR in medicine and finally business
industries seeking new medical technology to distribute. It can act as a statistical guide for
the above mentioned audiences.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

3.3 Primary Research

3.3.1 Interview feedback summery

The author got the chance to interview, Dr. Bertalan Meskó, MD at University of Debrecen,
Medical School and Health center, a last year medical student, medical blogger at
Scienceroll.com and micro-blogger who had won several awards, such as Young Student
Award for his contribution at SMIT 2008 (August, 2008), Student Excellence Award 2008 at
Hungarian Medical Association of America, Bloggers' Choice Awards Best Healthcare Blog

2007: Scienceroll.com and at Twitter.com known as Berci. He is also the founder of the first
medical web 2.0 guidance service at Webicina.com and he recently launched the first
university credit course for medical students that focuses on web 2.0 and medicine.

Other than that Dr. Meskó has given lectures at several clinics and departments at the
Faculty of Medicine of the University of Debrecen. He had given presentations at the
Medicine Meets Virtual Reality Conference (Long Beach, CA in 2008 and 2009); at the
University of Yale, School of Medicine, at the centre of World Health Organization, at the
Medicine 2.0 Congress in Toronto or at the clinics of Greenwich, among others.

Dr. Meskó was interviewed through online contact at the beginning of October 2009. The
first question raised was if he knew about any companies that are working on creating true
virtual reality. He answered that It depends on what you mean by true virtual reality. There
are companies that are focusing on and developing virtual environments for organizing
meetings and conferences (Second Life, Visuland.com, etc.). There are also companies that
are developing VR masks and force-feedback solutions, but as far as he knew, there aren’t
companies that aim to develop virtual reality devices mainly for medical education.

A follow up question was brought and the author wanted to know how far are they along if
there were any such companies. Despite of saying that the progression is stunned on VR,
doctor did mentioned about a conference held in Long Beach, CA to share some of the new
technologies brought into the existence of Virtual reality.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

"I attended this year’s Medicine Meets Virtual Reality conference in Long Beach, CA and
there was a long discussion about what kind of VR devices could be used in medical
education or diagnostics. I saw a few examples myself...I had a chance to try a VR mask that
lets you orientate while you are logged into Second Life. It was a useful experience because I
realized even if the concept was promising, there were still a lot of areas where serious
development was needed."

That meant that there are some boundaries and barriers which are blocking the
development of VR. It would be a wise idea to understand what these challenges are in
developing and creating Virtual reality machines in a fashion the industry will greatly accept
and appreciate. He noted that the biggest challenge was to determine whether virtual
reality systems are useful at all in education or in diagnostics as it’s still not clear. He
believes these are only useful if we have to face geographical or financial limitations; or
when the tissue or biological system cannot be discovered properly without VR devices (e.g.
neural imaging before surgeries).

If this is the case, as some might expect would VR ever so become indistinguishable from
"regular" reality to experience close call phenomenon's that mocks our true world with use
of complicated complex apparatus? Well, he hopes that it will not because albeit VR devices
may have an immense future and may revolutionize some field of medicine, but we always
have to keep one important thing in mind; these are just additional tools in the hands of
clinicians and therefore should never substitute the real process of practicing medicine. He
also quoted a saying from one of his neurology professors. “You have to feel, touch, see and
smell the patient yourself.”

This answered doubts about imaginary expectations on VR, therefore the author
concentrated more on finding reactions on the current VR systems in general. Since it is
becoming somewhat a popular research and practice that these machines are used in
teaching and educating medical students, especially the well known surgical simulators. The
efficacy of simulators like these plays an important role in further development of VR.
Nonetheless the effectiveness again, as doctor mentioned, it depends on the circumstances.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

"We, at the Ann Myers Medical Center in Second Life, organize case presentations and
medical meetings regularly. In these meetings, professors present their favorite cases
through patient histories, images and videos, and then medical students have to come up
with the proper diagnosis. In this example, VR masks would be useful because it would
make the whole process even more realistic as we can also listen to cardiac or lung sounds;
examine the patient and check pulse, oxygen saturation, etc. VR devices and force-feedback
tools would help students get to the solution more easily."

There are so many types of medical instruments and the technology immersed with
different types of hardware and software to run them. Dr. Meskó shared references to some
internet links containing lots of information on what is implemented in VR today. Some of
them are mentioned below for anyone who is interested.

1. Use (Meskó 2009) of VR in Addiction Medicine. During the exposure, participants are
encompassed within a sensory isolation apparatus, including a 32” LCD monitor and a
surround-sound audio system. Participants interact with the specially created virtual world
in Second Life, run from a standard Dell PC, using a simple gaming remote control. An
additional monitor is placed outside of the apparatus for outside observation. This method
can be used in behavioral pharmacology research and it also makes it possible to improve
cognitive behavioral treatments and exam drug taking behavior in a naturalistic
environment.

2. HITLab (Medgadget.com 2007) at the University of Washington has been working on the
SnowWorld project, a virtual reality simulation of a frozen world, in which burn patients can
play games involving snow, which actually lets them forget the pain.

3. NeuroTouch (Meskó 2009), the prototype simulator developed by Canada’s National
Research Council (NRC) and several other research groups, gives surgeons a dry run in
virtual reality before entering the operating room, potentially reducing mistakes.

4. Virtual (Meskó 2009) Patients and Guinea Pigs are used to practice surgeries.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

5. VOXEL-MAN (Meskó 2009) provides state of the art surgery simulators and virtual body
models.

6. Simulated biopsies in 3D environment.

7. Gaze-Driven (Eyeseecam.com 2009) head mounted Camera: EyeSeeCam is a unique and
award-winning camera system that is controlled with the eyes. It is the only system that can
record what the eyes of its user really see. Unrestricted user mobility and field of view as
well as the utilization of biological image stabilization reflexes are main benefits of
EyeSeeCam.

8. Psychiatric (Medgadget.com 2005) VRx: Virtual reality therapy, Georgia State University is
beginning a clinical trial to determine the effectiveness of virtual reality therapy for the
treatment of public speaking phobia.

9. Laparoscopic (Medgadget.com 2005) Virtual Laparoscopy for Surgeons.

10. PerioSim (Medgadget 2008) Force feedback Dental Simulator: Researchers at the
University of Illinois at Chicago are working on optimizing heptic interactive technologies to
be more realistic and practical for fine hand work such as dentistry, and have released a
dental training simulator called PerioSim that utilizes much of their work.

With all these equipments and procedures involved in VR , mostly in research there could be
the possibility of some accidental fatalities. But he thought there is but mainly in psychiatry
where the patients are more vulnerable. Though, he still believed that we can come up
much more pros than cons when talking about VR devices in healthcare. So the typical
scenarios of such events are rare and negligible.

Talking about the challenges shows there should be improvements. Dr. Meskó says " There
are 3 areas where virtual reality must improve in general. First, we have to prove such
applications have a reason for existence in medicine and healthcare. Second, VR devices
must be developed than can be directly used in practice. And third, force feedback should

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

be a major addition to virtual realities in order to make virtual processes as realistic as
possible."

Of course with all these new technology being brought into the world, there are some very
interesting achievements made in medical history. I can be said that these are major
stepping stones in the field of health care and we can expect the unexpected. He mentioned
surgery as the perfect example in this aspect. Using VR devices in the education and training
of surgeons improve their skills according to recent studies; and also it improves patient
safety, and he forwarded a British Medical Journal, BMJ (2001) article that addresses this
issue in details.

The last question asked was of the expectations in the near future of Medicine. There are
some areas such as surgery, diagnostic imaging, medical education where we can really
expect VR to initiate improvements. But in the bravest fantasies, there might be patient who
will want to communicate with their doctors online via VR solutions or doctors attending
meetings for free without travelling thousands of kilometers.

It was a pleasure meeting and citing his answers on the report.

__________________________

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

3.3.2 Questionnaire Feedback Summery

The author distributed the some general questions regarding the research. (The set of
questions given to the respondents is included at the end of this report). Out of 50
respondents, some of the respondents replied the questionnaire through email and were
from different nationalities. Others were handed with printed copies of the questionnaire.
Below are the feedback received and analyzed according the questions given.

__________________________________________________________________________________

Age groups of correspondents

6% 14%
12% 14-19 yrs

16% 20- 25 yrs
25-30 yrs
52%
31- 40 yrs
41 and above

Description:

There were 6% of respondents who are of age 41 and above. 12% were between the age 31
to 40 years, and a close 14% were between the age 14 to 19 years. 16% were of 25 to 30
years old. The highest number of people who participated were of age between 20 to 25
years old.

It was very difficult to convince most adults to participate in the questionnaire because they
were either busy at work or rushing for and from work. That is only 3 people among the
crowd of 50.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

The close percentages for age 14-19, 25-30 and 31-40 are because they were not very
enthusiastic to look over the questionnaire.

The highest crowd of participants at 52% age from20 to 25 years, and this is because the
area which the printed questionnaire were distributed were full of students going to
universities. They were willing and eager to help answer the questions when mentioned
"Virtual reality".

Percentage of Genders who took the questionnaire

44%
Male
56%
Female

Description:

56% were males and 44% were females.

There were more males than females at vicinity and they easily accepted to take the
questionnaire while the females were a bit fussy and judgmental when approached with the
questionnaire. However it was not much of a difference, females also did answer to a close
proximity to male percentage.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

QUESTIONS
1. Have you ever experienced ANY form of virtual reality?

50%
50%
Yes
No

Description:

50% said yes, they have experienced some form of virtual reality but 50% also said they
have not experienced any type or form of virtual reality.

Amazingly this shows a tie between experience. It was expected that more people would
have not at all had a virtual reality experience than having an experience, but somehow it
reveals 1/2 of the population might have had a virtual reality experience before they turn 30
years. This might be because the majority of the participants were of youths (20-25 years)
and their probability of having virtual reality experience will be more, thus balancing off the
rest who said "No".

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

2. The applications which respondents know, that uses virtual reality

Games
12% 18% Graphics
11% Medicine
14%
13% Forensics
12% Human Interfaces
10%
10%
Space Exploration
Crime Investigation
Environment Design

Description:

A lot of the respondents know that virtual reality is used in games. They are averagely more
aware of the application of virtual reality in games by almost 5%, giving an overall
understanding of virtual reality in games an 18%. It might be because of the fact that they
might be assuming games as the doorway to 3D or confusing 3D in games as virtual reality
and not as it as an entirely different form of interaction.

