Healing the Wounded Warrior

• Charles Levy, Chief of Physical Medicine and Rehabilitation, Malcolm Randall VA Medical Center (MRVAMC)
• James Oliverio, Director, Digital Worlds Institute (DW), Co-Director, Office for Transdisciplinary Research and Innovation (OTRI), University of Florida
• Jill Sonke, Director, Center for the Arts in Healthcare (CAHRE), Co-Director, Office for Transdisciplinary Research and Innovation (OTRI), University of Florida

Preamble
Through a grant from the US Department of Commerce, the partners listed above have conceptualized and mobilized a major initiative to support returning Iraq war veterans through online virtual reality-based therapeutic, psychosocial, and vocational interventions.  The project focuses on therapeutic rehabilitation and re-integration of wounded warriors into their families, communities, and the workforce.

Background and Rationale
A staggering 31% of soldiers returning from active duty in Afghanistan or Iraq and seen in veterans administration medical centers between 2001-2005 were diagnosed with mental health or psychosocial conditions1.  The prevalence of Post Traumatic Stress Disorder (PTSD) and Mild Traumatic Brain Injury (MTBI) in returning combat veterans is estimated at 20%, and the Defense and Veterans Brain Injury Coalition estimates that roughly 40% of injured warriors suffer from MTBI2.  It is estimated that a significant number of additional veterans suffering from such disorders go undiagnosed and untreated3.

Often the most troubling symptoms of Post Traumatic Stress Disorder (PTSD) and Mild Traumatic Brain Injury (MTBI) are behavioral: mood changes, depression, anxiety, impulsiveness, emotional outbursts, intolerance of crowds, hyper-vigilance or inappropriate laughter. Other symptoms include disturbances in attention and memory, as well as delayed reaction time during problem-solving. Behavioral therapy, a mainstay of successful rehabilitation, generally requires that veterans be able to organize and negotiate daily activities, travel considerable distances, and interact with individuals in public to meet scheduled appointments - the very areas where impairments may be most profound. An additional barrier to rehabilitation for many returning combat soldiers is generational. Many younger warriors feel uncomfortable entering veterans administration medical centers, where both the patients and health care providers are older, and may be perceived as unsympathetic or unable to understand the issues of newly returning warriors.

Currently, there is not a widely recognized and effective treatment procedure to allow returning veterans to successfully re-integrate into the society they fight to defend. Yet there is compelling evidence that the use of virtual reality can contribute greatly to cognitive and affective rehabilitation and recovery4-6. A recent article (Oct. 6, 2007) on the front page of The Washington Post, entitled “Real Hope in Virtual Worlds: Online Identities Leave Limitations Behind”, describes how an increasing number of major health organizations are taking advantage of virtual worlds for public health education and patient support, and that many disabled individuals are “getting their lives back” through virtual world engagement7.

Virtual World Environments (VWEs) hold great potential to solve many of the problems limiting effective treatment, support, and reintegration of wounded combat veterans into their families and into American society.  Internet-based VWEs are readily accessible from home at the user’s convenience. But unlike the public internet, the content of the VETS interaction can be carefully structured, controlled, and monitored by medical professionals. Many younger warriors are not only familiar with, but actually comfortable and fluent in, virtual realities through their exposure to electronic gaming and virtual combat training programs.  Although there are compelling precedents for the potential use of virtual reality-based scenarios8, not enough research and development has been undertaken to fully utilize today’s online virtual worlds to develop effective therapeutic interventions for veterans.

Innovation
This VETS initiative combines current digital technologies, clinical expertise, and focused testing to create an accessible and effective 21st century approach to the increasingly urgent problem of PTSD and MTBI in returning service-disabled veterans.

Technology
Virtual World Environments are easily accessible, intuitive, and effective forms of virtual reality that provide secure real-time interaction between multiple users via the Internet. The VETS project will develop and test a novel online VWE platform that will serve as the basis for development and delivery of real-time interactive therapeutic treatment modalities. These readily accessible VWEs provide both psychosocial and psychoeducational interventions and vocational training for service disabled veterans suffering from PTSD/MTBI. The system will embody a unique capability to constantly enhance its efficacy based on user input, including user-designed content, clinical outcomes, and general use patterns. Thus, VWEs show great potential to augment or replace conventional treatment of PTSD/MTBI in returning combat veterans.