The usage of virtual reality in Graphics and certain cases of scientific space exploration,
(simulation of universe, star clusters, planets, cosmic energy etc for studies) is known by
14% and 13% respectively. It can be due to the similarity in simulation of these two virtual
realities since both are more for viewing and studying than anything else.

Both Medicine, and Environment design in VR is known by 12% of respondents. It is in a
middle category of awareness as seen by the pie chart above. Half of the total know virtual
reality is used in environment design and medicine. This gives somewhat 50% certainty on
authentic answers regarding knowledge base questions on virtual reality in medical field for
the rest of the questionnaire.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

VR in Crime investigation is acknowledged by 11% of the crowd. Very close to medicine and
environment design, but crime investigation is actually the forerunner of medicine in VR
business.

The least understood applications of VR are in Forensics and Human interfaces (interactive)
by only 10%. It could be because of the term forensics is not literally understood by most of
the respondents. A higher percentage for these two might have occurred if the definitions
was given next to it. Likewise for Human interfaces.

NOTE: Respondents can choose more than one option, therefore gives cumulative
percentage scores.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

3. Under what circumstance will you accept a virtual reality surgery?

Just to try the difference
12% 18%

If I have enough money
28%
42%
If there is no other
medical cures
Never

Description:

42% of the people said, they will accept a virtual reality surgery (where the doctor can
operate the patient via satellite connection even if they are in different time zones using
some virtual reality applications), if there is no other medical cures for their medical
calamity.

28% of them will do it if they are financially secure. Their reasoning might be because they
already know of such treatments and that it works too yet its pricy.

Some of them will take a VR surgery just to try the difference. Their minds would have
probably thought of small surgeries with minor side effects and implications, but roughly it
is 1 in every 5 person.

The rest 12% would never take a virtual surgery. Even though the percentage is a small
amount, they are of great intellectual significance to the questionnaire because they will
give proper answers on the negative aspects of VR in medicine, which can give ideas to
establish better hallmarks in medical field and raise up VR's current benchmarks.

4. If virtual reality was to be given, what are the security measures you might consider?

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

Medical Insurance
14% 23%
Doctors Guarantee
33%
30% Probability of
success
Ease of use

Description:

Probability of success of the surgery was the most important security measure respondents
wished to have before they would undergo a virtual reality surgery. 1/3, of the people, i.e.,
33%. The next was the doctors guarantee on the surgery (often from an well known and
experienced doctor) by 30% of the respondents.

23% replied if they have a medical insurance coverage for the VR surgery, they might take
the course. It is a well known fact that medical insurance does not cover dental procedures,
therefore patients would want to consider medical insurance in VR as a factor for surgery.
Possibly some of them wants to take the surgery, despite the probability of success and
doctors guarantee, but might not be insured. In this case 1 in every 5 person is not
financially stable for a VR surgery thus needs to be medically insured.

14% among the 50 respondents care for the ease of use (both on the patient's side and
surgeon's side). This illustrates that nearly 85% of respondents will take the surgery even if
it's uncomfortable for both parties, provided with a high probability of success, doctors
guarantee and medical insurance for cover.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

5. How can this type of medicine become more famous?

Advertising
17%
31%
Marketing
25%
Reducing the cost of
27%
servicing
Improving the
technology

Description:

The author sought of finding out why VR is not very well understood or known to have an
applicable use in the medical field. It could be due to some simple general reasons. This pie
chart demonstrates some of the factors affecting the popularity of virtual reality in publics
opinion.

31% agreed with better VR technology could improve the popularity of this application. If
the cost of servicing was reduced then more people will enjoy the technology and it will
become publicly available to a greater number of people. 27% agreed on this factor.

25% believed that by changing the marketing techniques, VR could be prone to the business
of trade. It could open new ways to advertise.

If the VR industry uses advertising, it can also have a positive impact on its perspective. Only
17% respondents think this is the least factor affecting VR's popularity. Meaning that
medical virtual reality is well advertised however the cost of service and current technology
is pulling it down.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

6. Do you think virtual reality therapies will eventually replace the traditional methods of
medication?

48%
52% Yes
No

Description:

52% said VR can't eventually replace the traditional methods and a 48% of them said VR
therapies will eventually replace the traditional methods of medication.

If the answer was "Yes", the respondents were given a choice to choose why they think VR is
the next modern medical hallmark. This will give the research a clue on why VR can establish
another medical stepping stone in the future of next-gen medicine.

If the answer was "No" then the author has assumed it is because the understanding of
virtual reality's potential is not very clear to the public. Usually a decision based on instinct
rather than knowledge.

NOTE: If the answer was no respondents have to skip the next question (no. 7) of the
questionnaire and proceed to question no. 8.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

7. If so, then why?

Traditional methods are
time consuming
11%
32%
We crave for new
32% technology which gives
quicker results
25% These treatments are real-
time

Virtual reality can be fun and
not painful

Description:

This question gives the correspondents a chance to say why they feel or know that
traditional medical methods and therapies will eventually be replaced by virtual reality
treatments. It might not occur very soon but maybe given another half a century we might
to have to take treatments in the hospital anymore. It might be in our own room with a
simple use of a VR gadget.

11 % voted on traditional methods are time consuming since often it require lots of after
treatment follow-ups and takes long periods of time for simple phobia therapies. Also
considering the time spent on traveling to the medical institute and waiting in long queues
for the appointment.

25% knows virtual reality gives constant real-time feedback on the treatment session, data
which can be speculated to see how much a person is recovering. Observing a patients
recovery is very easy on VR systems because it is based on patients input and interactivity
upon specific conditions which the therapist or doctor has given.

32% craves for and depends on the new technology and another 32% tells VR can be fun
and the therapies are not painful. It must the opinion of youth so it matters to them when it
comes to healthcare. They are more concerned of the technology behind it meanwhile does
not cause them any uneasiness and so more fun taking a VR treatment.

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Virtual Reality Establishing Medical Hallmarks
Research Methodology, AMDD 2421, (Jul-Dec 2009)
Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

8. Is VR an effective way of educating medical students?

Yes, Because you can simulate
the operation before its actually
done
23%
Yes, Because you don't need to
depend on practicing the
8% 53% surgeries on dead animals.
16% No, Because the simulation is
controlled by human inputs

No, Because it lacks the tension
we have in reality

Description:

Total 69% of respondents replied that VR is an effective way of educating medical students,
but they were of two different reasons. The main reason is because they believe VR can
simulate the surgery before it is actually carried out. This can save major casualties in
dangerous operations and can help in avoiding fatalities. 53% of people agreed on this
reason, and 16% agreed because VR is a platform where you can practice surgeries on an
generated environment and specimens. So students do not have to depend on practicing
their procedures on dead stock.

Total 31% of respondents said it's NOT an effective way because (23%) thinks it lacks the
tension we have in reality, because students will know they are testing specimens and be
undone. The other reason (by 8%) is because people think the simulation is controlled by
human input so conditions can be altered to the need or the mock reality can be controlled.
In rare cases this can lead to wrong simulations.

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9. Would you rather go on a virtual treatment or for the traditional methods?

34% I will stick with
traditional methods

66%
I would rather take
Virtual reality
simulation

Description:

Astounding 66% of people are willing to take virtual reality treatments because it will not
cause physical harm to the user. They could feel completely secure and by time recover
from the phobia That means even though people say VR cannot replace traditional
methods, the future of VR in medicine is quite bright. VR has a lapse in showing up in
medical field due to some technical difficulties. (Analyzed in question 11 and 12 of this
questionnaire). Otherwise it would have been a common practice by now!

34% will stick to traditional methods, given the circumstance to take a therapy based on
fear of flying. Usually the patient will have to fly a real plane, all the while thinking of a way
to escape death. However 1/3 of people who participated in the questionnaire rather take
the risk and fly a real plane to get over the phobia.

NOTE: An specific example was given so respondents can decide easily.

EXAMPLE:

A person having phobia (fear) of flying doesn't have to travel to airports for treatment. So
no need of scheduling flights for the patient. In the long run virtual therapy is cost effective.

10. How reliable are these kinds of test results?

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20%
30%

Very reliable
Reliable
Not reliable
50%

Description:

Another medical use is forensics. Virtual reality can simulate crime scenes by connecting
the data taken from specimens from the crime scene. This is a powerful way of finding out
how the crime was done which helps to find the missing parts of most murder cases.

20% says it is very reliable. 50% denotes the tests done on virtual reality is reliable, but 30%
says it is not reliable. Overall it can be concluded VR is a reliable way of forensics and even
medicine.

NOTE: An specific example was given so respondents can decide easily.

EXAMPLE:

The well known case of the death of Princess Diana, the investigation was later done on
virtual reality to determine how the accident actually happened.

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Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

11. What do you want to improve about virtual reality in general?

24% 27%
Graphics and Audio
Software User Interface
21%
Marketing Strategy
28%
Product Design Interface

Description:

The biggest improvement people want to see on virtual reality is its software user interface ,
Graphics and audio by 28% and 27% of people respectively. Some 24% thinks it needs to
improve the products design interface but 21% wants to see an improvement in VR's
marketing strategy. This is a reflective percentage from the question no. 3 which asks of
how VR can become more famous.

Since 50% of people have experienced VR, they want larger scale improvements on the
application area than the selling point.

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12. What is your perspective on today's virtual reality?

13%
30%
19%

39%

Needs a big improvement It has limited interactivity
Not easily accessible to public Service is too expensive

Description:

The prime drawback of virtual reality is that is it not easily accessible to the public. 39%
agrees on that. Meaning most of the VR is still at an experimental stage and done
underground for testing purposes only.

30% said the services are costly.

A 19% replied that they see VR having a very limited interactivity. Improving the hardware
and technical protocols mention on question no.11 will definitely help to increase the
interactivity of VR systems.

13% just generally said it needs a big improvement. This state's they want improvements in
rest of 3 factors given in this question.

There is a vast difference between person to person on how they view and judge today's
virtual reality in general. This view can be applied and helpful to any field which uses VR.
Using this statistical data can enhance today's virtual reality tomorrow.

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3.3.3 Self Observation Survey

This section is divided into observations carried out by placing author himself in a virtual
reality experience and described as self observation while the other observations are done
and analyzed based on the reaction of other people on experiencing a medical virtual reality
and described as public observation.

LIMITATIONS RESTRICTIONS FOR OBSERVATIONS :

These machines are found and practiced in most hospital universities in parts of Europe,
Japan, Australia and the States (Developed nations) and are rarely seen is parts of Middle
and South Asia. Due to the difficulty in accessing a proper virtual reality experience (using
the machines) the subjects of this experiment are exposed to three different videos which
show application usage of virtual reality in medical procedures in these hospitals.

1. Virtual Iraq

2. LapSim laparoscopic simulator

3. Virtual Reality Training: A randomized controlled trial.

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Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

1. Virtual Iraq

Figure 1: U.S. Army Staff Sgt. Jeff Ebert, who served as a Figure 2: A scene from the virtual Iraq simulation. The
behavioral health specialist while on active duty in Iraq, recreation uses graphics from a training game called
puts an experimental virtual reality computer simulator Full Spectrum Warrior. (Courtesy University of Reading)
through its paces at Madigan Army Medical Center at Fort Source: (world-science.net, 2009)
Lewis, Wash
Source: (ama-assn.org, 2009)

The author was exposed to see his reaction on one of the three videos on virtual reality
therapy given to overcome PTSD sufferer's point of view. This is a virtual-reality simulation
hoped to treat veterans suffering from post-traumatic stress disorder. "Virtual Iraq"
simulator is adapted from the video game Full Spectrum Warrior (Figure 2) and then the
environment is simulated to treat suffers to release the stress of post-war wraths.

This world is experienced through a VR headset (Figure 1) and the system generates the
odors of the Iraqi combat zones. The explosions are felt as well as heard. The goal of this VR
in authors opinion is to recreate battle conditions experienced by a soldier in a moment of
crisis. It shows bestselling video games might blow away this VR's primitive graphics but
that's by designs. They have sort of purposely designed so that patients can bring their own
memory into the scenario without distracting them with too much detail but to focus on
ridding the reconciliation of the whole trauma. One other interesting found was the
weapons were not programmed to return fire. They do not have a mechanism for firing back
because this is not a game or a platform where you get to kill as many Iraqis, do a revenge
fantasy, cathartic experience rather it aids them in the process of recovery. It also lets the
patient experience a safe supportive environment.

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2. LapSim laparoscopic simulator

Figure 3: VR simulator example

Source: (biomedcentral.inist.fr)

Figure 4: Images of VR simulation graphics

Source: (surgical-science.com)

The next observation was on the video which depicts the realism of a virtual reality surgery.
This video shows a simulated cholecystectomy procedure from the LapSim laparoscopic
simulator (Figure 3).

The organs in the simulation look very life like (Figure 4) and they have the exact biological
resemblance. The colors, volume, texture are very realistic and rendered in real-time while
the student practices the procedure. The student can use medical tools provided in the
LapSim simulator to carry out the surgery. There is also small pop-up helper with
instructions and steps of the surgery at the left hand corner of the screen. The reaction on

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Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

the organs when doing the surgery is applied with kinetic and mechanical 3D physics
systems that mocks reality such as bleeding, bounce and action-reaction forces. This VR
simulation is in the long run very cost effective and students can become proficient for
specific surgeries within no time. This can also help students to time their surgeries and
gives a stage to be ready before the surgery can be done on a real patient.

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3. Virtual Reality Training: A randomized controlled trial.

Figure 5: Sofie Leisby, a trainee surgeon, through laparoscopic surgery—from practicing in VR to a real life procedure.

Source: (bmj.com)

The last observation was done on a Doctor taking a VR simulation on the LapSim simulator.
This video follows Sofie Leisby, a trainee surgeon, through laparoscopic surgery - from
practicing in VR to a real life procedure at University Hospital, Copenhagen, Denmark (Figure
5). The reason to observe this is to find out the effectiveness of VR and what it can establish
in the near future.

The traditional way of learning surgery has come under great pressure both because of the
operating room is actually more a place for producing surgical procedures than learning. It is
very stressful environment to learn surgical procedures and because they have less time for
learning. Sofie was afraid of making mistakes when she is not confident is knowing how
some procedures work.

At the moment of simulation, the simulator holds four programs of laparoscopic surgeries.
When she does the VR it feels real. When she holds the instruments, it is like the real ones
at the operating world and when she cuts a blood vessel, it bleeds like in normal tissue. She
ran the surgery test on VR (laparoscopic fallopian removal surgery) and failed on her
attempt, because she used too much time and cut into a vessel. If she is not precise with the
instruments, she can do damage on a real patient.

Trainees need to have a certain score number on the VR simulator before they are allowed
to go on a real surgery. Some trainees take longer than the others to learn. They had to
keep them training until they reach the expert level. Even though Sofie was signed off from
the VR system she was allowed to do live surgery on a real patient. Another observation was

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that in reality they are not only introducing a lot of new laparoscopic procedures, but other
protocols of surgery too. They have to communicate with other persons in the room, they
get the smells, blood and stress. A senior consultant keeps an eye on what Sophie does on
the theater. A supervisor takes the recorded video of the surgery and evaluates it. He does
not know if the trainee has undergone VR training or the traditional method.

One of things learned from this study was that they could reduce the operation time. If
simulated training in VR system could reduce the time of operation, it will be the save time
in the theater. Sophie was happy about the operation but she feels that she need more
experience so she has to go back to the VR and train some more before she tries on another
real patient.

There was a huge difference between the trainees who took traditional training versus VR
trainees. The VR trained groups performed as if they have done fifty surgeries before and it
was at their first real operation. Skills in laparoscopic surgery can be improved by using
proficiency based virtual reality simulator training. The performance level of novices was
increased to that of intermediately experienced laparoscopists and operation time was
halved in this randomized controlled trial. VR training will surely save time, money and
increase patient's safety.

__________________

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3.3.4 Public Observation Survey

A few people were also brought in to test their reactions on the video. The author did not
mention the people to give their reactions after watching the video. Next, author observed
and noted the reactions of these people while they watched the video and waited for their
comments which are paraphrased and mentioned below. While some made agreements,
others had a negative perspective on the medical procedure of VR.

1. Virtual Iraq

As far as the PTSD is concerned in "Virtual Iraq" it is based on the same concept as therapy,
and psyches along with game developers are the ones who came up with this idea. This
virtual simulation has shown a dramatic improvement in nearly all of the veterans who
participated. It directly simulates some of the most traumatic experiences they have went
through and allows them to relive it and come to accept it. This also allows the psychologist
psychiatrist to better evaluate them and counsel them.

On the negative side some of them happen to comment that it is morally abusive, and cruel,
plus the fact it is a discrimination issue. The viewers would rather see this chain of events in
real time. There were critical points of view, because they think that this way of treatment is
not the way to treat people with trauma. It was unconvincing for people who are
experiencing this to actually people, by exposing a stressed patient into the simulated
environment of stress to induce a curing effect.

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2. LapSim laparoscopic simulator

The simulator, was amusing and easy to use. The output of the visuals made most of the
people drop their jaws in awe. It was very interesting piece of instrument by opinion for
students to study, learn the teachers to educate the students with certain types of surgeries
available in the simulator. Some of the people knew that this technology existed but never
knew how it was applied in real life science and medicine.

Others were attracted to understand how this mechanism actually works. Unfortunately this
technology is not available to everyone and every society. The simulator machine is very
expensive and it is used as an experiment for studies in hospital universities in developed
nations to evaluate the progress of surgeons and student trainee doctors. One shortcoming
of this simulator is that it does not have many types of surgical procedures to simulate at
the moment but expected to see more in the future. Simulations are limited and currently
most of them have 4-6 simulation programs of laparoscopy in the machine.

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3. Virtual Reality Training: A randomized controlled trial.

Similarly as the above observation, the main point found from the observers were VR is a
very effective way of training people who are working in the medical field. It might be
limited but it can save a lot of time and in the long run the method of training people in VR
is far more cost effective and conventional than any other way present now.

The lapse of this VR training sessions are the absence of tension compared to studying
procedures in the theater itself. It will be the next most productive education system for all
medical university hospitals provided that they are able to afford and implement the
technology within the building. The challenge will be to bring people to a common
understanding ground of this VR technology and convincing them of the superimposed
benefits of Virtual reality.

_____________________________

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Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

3.4 Secondary Research

3.4.1 Literature Reviewing

Further investigations and findings of Virtual reality has to be done. Achieving documentary
evidence on how the current VR systems work on the real stage and how it has been
evaluated by the public, ranging from the producers to users to the susceptible readers who
seek information, is of great necessity. Due to the vastness of the topic and the influences of
technology on the revolutionizing world, the author has decided to focus on concentrated
objectives of VR the reader can easily understand the prospects of this entire research. The
secondary sources will act as a augment to the qualitative analysis done. The main reason of
going through written document is to cover the topics listed below.

Topics covered in this section

1. Potential of applied Virtual Reality and animation in Medical field.

2. Efficiency and Valuable usage of VR in medical applications.

3. Challenges faced by VR systems.

4. Expectations of VR in the near future of medicine.

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1. Potential of applied Virtual Reality and animation in Medical field.

Wired Science.com (2009) says that the latest VR devices have response to stimuli and
sensor-feedback capabilities.

"The latest devices have touch-feedback systems that let practicing surgeons not just see
and hear their virtual patients, but also feel the sensation of pressing a scalpel against
muscle or drilling into bone." (Leggett 2009)

As on the above quote it can be expected that VR in going to be able to mimic somewhat
life-like surgeries so that doctors and medical trainees can actually have a reasonable
representation of what they will perform in the theaters in reality. Some systems are so
sensitive to motion and has several mechanisms to detect the force and give feedback to
the person who is doing the simulation.

Surgeon Nikolas Blevins of the Stanford University School of Medicine, who co-authored a
paper about the VR simulator published in the Journal of Rhinology and Allergy mentioned
to support Leggett's idea for the article.

"The device can sense motion in six different directions and give touch feedback in three,
but that’s only enough to simulate simple surgical instruments, such as a drill, suction tube
or camera." (Belvins 2009)

Even Sherman (1997) years before, described some of the very fascinating potentials of the
medical simulations done, " Virtual Reality is truly a way to make dreams come true. It is
multi-sensory, interactive, real-time 3D graphics ... and our sense of presence, i.e., a strong
sense of being in a place. ... “DETOUR” documents that VR technology can evoke empathy...
emotion have demonstrated extraordinary potential to deliver training."