Expertise
The VETS project utilizes the expertise of a unique interdisciplinary team consisting of Malcolm Randall Veterans Administration Medical Center physicians specializing in physical medicine, rehabilitation, psychiatry, and psychology, as well as specialists from UF’s Digital Worlds Institute, Center for the Arts in Healthcare, the UF Health Sciences, and College of Engineering. This team will collaborate to ensure that the system platform and modalities are clinically, technically, and functionally relevant, and likewise appropriate, to the current treatment needs of wounded warriors.  UF’s Digital Worlds Institute, an international leader in digital technology innovation, will lead development of the system.

Accessibility
VWE interventions can be accessed not only during traditional sessions in the offices of healthcare providers, but also from a computer in the privacy of warriors’ homes. In many cases this can reduce or even eliminated the need for recurring travel to a distant medical facility. They provide opportunities for interaction with others in a fully immersive, more controlled, and less threatening virtual environments, and capitalize on pre-existing technological skillsets possessed by many warriors in their 20s and 30s. VWEs can also provide veterans with 24-hour on-demand access to therapeutic modalities, as opposed to the ordinary business hours of healthcare workers. The potential applications of this system are far-reaching in this regard.

Objectives
The overarching aim of the VETS project is to build working prototypes of VWEs that are conceptually sound and ready for testing and refinement in clinical trials with combat veterans.  Three VWE applications will be modeled within this project:

• Therapeutic Modalities that allow health professionals to interact with patients individually and in groups via the Internet.  The VWE will allow veterans to remotely participate in the creation of their own therapeutic environment using “avatars” (visual representations of themselves) with real-time text and audio communication. It is anticipated that this delivery platform will increase participation, accessibility, and acceptance of therapeutic interaction by warriors;
• Therapeutic Simulations of ordinary social and vocational challenges to allow veterans to practice problem-solving in virtual real-life scenarios. Participants will be able to review the consequences of decisions, and get direct and immediate feedback regarding choices and responses. Unlike real life, they will have multiple opportunities to learn to deal with challenging situations with no penalty for failure; and
• Vocational Tools and Creative Learning Modules for the development of digital media skillsets that are increasingly in demand for the workforce of the 21st Century. As the American job market moves from traditional service and manufacturing industries to digital and creativity-based professions, skills in 3D modeling, animation and graphical environments are increasingly sought after. One of the potential outcomes of VWE-assisted therapy is an increased fluency in both the tools and techniques of computer-based interactive media skillsets. We continue to develop our partnership with Navigator Development Group (National Disabled American Veterans (DAV) Small Employer of the Year 20079) and educational programs such as the Advanced Visualization and Interactive Design Center10 to develop and implement programs that are not only therapeutic but also accompanied by a significant vocational component.

Expected Outcome
The proposed VWE-based system platform and modalities will effectively augment conventional treatment of PTSD/MTBI in returning combat veterans. It is scalable to regional, state and national levels and will significantly enhance our country's ability to deliver therapeutic and vocational support services to returning warriors as an appropriate reward and recognition of their tremendous sacrifice. 

References Cited

1. Seal, K.H., Bertenthal, D., Miner, C.R., Sen, S., Marmar, C. (2007). Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities.  Arch Intern Med., 167(5):476-82.
2. [No authors listed] (2006). The neurological burden of the war in Iraq and Afghanistan. Ann Neurol., 60(4):A13-5
3. Reeves R.R. (2007). Diagnosis and management of posttraumatic stress disorder in returning veterans. J Am Osteopath Assoc. 107(5):181-9.
4. Rose, F.D., Brooks, B.M. & Rizzo, A.A. (2005). Virtual Reality in Brain Damage Rehabilitation: Review. CyberPsychology & Behavior. 8(3):241-262.
5. Rothbaum BO, Hodges LF, Ready D, Graap K, Alarcon RD (2001). Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder.  J Clin Psychiatry, 62(8):617-22.
6. Josman N, Somer E, Reisberg A, Weiss PL, Garcia-Palacios A, Hoffman H. (2006). BusWorld: designing a virtual environment for post-traumatic stress disorder in Israel: a protocol. Cyberpsychol Behav., 9(2):241-4.
7. Stein, R. (2007). Real Hope in Virtual Worlds: Online Identities Leave Limitations Behind.  Washington Post.  Oct 6, 2007 edition, pg A01.
8. Halpern, S (2008). VIRTUAL IRAQ: Using simulation to treat a new generation of traumatized veterans. Annals of Psychology, The New Yorker. August 28, 2008. http://www.newyorker.com/reporting/2008/05/19/080519fa_fact_halpern?currentPage=all
9. http://www.ndgi.com/index.php?option=com_content&view=article&id=86&Itemid=100
10. http://www.i3dtrain.com/about.html