Sherman's introduction to simulation potential is toughened with backup by a quote from
Times magazine, it says

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"The patient is immersed in the sight, sounds, smells of the virtual world. The therapist sits
beside the patient in front of a screen, through which he or she can see exactly what the
subject sees. The therapist can speak through a microphone wired into the patient's
headphones." (Wighton 2008)

VR systems becoming more and more user friendly and mobile too. It may even be used at
your home in your personal computer, Belvins (2009) supports the idea and mentioned in
the same article “In the past, devices were extremely expensive and extremely cumbersome
but now with the availability of commercial devices, these kinds of systems can be put on an
average desktop or operating room and can be used by whoever needs it whenever they
want it.”

As told by Belvins it is reinforced by Székely (2006) denoting that some VR systems are
integrated with mobile robotics. The patients used a robot to access mobile medical systems
and it is necessary to develop techniques to a level where it can be accessible to patients
who wants the service at home when they want.

The potential use of VR is huge in medical field. Scientists, engineers and doctors are
experimenting and researching on various ways by which VR can be applied to generate
positive output for better health care. Riva (2003 pp.527-pp.528) states currently
established and used VR includes medical education, surgical simulation and planning,
Virtual Endoscopy, VR in Neuro-Psychological Assessment and Rehabilitation are some of
the few ways.

There are lots of other possibilities and latent capacity for VR nowadays. Ranging (Meskó
2009) from gigabyte sized resolution microscopy, for fuller visuals and new environments
for VR by Forterra Systems to use in SecondLife, is a closed platform VR system where many
simulations have already been implemented with a very different ambition and style to
creative science for bleeding simulations.

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Figure 6: The Digital Light Box is a scalable visualization environment for radiological and pathological examinations in high
resolution.

Source: (mmvr17.wordpress.com)

Figure 7: The Virtual Reality Medical Center presented the next generation injury creation science.

Source: (mmvr17.wordpress.com)

Even though there are some challenges facing today's Virtual reality, the potential of where
it is leading us is unmistakable and promising. It might someday become real but not as
much to be so indistinguishable from reality, yet enjoyable.

2. Efficiency and Valuable usage of VR in medical applications.

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It is compulsory to appreciate the efficiency of virtual reality in context to medicine before it
can be considered as a general implementation for medical protocols. It should be able to
get easily recognized and valued by the public for the technology to flourish. There are
some well known areas and some known little about how efficient these VR treatment
systems are. People are still hesitant to feel that it is a form of medication where the world
has come to touch and react to, and has immense amount of potential which can harness a
better healthy life.

Wighton (2008) denotes scientists and doctors are using Virtual reality to treat many types
of disorders such as phobia of public speaking, flying, and even though these treatments are
hard to accomplish in real world scenarios however if you do it virtually, it can be cost-
effective in the long run because you can take-off or repeat the treatment as many times or
as you want. Therefore facing fears in virtual world is more tempting and may be more
accessible. Well known treatments and usage of VR comes in post-traumatic stress disorder
(PTSD) treatment in soldiers returning from Iraq were assessed before starting the
treatment to check that the experience won't devastate them or prove injurious. Initial
subjective reports from the study are promising. Recently, scientists have reported that it
can also be used to treat drink and drug addictions, binge-eating and even to help people
give up smoking.

Leggett (2009) has mentioned " Because the device can simulate the anatomy of a specific
patient, researchers hope it will be useful not just for new doctors, but also for senior
surgeons who want to practice different approaches before a particularly challenging case"
Another value of virtual reality comes in handy as above and this demonstrates more
efficient VR systems are going to be there to deal with all kinds of medical issues.

"For many of us this looks like a key technology that could really enable innovation and
creation of new jobs, opportunities and products." (Physorg.com 2009)

Based on this quote we can understand that there can be lots of value in business if we look
at it positively. Strategies for marketing has to be established and advertised properly so

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Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

that the people will get to know the treatments it offer. For most people when it comes to
medical problems, their main concern will be the efficiency of the treatment taken. The
importance of efficiency is critical for any application, and Gabe (2009) claims on his
CompSci: Virtual reality and Medical field blog that " It is my opinion that such technology
should be investigated and promoted by the scientific community and perhaps federally
funded in an effort to increase medical treatment efficiency. There are certainly issues with
such technology, but that is the case with all new technologies. Virtual reality medical
treatment could represent a new wave of treatment for all ailments, including routine
procedures or even cancer."

Both statements indicated VR has lots of hope, and gives proof for one fundamental aspect,
realizing the worth of it and providing means to enhance the efficiency can make a bright
future in the field of medicine. It can be understood that Virtual reality needs to improve its
efficiency yet it has got high values to it.

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Mauroof Ibrahim, Semester 4, BAA 4A, Limkokwing University, Malaysia

3. Challenges faced by VR systems today

From the analysis done before, from the questionnaires and the interviews, it can be
derived that there are so many challenges to VR and these difficulties should be overcome
in order for this technology to become better. In the face of general public, the VR systems
need easy accessibility, reduced costs and some of the software integrity and interface
should be understandable to users who take medical treatments using VR but what are the
other challenges other than these?

As Dr. Meskó states in his interview with the author "The biggest challenge is to determine
whether virtual reality systems are useful at all in education or in diagnostics as it’s still not
clear. I believe these are only useful if we have to face geographical or financial limitations;
or when the tissue/biological system cannot be discovered properly without VR devices (e.g.
neural imaging before surgeries)."

Furthermore Riva (2009 pp.530) in her book about Applications of Virtual Environments in
Medicine also mentions something similar to what Dr. Meskó stated "Even today no off-
shelf solutions are available.... As we have seen, a typical area for VR applications is surgery.
However, there have been few developments in the area of tactile feedback. The ability to
feel tissue is important."

"The ability to remotely sense small scale shape information and feel forces that greatly
mesh with the natural hand motions would greatly improve the performance of minimally
invasive surgery and bring a greater sense of realism to virtual realism to trainers" (Moline
1997, pp21) underpins the limitations in the technology in software interface.

People who are working in this industry in excepting improvements on making in useful by
refining the systems output quality. Mostly the graphical models which the doctors and
trainees work on. If this can be slowly perfected by the software engineers, animators and
graphic designers, a greater sense of feedback to stimuli can be achieved.

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"It is difficult to create a model of the human body that is realistic enough to accurately
portray a surgical mission that is planned. The interface tools that are presently available are
much more advanced than the ones discussed here ... however, without a true model to
interact with they are unable to provide the realism for surgical education and training that
is needed.. It is unlikely that present VR simulators will change this without a significant
improvements in the models" (Rosen 2001)

Having confirmed that, (Scribd.com 2009 pp.10-pp.11) also shows the cause "Virtual reality
has been heavily criticized for being an inefficient method for navigating non-geographical
information. At present, the idea of ubiquitous computing is very popular in user interface
design, and this may be seen as a reaction against VR and its problems"

If true, then safety issues might be also considered as a challenge to Virtual reality. Even
though there are no known cases of fatality or physical injury to the patient undergoing VR
treatments, of course everyone will think of their safety before taking any medical
treatment. There are few safety issues and measures taken, and the authors feels improving
the safety precautions can enhance the VR, and improving the security will definitely be
called in for challenge.

It is evident that improving the quality of the VR systems would drastically reduce the
occurrence of simulation sickness, but some users still experience health and safety
problems associated with use of VR.

"In general, for a large proportion of VR users these effects are mild and subside quickly"
(Nicholas & Patel 2002) and in a report, US National Advisory Mental Health Council (1995)
suggests that, "Research is needed to understand both the positive and the negative effects
of Virtual Environments...on children's and adults perceptual and cognitive skills." Such are
the condition and challenges of VR and will entail the amalgamation of knowledge from a
variety of disciplines.

For the most part that covers the general problems with VR systems. Clinically speaking, it is
totally a different story. Riva (2003) points out that there are so few controlled trials

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(Observations to attest if VR simulations are effective) is because of the lack of
standardization in VR devices and software, the lack of standardized protocols that can be
share by the community of researchers (If we check we can find only four published clinical
protocols; for the eating disorders, fear of flying, fear of public speaking and panic disorders)
and lastly, the costs needed for the set-up trials are high.

According (Bolzoni, et al. 1997) to the European funded project VEPSY Updated, the cost
required for the designing a clinical VR application from scratch and testing it on clinical
patients using controlled trials may range between one hundred and fifty thousand (150,00)
and two hundred thousand (200,000) U.S dollars. This can tell us that doing research and
implementing protocols to improve VR is underway but there are huge complications to
cross just to see the VR in light. This proves why we don't see VR everywhere. Dr. Meskó
was true in telling that they have financial limitations after all.

Overall, challenge is to make the VR a real force feedback system with ability to mock
reaction to stimuli like reality, reducing side effects caused by the usage of VR and
developing VR simulation tests under low budgets so more and more progressions are
easier to initiate.

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4. Expectations of VR in the near future of medicine.

It is difficult to predict the future of virtual reality with confidence. In the short run, the
graphics displayed in the HMD will soon reach a point of near realism. The audio capabilities
will move into a new realm of three dimensional sound. This refers to the addition of sound
channels both above and below the individual or a Holophony (3D sound) approach.

"Soon there will be patient-specific models derived from computed tomography or
magnetic resonance imaging scans that will permit a surgeon to practice a delicate surgical
procedure on the patient's specific virtual anatomy before actually performing the
procedure on the patient. These applications will afford the surgeon the opportunity to
provide the highest surgical care possible through the use of advanced technologies."
(Satava & Jones 1998)

That means there will be VR applications which can simulate anatomically correct figures for
medical research, making procedures precise and effective at the same time. Zeman (2005)
wrote in the book about Computational Modeling of Tissue Surgery that, "The advantages of
this modeling technique are its ability to study the ‘patient’ specificity." meaning VR will be
very accurate in the future.

"New technologies, in particular virtual reality and robotics, will have a major impact on
health care in the next decade. Clinically validated, powerful medical simulators are now
available and in use across the world." (Mccloy 2001)

Based on the above quote, we are going to see some dramatic, unbelievable changes to VR,
maybe robotics since there are very powerful simulators able to make high resolution
microscopic images for microscopy, and simulators such as Lapsim to simulate surgeries for
trainees and used at developed nations for research in medicine. What's next? telepresence
and robotics!. Rosenbaum (1992) predicted "The technology may not only empower
patients by helping them to communicate, but also may help physicians better diagnose and
treat patients in the future. Telepresence extends sensory apparatus to a remote location

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through robotics. The user, from a distant site, could see, feel and touch objects in the real
world." We should be expecting some robotic medicine in VR in the near future then.

However there are so many possibilities yet so little can be achieved due to financial
boundaries and affordability, otherwise, it could be very wide-spread but for now major
industries are the sole buyers that have the opportunity to utilize this resource. It is still
premature days for VR in medicine but the technology is advancing in credibility among the
medical community, whilst the superior price over performance ratios of today's hardware
is making virtual reality more acceptable from an economic standpoint. As momentum
continues to grow, the future looks bright for this technology sector.

________________________________

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4. Conclusion
Going through the many areas of VR in medicine has obviously shown where it is leading us.
A seen from the observations made in the research, the authors feels that the VR has the
largest potential in training people who work in the medical field.

As observed from the self and public observations, " There was a huge difference between
the trainees who took traditional training versus VR trainees. The VR trained groups
performed as if they have done fifty surgeries before and it was at their first real operation.
Skills in laparoscopic surgery can be improved by using proficiency based virtual reality
simulator training. The performance level of novices was increased to that of intermediately
experienced laparoscopists and operation time was halved in this randomized controlled
trial. VR training will surely save time, money and increase patient's safety."

There are lots of improvements needed when it comes for treatment procedures. Applying
what is experimental and premature, is the main reason why the public is not accepting VR
as a media for treatment.

It is clear that building new and additional virtual environments is important so therapists
will continue to investigate applying these tools in their day-to-day clinical practice.

Other than that, even though it is proven to be cost effective treatment during the
observations, "This VR simulation is in the long run very cost effective and students can
become proficient for specific surgeries within no time. This can also help students to time
their surgeries and gives a stage to be ready before the surgery can be done on a real
patient." and enjoyable at the same time, people do not consider taking the treatment
because of financial limitations.

It is evident from the questionnaire results too. " If the cost of servicing was reduced then
more people will enjoy the technology and it will become publicly available to a greater
number of people. 27% agreed on this factor and also from the review on what other
authors have said before. "These VR simulations can benefit the medical community in

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many ways. For example, they can lower the cost of training doctors by providing reusable
patients that can be operated on repeatedly."

The biggest challenges are in developing and creating Virtual reality machines in a fashion
the industry will greatly accept and appreciate. He noted that the biggest challenge was to
determine whether virtual reality systems are useful at all in education or in diagnostics.
Few regard VR as abusive. Some thought " it is morally abusive, and cruel, plus the fact it is a
discrimination issue. The viewers would rather see this chain of events in real time."

Significant efforts are still required to move VR into commercial success and therefore
routine clinical use. Possible future scenarios will involve multi-disciplinary teams of
engineers, animators, computer-programmers, and therapist working together in concert to
treat specific clinical problems. Finally communication networks have the potential to
transform virtual reality environments into shared worlds in which individuals, objects, and
the process interact without regard to their location. Future of potential applications and
medical usage of VR are really only limited by the imaginations of talented individuals. We
are expecting robotics!.

_______________________

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5. Reference List
Books, Magazines and Journals
1) A Report of the US National Advisory Mental Health Council 1995, U.S Government
Printing Office, NIH Publication, Report No.: 95-3682

2) Bolzoni, et al. 1997, Virtual reality Environments for psycho-neuro-psychological
assessment and rehabilitation, IOS Press, pp.34-pp.45

3) Moline,J 1997, Virtual reality in healthcare; a survey, IOS Press, pp.21

4) Nicholas,S & Patel,H 2002, Health and safety Implications of Virtual reality: a review of
empirical evidence, Appl Ergon, pp.251-71

5) Robb,N 1997, Medicine just beginning to tap potential of Virtual reality, Canadian Medical
Association, pp.305

6) Riva,G 2003, Applications of Virtual Environments in Medicine, Schattauer GmbH, pp.527-
pp.528

7) Satava,RM & Jones,SB 1998, Current and future applications of virtual reality for
medicine, Institute of Electrical and Electronics Engineers, pp.484-pp.498

8) Sherman,WR 1997, Experiences with virtual reality applications (panel), ACM
Press/Addison-Wesley Publishing Co, pp.473-pp.476

9) Székely,G 2006, Recent advances in virtual reality based surgical training simulation,
Elsevier Science Publishers Ltd, pp.195

10) Zeman,ME 2005, Computational Modeling of Tissue Surgery, WIT Press, pp.17

Internet
1) Belvins,N 2009, Journal of Rhinology and Allergy Retrieved November 7th 2009 from

http://www.ingentaconnect.com/content/ocean/ajr

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2) BMJ.com 2001, Science, medicine, and the future: Virtual reality in surgery Retrieved
October 8th 2009 from

http://www.bmj.com/cgi/content/full/323/7318/912

2) Chapman,G 2009, Second Life creates virtual world for businesses Retrieved November
7th 2009 from

http://news.theage.com.au/breaking-news-technology/second-life-creates-virtual-world-
for-businesses-20091105-i00z.html

3) Delingette,H 2009, Heptic Surgery Simulator Retrieved August 10th 2009 from
http://www.ercim.org/publication/Ercim_News/enw29/delingette.html

4) Eyeseecam.com 2009, EyeseeCam Retrieved October 9th 2009 from

http://eyeseecam.com/

5) Gabe 2009, CompSci: Virtual reality and the Medical field Retrieved September 21st 2009
from

http://logicalscience.wordpress.com/2009/09/06/compsci-virtual-reality-and-the-medical-
field/#more-505

6) Legget,H 2009, Virtual Reality Could Keep You From Being a Surgical Guinea Pig Retrieved
August 21st 2009 from

http://www.wired.com/wiredscience/2009/08/virtualsurgery/

7) Mccloy,R 2001, Clinical Review: Science, medicine, and the future, BMJ.com Retrieved
from

http://www.bmj.com/cgi/content/extract/323/7318/912

8) Medgadget.com 2005, Psychiatric VRx: Virtual reality therapy Retrieved October 9th
2009 from

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http://medgadget.com/archives/2005/05/psychiatric_vrx.html

9) Medgadget.com 2005, Virtual reality for Laparoscopic Surgeons Retrieved October 9th
2009 from

http://medgadget.com/archives/2005/06/virtual_reality.html

10) Medgadget.com 2007, SnowWorld VR for Pain Retrieved October 9th 2009 from

http://medgadget.com/archives/2007/08/snowworld_vr_for_pain.html

11) Medgadget.com 2008, PerioSim Force feedback Dental Simulator Retrieved October 9th
2009 from

http://medgadget.com/archives/2008/03/force_feedback_dental_simulator.html

12) Meskó,B 2009, The Use of Virtual Reality in Addiction Medicine Retrieved October 9th
2009 from

http://scienceroll.com/2009/01/05/the-use-of-virtual-reality-in-addiction-medicine/

13) Meskó,B 2009, Virtual Patients and Surgical Guinea Pigs Retrieved October 9th 2009
from

http://scienceroll.com/2009/08/11/virtual-patients-and-surgeries-guinea-pigs/

14) Meskó,B 2009, Neuro Touch Retrieved October 9th 2009 from

http://scienceroll.com/2009/09/04/neurotouch/

15) Meskó,B 2009, MMVR 17: The Salon Retrieved October 9th 2009 from

http://scienceroll.com/2009/01/23/mmvr17-the-salon/

16) Meskó,B 2009, The Well: Virtual reality becomes real Retrieved September 23rd 2009
from

http://mmvr17.wordpress.com/2009/01/20/the-well-virtual-reality-becomes-real/

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17) Physorg.com 2009, Really virtual reality Retrieved November 11th 2009 from

http://www.physorg.com/news162653042.html

18) Rosen,JM 2001, Virtual Reality and Medicine - Challenges for the Twenty-First Century,
Wiley Interscience.com Retried 10th November 2009 from

http://www3.interscience.wiley.com/cgi-
bin/summary/86512907/SUMMARY?CRETRY=1&SRETRY=0

19) Rosenbaum,S 1992, Robotics, virtual worlds meet medicine, Bnet.com Retrieved
November 11th 2009 from

http://findarticles.com/p/articles/mi_m3498/is_n11_v55/ai_14534764/

20) Scribd.com 2009, Virtual Reality Report Retrieved 11th November 2009 from

http://www.scribd.com/doc/20404486/Virtual-Reality-Report

21) Wighton,K 2008, The latest trend in medicine - Virtual reality, Times Online Retrieved
15th August 2009 from

http://www.timesonline.co.uk/tol/life_and_style/health/article3945251.ece

22) Wiredscience.com 2009, News for your Neurons Retrieved 23rd September 2009 from

http://www.wired.com/wiredscience/2009/08/virtualsurgery/

Images

1) U.S. Army Staff Sgt. Jeff Ebert, who served as a behavioral health specialist while on active
duty in Iraq, puts an experimental virtual reality computer simulator through its paces at
Madigan Army Medical Center at Fort Lewis, Wash[Image] 2009 Retrieved October 25th
2009 from
http://www.ama-assn.org/amednews/2009/09/28/bisc0928.htm

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2) A scene from the virtual Iraq simulation. The recreation uses graphics from a training
game called Full Spectrum Warrior (Courtesy University of Reading) [Image] 2009 Retrieved
October 19th 2009 from http://www.world-science.net/othernews/070306_virtual-iraq.htm

3) VR simulator example. Hardware: Xitact® (Xitact S.A., 1110 Morges, Switzerland),
software: LapSim® basic tasks module (Surgical Science, SE 413 14 Göteborg, Sweden)
[Image] 2009 Retrieved October 24th 2009 from
http://biomedcentral.inist.fr/index_affiche_revue.php?Affiche=affiche_html&ui=1754-
9493-2-
16&format=html&journal=10141&PHPSESSID=8538e904e1c7cc1150611800ebc82ec4

4) Images of VR simulation graphics [Image] 2009 Retrieved October 24th 2009 from
http://www.surgical-science.com/

5) Sofie Leisby, a trainee surgeon, through laparoscopic surgery—from practicing in VR to a
real life procedure [Image] 2009 Retrieved October23rd 2009 from
http://www.bmj.com/cgi/content/abstract/338/may14_2/b1802

6) The Digital Light Box is a scalable visualization environment for radiological and
pathological examinations in high resolution. [Image] 2009 Retrieved September 23rd 2009
from http://mmvr17.wordpress.com/2009/01/20/the-well-virtual-reality-becomes-real/

7) The Virtual Reality Medical Center presented the next generation injury creation science.
[Image] 2009 Retrieved September 23rd 2009 from
http://mmvr17.wordpress.com/2009/01/20/the-well-virtual-reality-becomes-real/

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6. Bibliography
Books

Craig, A & Sherman, WR & Will, JD 2009, Developing Virtual Reality Applications:
Foundations of Effective Design, Morgan Kaufmann Publishers

Brenda K 2006, The Potential of Virtual reality to Improve Healthcare (C), The Virtual Reality
Medical Center, VRMC

Marsh,A & Simistira,F & Robb,R 1998, VR in medicine: Virtual colonoscopy, Future
Generation Computer Systems, Volume 14, Elsevier Science Publishers Ltd, pp.253-pp.264

Swennen,GR & Mollemans,W& Schutyser,F 2009, Three-dimensional treatment planning of
orthognathic surgery in the era of virtual imaging, Department of Surgery, General Hospital
St-Jan Bruges, Bruges, Belgium

Internet

Fosse,E 2008, Medical images and the future of medicine Retrieved November 11th 2009
from

http://www.docstoc.com/docs/2455450/Microsoft-PowerPoint---Medical-images-and-the-
future-of-medicineppt

Martin,S n.d, Virtual Reality in Medicine Retrieved November 11th 2009 from

http://web.cs.wpi.edu/~matt/courses/cs563/talks/smartin/vr_med.html

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7. Appendix
Interview Questions : Answered by Dr. Bertalan Meskó, MD

1. Are there any companies that are working on creating true virtual reality?

2. How far are they along?

3. What are the biggest challenges in development and creating virtual reality
machines?
4. Do you think Virtual reality will ever become indistinguishable from "regular" reality?

5. What is the basic structure of a VR machine?

6. How effective are these machines in teaching and educating personals into the field
of medicine?

7. What type of medical equipment, technology, virtual reality, software, hardware is
already released in health care?

8. Is there a possibility of fatality or destruction caused to human by using VR?

9. If so what are the main typical scenarios?

10. What is there to improve on Virtual reality in general?

11. What is the biggest achievement in Virtual reality history on medicine?

12. What can we expect from Virtual reality with regards to medicine and crime fighting
in the near future?

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How can doctors use virtual reality to treat phobias?
by Jonathan Strickland

Inside this Article
1. How Virtual Medicine Works

2. Virtual Medicine Treatments

1. How Virtual Medicine Works

Millions of people suffer from phobias that limit their activities and negatively impacting
their lives. Many seek psychological treatment in order to manage or conquer their fears.
For years, a popular form of treatment was exposure therapy, in which a therapist would
expose a patient to stimuli related to his fear in a controlled environment. In many cases,
patients would learn to manage their anxiety through repeated exposure coupled with
encouragement from a therapist.

Exposure therapy is time consuming. Often it's also expensive and inconvenient, and it can
compromise patient confidentiality. For example, treating a patient with aerophobia, or the
fear of flying, usually involves a trip to the airport. It might take several visits for a therapist
and patient to make their way through security to a gate. Eventually both have to get on a
plane and fly to a destination. Now that you have to be a ticketed passenger to pass through
security at airports, it can be prohibitively expensive to treat a patient with exposure
therapy. Because patients and therapists travel together, the patient's confidentiality is
compromised because the public has the opportunity to see the therapy in action.

Virtual Reality Image Gallery

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Figure 8: Virtually Better, Inc. uses
virtual therapy to treat a patient's
fear of flying.

Source: (VirtuallyBetter.com, Inc)

One alternative to traditional exposure therapy is virtual reality exposure therapy. This kind
of therapy uses a virtual reality unit to simulate situations that cause anxiety in phobia
patients. It has several advantages over traditional therapy. Doctors don't have to leave
their offices. Scheduling treatment is easier. It's less expensive in the long run. And patients
are often more willing to participate in a program they know will allow them to deal with
their fears in a nonphysical setting. Since patients can undergo therapy inside the doctor's
office, confidentiality isn't an issue.

Dr. Larry Hodges, a virtual reality computer scientist at the University of North Carolina --
Charlotte, became interested in a possible therapeutic application of VR technology in the
early 1990s. He approached Dr. Barbara Rothbaum, a professor of Psychiatry at Emory
University, and together they collaborated on a project that would test VR technology's
efficacy in recreating patients' fears. They decided to design a simulation for patients
suffering from acrophobia, or a fear of heights. Dr. Hodges felt that it would be relatively
easy to create a program giving the illusion of height compared to other, more complex
fears.

Dr. Hodges and his team worked with Dr. Rothbaum and volunteer patients to determine
what stimuli were particularly powerful. Volunteers would wear a head-mounted display
(HMD) that would create the illusion that they were on a tall ledge. Going into the project,
Hodges and Rothbaum weren't certain that they would get the same reactions from
volunteers in a virtual environment as they would a real one, nor were they sure that by

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treating someone using virtual environments that progress would translate into the real
world.

2. Virtual Medicine Treatments

Very early in the simulation, Dr. Rothbaum observed that the volunteer patients were
exhibiting classic signs of anxiety, including an accelerated heart rate and shortness of
breath. Rothbaum and Hodges had successfully demonstrated that a virtual environment
could evoke real physical reactions from users. Dr. Rothbaum began to use the simulations
to work with patients as if they were undergoing regular exposure therapy. Before long,
several of the volunteers reported they had purposefully sought out experiences in real
situations that tested their fear. These were patients who normally would have avoided
these situations at all costs before trying the virtual therapy.

After some additional research, Hodges created the company Virtually Better, Inc. The
company designs and sells virtual reality systems that accurately recreate several different
classic phobia situations, including social phobias involving crowds of people. Now a
therapist can take a patient on a virtual flight without the hassle of scheduling travel, go on
a virtual elevator ride without ever stepping out of the office, or give a speech in front of a
crowd of people, all without leaving the office or compromising patient confidentiality.

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Photo used under the GNU Free Documentation License
Virtually Better may create an environment such
as this to help patients overcome their fear of heights.

The company also offers scenarios to treat veterans with post-traumatic stress disorder. A
program designed for Vietnam veterans can recreate a couple of different situations that
were common for most soldiers in the conflict. One simulates a helicopter ride over jungle
landscape, while the other puts the patient in the middle of a virtual clearing. Engineers
created both scenarios based on veterans' descriptions of situations that triggered their
anxiety.

In addition to treating fears and anxieties, Virtually Better uses VR technology to help treat
addiction. These scenarios put the user in a situation where characters within the virtual
environment are indulging in alcohol or drugs. While it might seem strange to think a virtual
character can trigger addiction cravings, Dr. Hodges says their research shows that once
someone is habituated to a virtual environment (meaning the user feels as if he's inside and
a part of the virtual world) he reacts as if it were the real world. In fact, according to some
research projects, virtual characters can impact a real person as if they were actually real.
Dr. Hodges says that the gender of a character seems to make a bigger difference in users'
reactions rather than whether the character they see is virtual or real.

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Virtually Better has sold units to therapists around the world and continues to develop new
therapy applications of VR technology. Dr. Hodges is also continuing his research in the VR
field, studying how virtual persons and environments can impact human users.

Source: http://health.howstuffworks.com/virtual-medicine.htm

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How Virtual Reality Works
by Jonathan Strickland

Photo courtesy of Dave Pape
A virtual reality CAVE display projecting images onto the floor, walls and ceiling to provide full immersion. See more
virtual reality pictures.

What do you think of when you hear the words virtual reality (VR)? Do you imagine
someone wearing a clunky helmet attached to a computer with a thick cable? Do visions of
crudely rendered pterodactyls haunt you? Do you think of Neo and Morpheus traipsing
about the Matrix? Or do you wince at the term, wishing it would just go away?

If the last applies to you, you're likely a computer scientist or engineer, many of whom now
avoid the words virtual reality even while they work on technologies most of us associate
with VR. Today, you're more likely to hear someone use the words virtual environment (VE)
to refer to what the public knows as virtual reality. We'll use the terms interchangeably in
this article.

Naming discrepancies aside, the concept remains the same - using computer technology to
create a simulated, three-dimensional world that a user can manipulate and explore while
feeling as if he were in that world. Scientists, theorists and engineers have designed dozens
of devices and applications to achieve this goal. Opinions differ on what exactly constitutes
a true VR experience, but in general it should include:
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Three-dimensional images that appear to be life-sized from the perspective of the user

The ability to track a user's motions, particularly his head and eye movements, and
correspondingly adjust the images on the user's display to reflect the change in perspective

In this article, we'll look at the defining characteristics of VR, some of the technology used in
VR systems, a few of its applications, some concerns about virtual reality and a brief history
of the discipline. In the next section, we'll look at how experts define virtual environments,
starting with immersion.

Virtual Reality Immersion

In a virtual reality environment, a user experiences immersion, or the feeling of being inside
and a part of that world. He is also able to interact with his environment in meaningful
ways. The combination of a sense of immersion and interactivity is called telepresence.
Computer scientist Jonathan Steuer defined it as “the extent to which one feels present in
the mediated environment, rather than in the immediate physical environment.” In other
words, an effective VR experience causes you to become unaware of your real surroundings
and focus on your existence inside the virtual
environment.

Photo courtesy of VIRTUSPHERE
A virtual reality unit that allows the user

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Jonathan Steuer proposed two main components to move freely in any direction
of immersion: depth of information and breadth of
information. Depth of information refers to the amount and quality of data in the signals a
user receives when interacting in a virtual environment. For the user, this could refer to a
display’s resolution, the complexity of the environment’s graphics, the sophistication of the
system’s audio output, et cetera. Steuer defines breadth of information as the “number of
sensory dimensions simultaneously presented.” A virtual environment experience has a
wide breadth of information if it stimulates all your senses. Most virtual environment
experiences prioritize visual and audio components over other sensory-stimulating factors,
but a growing number of scientists and engineers are looking into ways to incorporate a
users’ sense of touch. Systems that give a user force feedback and touch interaction are
called haptic systems.

What's in a Name?

Virtual reality has gone by many other names besides virtual environments. Other terms for
virtual reality include cyberspace (a word invented by science fiction author William
Gibson), artificial reality, augmented reality and telepresence.

For immersion to be effective, a user must be able to explore what appears to be a life-sized
virtual environment and be able to change perspectives seamlessly. If the virtual
environment consists of a single pedestal in the middle of a room, a user should be able to
view the pedestal from any angle and the point of view should shift according to where the
user is looking. Dr. Frederick Brooks, a pioneer in VR technology and theory, says that
displays must project a frame rate of at least 20 - 30 frames per second in order to create a
convincing user experience.

The Virtual Reality Environment
Real Virtual Objects

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Passive haptics are one way VE developers have tried to enhance interactivity. Passive
haptics are real objects in a physical space that are mapped to virtual objects in a virtual
space. Users wear an HMD or similar portable display while in the physical space. When
they look toward the physical object, they'll see the virtual representation of it in their
display. When they approach the object and try to touch it, they encounter the real object in
the physical space. Anything a user does with that object in real space appears as a reflected
action upon the virtual object in virtual space.

Other sensory output from the VE system should adjust in real time as a user explores the
environment. If the environment incorporates 3-D sound, the user must be convinced that
the sound’s orientation shifts in a natural way as he maneuvers through the environment.
Sensory stimulation must be consistent if a user is to feel immersed within a VE. If the VE
shows a perfectly still scene, you wouldn’t expect to feel gale-force winds. Likewise, if the
VE puts you in the middle of a hurricane, you wouldn’t expect to feel a gentle breeze or
detect the scent of roses.

Lag time between when a user acts and when the virtual environment reflects that action is
called latency. Latency usually refers to the delay between the time a user turns his head or
moves his eyes and the change in the point of view, though the term can also be used for a
lag in other sensory outputs. Studies with flight simulators show that humans can detect a
latency of more than 50 milliseconds. When a user detects latency, it causes him to become
aware of being in an artificial environment and destroys the sense of immersion.

Going for a Swim

Swimming in VR systems doesn’t refer to jumping into a pool -- it describes the effect of
latency within a virtual environment. If you were to look around in a VE and notice that the
change in point of view was not instantaneous, you would experience swimming. The effect
is distracting and can even make you experience motion sickness, called simsickness or
cybersickness in VR circles.

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An immersive experience suffers if a user becomes aware of the real world around him.
Truly immersive experiences make the user forget his real surroundings, effectively causing
the computer to become a non entity. In order to reach the goal of true immersion,
developers have to come up with input methods that are more natural for users. As long as
a user is aware of the interaction device, he is not truly immersed.

In the next section, we’ll look at the other facet of telepresence: interactivity.

Virtual Reality Interactivity
Immersion within a virtual environment is one thing, but for a user to feel truly involved
there must also be an element of interaction. Early applications using the technology
common in VE systems today allowed the user to have a relatively passive experience. Users
could watch a pre-recorded film while wearing a head-mounted display (HMD). They would
sit in a motion chair and watch the film as the system subjected them to various stimuli,
such as blowing air on them to simulate wind. While users felt a sense of immersion,
interactivity was limited to shifting their point of view by looking around. Their path was
pre-determined and unalterable.

Today, you can find virtual roller coasters that use the same
sort of technology. DisneyQuest in Orlando, Florida features
CyberSpace Mountain, where patrons can design their own
roller coaster, then enter a simulator to ride their virtual
creation. The system is very immersive, but apart from the
initial design phase there isn't any interaction, so it's not an
Photo courtesy of Sue Holland
example of a true virtual environment.
DisneyQuest’s Cyber
Interactivity depends on many factors. Steuer suggests that Space Mountain Capsule
three of these factors are speed, range and mapping. Steuer
defines speed as the rate that a user's actions are incorporated into the computer model
and reflected in a way the user can perceive. Range refers to how many possible outcomes
could result from any particular user action. Mapping is the system's ability to produce
natural results in response to a user's actions.

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Navigation within a virtual environment is one kind of interactivity. If a user can direct his
own movement within the environment, it can be called an interactive experience. Most
virtual environments include other forms of interaction, since users can easily become
bored after just a few minutes of exploration. Computer Scientist Mary Whitton points out
that poorly designed interaction can drastically reduce the sense of immersion, while finding
ways to engage users can increase it. When a virtual environment is interesting and
engaging, users are more willing to suspend disbelief and become immersed.

Immersion vs. Interaction

Developers have discovered that users feel a stronger sense of telepresence when
interaction is easy and interesting, even if the VE isn't photorealistic, whereas very realistic
environments that lack opportunities for interaction cause users to lose interest relatively
quickly.

True interactivity also includes being able to modify the environment. A good virtual
environment will respond to the user's actions in a way that makes sense, even if it only
makes sense within the realm of the virtual environment. If a virtual environment changes
in outlandish and unpredictable ways, it risks disrupting the user's sense of telepresence.

In the next section, we'll look at some of the hardware used in VE systems.

The Virtual Reality Headset

Photo used under the
GNU Free Documentation License
The Nintendo Power Glove used

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Today, most VE systems are powered by normal personal in virtual reality gaming
computers. PCs are sophisticated enough to develop and
run the software necessary to create virtual environments. Graphics are usually handled by
powerful graphics cards originally designed with the video gaming community in mind. The
same video card that lets you play World of Warcraft is probably powering the graphics for
an advanced virtual environment.

VE systems need a way to display images to a user. Many systems use HMDs, which are
headsets that contain two monitors, one for each eye. The images create a stereoscopic
effect, giving the illusion of depth. Early HMDs used cathode ray tube (CRT) monitors, which
were bulky but provided good resolution and quality, or liquid crystal display (LCD)
monitors, which were much cheaper but were unable to compete with the quality of CRT
displays. Today, LCD displays are much more advanced, with improved resolution and color
saturation, and have become more common than CRT
monitors.

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Other VE systems project images on the walls, floor and Photo courtesy of Dave Pape
ceiling of a room and are called Cave Automatic Virtual A data suit to provide user input
Environments (CAVE). The University of Illinois-Chicago
designed the first CAVE display, using a rear projection technique to display images on the
walls, floor and ceiling of a small room. Users can move around in a CAVE display, wearing
special glasses to complete the illusion of moving through a virtual environment. CAVE
displays give users a much wider field of view, which helps in immersion. They also allow a
group of people to share the experience at the same time (though the display would track
only one user’s point of view, meaning others in the room would be passive observers).
CAVE displays are very expensive and require more space than other systems.

Closely related to display technology are tracking systems. Tracking systems analyze the
orientation of a user’s point of view so that the computer system sends the right images to
the visual display. Most systems require a user to be tethered with cables to a processing
unit, limiting the range of motions available to him. Tracker technology developments tend
to lag behind other VR technologies because the market for such technology is mainly VR-
focused. Without the demands of other disciplines or applications, there isn’t as much
interest in developing new ways to track user movements and point of view.

Input devices are also important in VR systems. Currently, input devices range from
controllers with two or three buttons to electronic gloves and voice recognition software.
There is no standard control system across the discipline. VR scientists and engineers are
continuously exploring ways to make user input as natural as possible to increase the sense
of telepresence. Some of the more common forms of input devices are:

Joysticks

Force balls/tracking balls

Controller wands

Datagloves

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Voice recognition

Motion trackers/bodysuits

Treadmills

Virtual Reality Games
Scientists are also exploring the possibility of developing
biosensors for VR use. A biosensor can detect and interpret
nerve and muscle activity. With a properly calibrated
biosensor, a computer can interpret how a user is moving in
physical space and translate that into the corresponding
motions in virtual space. Biosensors may be attached
directly to the skin of a user, or may be incorporated into
gloves or bodysuits. One limitation to biosensor suits is that Photo courtesy
they must be custom made for each user or the sensors will Nintendo of America, Inc.
The Wii controller in action
not line up properly on the user’s body.

Mary Whitton, of UNC-Chapel Hill, believes that the entertainment industry will drive the
development of most VR technology going forward. The video game industry in particular
has contributed advancements in graphics and sound capabilities that engineers can
incorporate into virtual reality systems’ designs. One advance that Whitton finds particularly
interesting is the Nintendo Wii’s wand controller. The controller is not only a commercially
available device with some tracking capabilities; it’s also affordable and appeals to people
who don’t normally play video games. Since tracking and input devices are two areas that
traditionally have fallen behind other VR technologies, this controller could be the first of a
new wave of technological advances useful to VR systems.

Some programmers envision the Internet developing into a three-dimensional virtual space,
where you navigate through virtual landscapes to access information and entertainment.
Web sites could take form as a three-dimensional location, allowing users to explore in a

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much more literal way than before. Programmers have developed several different
computer languages and Web browsers to achieve this vision. Some of these include:

Virtual Reality Modeling Language (VRML)- the earliest three-dimensional modeling
language for the Web.

3DML - a three-dimensional modeling language where a user can visit a spot (or Web site)
through most Internet browsers after installing a plug-in.

X3D - the language that replaced VRML as the standard for creating virtual environments in
the Internet.

Collaborative Design Activity (COLLADA) - a format used to allow file interchanges within
three-dimensional programs.

Of course, many VE experts would argue that without an HMD, Internet-based systems are
not true virtual environments. They lack critical elements of immersion, particularly tracking
and displaying images as life-sized.

Source: http://electronics.howstuffworks.com/gadgets/other-gadgets/virtual-reality.htm/printable

Hot Virtual Reality Sites

Reprinted with permission of Bob Thaves. Inclusion on this list does not constitute an
endorsement by NIST and is for informational purposes only. By selecting these links, you
will be leaving NIST web space. We have provided these links to other web sites because
they may have information that would be of interest to you. No inferences should be drawn

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on account of other sites being referenced, or not, from this page. There may be other web
sites that are more appropriate for your purpose. NIST does not necessarily endorse the
views expressed, or concur with the facts presented on these sites. Further, NIST does not
endorse any commercial products that may be mentioned on these sites. Please address
comments about this page to sressler@nist.gov.

New Entries

VizTek creators of VR walls and CAVE type sytems along with systems integration
capabilities, fully immersive PC-based VR system.2/11/02

Academia

Clemson University's VR research and activities. 6/29/95

The Graphics, Visualization and Usability Center at the Georgia Institute of Technology
illustrates many graphics and user interface projects including a good section on virtual
environments.

Greg Seidman a clever summer student here at NIST has some VRML goodies for you.
8/29/95

Ian's VR Buying Guide., a nice set of VR products and tables. 2/13/96

U of Michigan Virtual Reality Laboratory (VRL), a very nice collection of info on VR. 7/30/96

Rutgers CAIP Virtual Reality Lab, terrific VR laboratory with emphasis on force feedback.
4/18/96

The Human Interface Technology Lab at the University of Washington in Seattle probably
contains the most extensive collection of information about VR avaliable on the net.

The Interactive Visualizer at Georgia Tech is a full fledged VR environment being used in a
wide variety of projects.

Virtual Polyhedra a way cool page of VRML polyhedra. 10/9/96

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Mississippi State Virtual Environment/Interactive Systems Programat the National Science
Foundation Engineering Research Center for Computational Field Simulation

Montgomery Blair High School Virtual Walkthrough shows how all us old geezer computer
types better watch out as the kids are catching up.

The MR Toolkit from the University of Alberta is one of the most robust and widely used VR
software tools and libraries. It is available with source code.

VENUS the Virtual Environment Navigation in the Underground Sites is a large scale effort at
CERN to use virtual prototyping for the next generation particle accelerator.

Commercial

3D Imager, Stereoscopic image creation, a shareware product by AMPK Software Ltd.
10/22/96

5DT Fifth Dimension Technologies, makers of a variety of consumer oriented VR
products.2/28/97

Acuris, 3D models, including VRML. 12/10/96

Aereal Inc. , has oodles of VRML and is home of Proteinman's Top Ten VRML
Sights.11/22/95

Aesthetic Solutions Creators of some new VRML authoring tools.2/5/98

Amusitronix a leading supplier of VR entertainment.5/31/01

The Apple QuickTime VR Web Site has lots of cool QTVR examples and information. 7/19/95

Applied Virtual Reality Corporation (AVR) in their words "Founded in 1994, AVR was formed
to be Canada's leading resource for information, education, research and VR technology
acquisition in the application of the Virtual Reality medium".

Argus VR International Creators of VR for exhibits and much more. 1/29/99

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The Armchair Travel Company Ltd, some folks really using QuickTime VR in interesting ways.
10/19/95

Atlantis Cyberspace Virtual Reality Entertainment Centers a location based entertainment
outfit with an extensive web site. 8/24/95

blaxxun interactive, (formerly Black Sun) tool makers for building online communities and
collaborative environments.2/19/97

Biomechanics, Inc. a motion capture company, has some way cool MPEGs of human motion.

Cicada Web Development, VRML and Web site developers. 5/21/96

Computers and More, sellers of Virtual Reality Gear.3/17/97

Crystal River Engineering offers a variety of 3D sound systems for your virtual worlds.

CyberEdge Electric, the on-line companion to the CyberEdge Jounal, chock full of
information on all aspects of VR. 10/26/95

Cybermind formerly Virtuality the main purveyors of VR arcade game units and more.
10/21/98

Cybertown ,a cyberspace web environment that's extremely well designed, uses VRML and
lots of other techno-widgets.12/7/95

dFORM LLC A VRML consulting house with a really cool set of pages on Euclid's and
geometric primitives. 9/3/96

Deneb Robotics, makers of robotic and facotory simulation software with VR capabilities.
12/6/96

Digital Tech Frontier vendors of VR systems for rental and trade show applications.2/16/00

DIVE Laboratories, makers of a variety of interesting VR products such as Amber (modeing
tool) and vrTrader a VR financial application. 10/5/95

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Division Ltd one of the few VR players that can provide complete systems. 7/18/95

Dreamality Technologies manufacturers of VR simulators for hang gliders, ultralights and
more 10/7/97

E-Spaces a VR service house.9/3/99

EINET Galaxy a commercial provider of network communications and information has a nice
web page on Virtual Reality.

Electric Labs a QTVR and 3D grphics outfit with a large assortment of work. 9/3/96

ERG Engineering Inc., a cool collection of project done by Eben Gay and his cohorts.1/31/96

euroVR nice collection of QuickTimeVR images from around europe with links to
companies.10/6/99

euroVR nice collection of QuickTimeVR images from around europe with links to
companies.10/6/99

Extempo Systems, creators of improvisational synthetic characters. 1/15/97

Godbusters An intersting 3D search site, only a movie database but more coming.2/3/98

GOMIDa pure Java 3D web browser.3/16/01

GT Interactive Software has a nice web site of games including VR games such as Locus
8/28/95

High Techsplanations has a web site illustrating ther surgical simulation and biomedical
visualization systems. 6/28/95

HIMUM an interesting Italian VR site with the Cyclops educational VR (custom projects)
system. 6/1/98

Holophonics a 3D Virtual Sound system. 7/7/95

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Humana Virtualis, an interesting repository of links to topics related to virtual humans.
2/5/97

i-glasses developer page, a collection of resources for a popular HMD 7/8/98

Immersion Corporation has some way cool force feedback devices for medical applications.
3/11/96

Information Assets, Inc. Engineering VRML 2/15/96

Interactive Imaging makers of the VFX3D HMD and other VR tools.2/16/99

InWorld VR Inc, has an interesting JAVA 3D API. 12/11/96

Kaiser Electro-Optics HMDs a leading supplier of HMD's head mounted displays, very high
quality. 7/9/01 i

Liquid Image makers of a variety of Head Mounted Displays (HMDs).

Maelstrom vendors of VR hardware and software. Can create custom marketing
applications.3/21/00

Mesh Mart's VRML Page, Richard Tilmann's extensive collection of VRML sites and tools.
3/25/96

Paragraph International, a pioneer in VRML development tools. 4/10/97

RealiMation ,a VR Simulation and Game Development Tool.12/6/95

RMH A German Virtual Reality firm with a cool portable cave product. 11/13/98

SensAble Technology, makers of the PHANToM force feedback VR device. 4/25/97

SENSE8 Corporation, makers of the widely use WorldToolKit.11/30/95

SGI's VRML site 8/5/97

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StrayLight Corp. vendors of VR hardware and software, for applications like Location Based
Entertainment and more.8/30/00

Superscape makers of a complete suite of PC based VR software. 8/28/95

Template Graphics Software an old time vendor of lots of graphics software products is
working on a commercial 3D web browser using VRML.

ThemeKit makes a VR graphics engine for PCs with an API and WYSIWYG VR development
environment. 3/5/96

VFX1, makers of immersive VR gear for PCs. 2/12/97

VIS-SIM.ORG terrific resource for the visual simulation industry.10/25/99

Virtual Motion Immersive VR R&D company8/24/98

Virtual Reality Glossary, nice collection of Web sites and information about VR by Henry
Targowski of Mark/Space. 3/26/96

Virtual Realities vendors of all types of immersive VR equipment.12/9/99

Virtual Reality Publishing good collection of VR links7/15/97

The Virtual Reality Source offers a large collection of VR devices and services.7/7/99

The Virtual Reality Store, a place to find all those VR toys. 5/21/96

Virtual Technologies, makers of the CyberGlove a high resolution glove and other
CyberWear. 10/5/95

Virtuality, a leading immersive VR company. 1/3/97

VirtuallyReal Group a serivce bureau producing high quality 360 panoramas and
objects.1/2/01

Virtus home of the fabulous Virtus Walkthrough modeling system.

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VRealm Suite of VR products, including a VRML plug-in. 5/21/96

VResources, new improved updated link to site with healty collection of VR links. 1/31/97

The VR CD-ROM Revision 1 by Network Cybernetics Corporation. A collection of thousands
of up to date files on VR, Telepresence, Telerobotics and Computer Simulation. 8/17/95

VREAM, makers of WIRL a VRML browserand lots of other cool stuff. 4/12/96

Weblynx Ultimate World Library, a very thorough collection of VRML files and
information.1/22/96

WebMolecules A serous chemistry site with over 2000 VRML chemical structures12/15/97

ZD3D, Ziff-Davis VRML site.1/19/96

Cyberspace

The Contact Consortium, a nascent cyberspace culture, organizers of Earth to Avatars
conference. 11/12/96

Diabetes and VRML a fasicating combination of VRML and information about diabetes.
9/3/96

ExpressVR, Brad Anderson's (a high school kid!!) creation of the first Netscape VRML plug-in
for the Mac. 3/20/96

Focus on VRML comprehensive VRML Mining Co. site. 4/27/98

Scientific Analysis and Visualization of the Environment Maui Program VRML world 5/5/97

Ultimate Future, a site of VR philosophers, inventors and more. 12/23/96

The Virtual Reality Allience of Students and Professionals (VRASP) a not-for-profit
organization is up on the Web.

Virtual Reality Philosophical Essays, by Gil Markle. 12/9/96

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The VRML Repository, the mother-of-all-VRML sites. 2/19/97

VRML Worlds by Jeff Harrington some interesting artsy worlds, lots of textures. 10/17/96

Government

The Army Research Institute has a Mac based server illustrating research on the effects of
immersion.

Johnson Space Center VR Lab. check out one of the few "serious" VR applications, such a
training for Space Shuttle missions 3/5/96

The MCS (Mathematics and Computer Science Division of Argonne National Laboratory is
exploring virtual environment and hey...they have a CAVE.

Medical Virtual Reality at the National Cacer Center in Tokyo3/16/99

Metro Nashville Police, has some QTVR nodes for crime scene applications.11/20/95

The Naval Postgraduate School has lots of good VR work...check it out.

The NCSA VR Lab Home Page illustrates the ever expanding work being done at NCSA.

The The Virtual Environment Generator will carry virtual reality into space, courtesy of
NASA, in a 1998 Space Shuttle Mission.

Virtual Environment for Submarine Ship Handling Training 10/6/97

Virtual Reality Environments for Psychoneurophysiological Assessment and Rehabilitation, a
European Community project Telematics for health- HC 1053 4/4/97

Last but not least the Open Virtual Reality Testbed at the National Institute of Standards and
Technology.

Source: http://ovrt.nist.gov/hotvr.htm

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