1Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, MD 89011, USA.
2Department of Plastic and Reconstructive Surgery, The University of Texas Rio Grande Valley, Edinburg, TX 78539, USA.
3Department of Plastic and Reconstructive Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA.
© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Millions of people around the globe suffer peripheral nerve injuries caused by trauma and medical disorders. However, medical school curricula are profoundly deficient in peripheral nerve education. This lack of knowledge within the healthcare profession may cause inadequate patient care. We developed the Virtual Peripheral Nerve Academy (VPNA) as a reusable virtual learning environment to provide medical students with detailed education on the peripheral nervous system (PNS). Students are introduced to the PNS through virtual 3D rendering of the human body, wherein they visualize individual nerves through dissection and observe normal motor and sensory function associated with each nerve. PNS structures that are absent from traditional texts are included in this visualization, ranging from the innervation of joints to the normal anatomic variation required for differential diagnosis of pain after an injury. Detailed modules on peripheral nerve disorders allow students to observe pathophysiological mechanisms, associated symptomatology, and appropriate treatments. Students are briefed on a patient clinical case, then interact with a patient avatar to learn the appropriate diagnostics, including physical exam maneuvers and electrodiagnostic testing. Interactive modules on peripheral nerve surgeries detail surgical techniques. The VPNA data and analytics dashboards allow medical students and course instructors to assess skill improvement and identify specific learning needs. The built-in learner management system and availability on both computer-based and virtual reality platforms facilitate integration into any existing medical school curricula. Ultimately, this immersive technology enables every medical student to learn about the peripheral nervous system and gain competency in treating real-life nerve pathologies.
Virtual reality, peripheral nervous system, nerve, surgical education, medical education, simulation, plastic surgery
Peripheral nerve injuries (PNI) currently affect more than one million people worldwide, and the occurrence of trauma-induced PNI is steadily on the rise[1,2]. In addition to trauma-based PNI, disease-induced peripheral nerve disorders such as diabetic neuropathy are increasingly common with the rising prevalence of obesity and diabetes[3-5]. Over half of people with diabetic neuropathy in the United States present with upper and lower extremity nerve compressions. Additionally, iatrogenic injuries frequently occur through surgical procedures, such as hernia repair[7-9], total knee replacement, and episiotomy, with many patients reporting chronic pain due to neuromas of surgically transected nerves. These injuries are notoriously devastating and life-altering as patients can face severe lifelong disabilities, including sensory loss, motor loss, and neuropathic pain[2,12-14]. Despite advancements in microsurgical techniques and basic and translational research, traditional treatments for nerve repair continue to have unsatisfactory clinical outcomes[2,13]. Among the many factors that influence peripheral nerve injury prognosis - including age and co-morbidities - the amount of time that elapses prior to end-organ reinnervation is perhaps the most consequential[13-17]. The importance of time is evidenced by the poor outcomes that tend to occur with proximal nerve injuries and delayed repairs. Therefore, education of medical students about the urgency of injury identification and referral to a peripheral nerve surgeon in a timely manner is most important.
Patients are faced with numerous barriers to care, including a lack of awareness of the signs and symptoms of common nerve injuries. Furthermore, upon reaching a diagnosis, patients face barriers in finding a surgeon to care for their injury. In 2017, over 40% of counties in the U.S. had zero surgeons per 100,000 population. Additionally, access to surgeons trained in peripheral nerves, such as neurosurgeons, plastic surgeons, and hand surgeons, is even more limited, and consequently, injured patients may suffer from chronic pain and misdiagnoses.
Inaccessibility to peripheral nerve surgery is compounded by the lack of peripheral nerve training within the medical education system; much of the nervous system curriculum content focuses on the central nervous system and special senses. Medical students typically only gain brief exposure to the peripheral nervous system (PNS) through anatomy dissections and elective clerkships, despite the wide-stretched reach of this field. Consequently, this lack of knowledge leads to a gap in clinical skills related to gathering relevant, patient-centered, hypothesis-driven history, and physical examination data in the clinical setting. Therefore, it is imperative that medical students gain a thorough knowledge of how to identify and treat peripheral nerve disorders. For example, a simple clinical physical examination technique may be taught for the upper extremity carpal tunnel syndrome, but seems never to be taught for the nerve compression at the medial ankle, the tarsal tunnel syndrome, for which a positive Tinel sign has an 80% positive predictive value of successful nerve decompression.
Virtual reality (VR)-based education is a promising avenue to not only integrate peripheral nerve system-focused content into medical school curricula, but also promote sustained knowledge. Educational VR technology provides a powerful environment for meaningful learning, enhances retention of existing curriculum, and encourages active participation over passive lecture experiences. The use of VR technology within medical education has repeatedly been found to improve learning experiences and performance on examinations, and increase student confidence in their skills[23-26]. For example, VR-based anatomical education has been repeatedly found to improve examination performance over traditional prosection-based learning. Given the multitude of benefits demonstrated by VR-based education, we sought to develop a VR rather than lecture-based curriculum on the peripheral nervous system to provide medical students with a reusable virtual learning environment. Additionally, as a study by Bartlett et al. found that the use of surgical VR simulations made surgical residency more appealing to students, we hope integrating this content into medical schools will encourage medical students to explore and ultimately pursue nerve surgery-related fields. We partnered with BioDigital Systems LLC to create an immersive, user-friendly peripheral nerve education virtual reality platform dubbed the “Virtual Peripheral Nerve Academy (VPNA),” which enables virtually any healthcare student or provider to easily learn about the peripheral nervous system and gain competency in treating real-life nerve pathologies. BioDigital Systems, LLC has a history of successful collaborations in healthcare education, including anatomical modules at the Johns Hopkins School of Nursing and surgical simulations with the New York University Langone Medical Center Department of Reconstructive Plastic Surgery[28-31]. Studies have found that the use of VR modules based on the BioDigital platform significantly improves knowledge of the procedure and increases trainee confidence[29,30]. Herein, we will discuss how VPNA is being developed at the Johns Hopkins School of Medicine.
VPNA is an immersive, reusable virtual learning platform to provide medical students with a comprehensive education on peripheral nerve disorders and associated treatment. The VPNA curriculum is module-based and uses a variety of media, including still and animated graphics, motion video, and text. The VPNA is designed to be entirely virtual and can be integrated into existing medical school curricula led by experienced practitioners.
Trainees are first introduced to the VPNA historical timeline, which denotes significant figures like Santiago Ramon y Cajal of Spain (Nobel Prize, 1906), for his work on neuroanatomy, and Hanno Millesi of Germany, for his introduction of interfascicular interposition nerve grafting (1974), and Rita Levi-Montalcini of Italy (Nobel Prize 1986), for her discovery of nerve growth factor. This introduction serves both to set the foundation for the basics of the peripheral nervous system as well as the concepts that drive modern treatments.
After completing the introduction, trainees first learn about the components and inner workings of nerves at a cellular level. They can view the processes underlying normal synaptic transmission as well as the pathophysiology of nerve disorders and injury [Figure 1]. Trainees then learn how to classify nerve injuries into the Seddon and Sunderland classifications related to the degree of disruption of the neural structure.
Figure 1. Modules on the cellular and molecular mechanisms of nerves take a focused look at normal neurotransmitter activity, as seen here, and pathophysiological processes. Module captured with permission from BioDigital.
Trainees then explore the nerves within the human body through a virtual rendering and can dissect layer by layer to locate individual nerves and branches [Figure 2]. Natural variations in nerve location are described. Users can observe normal motor function and sensory innervation through a physical exam with an avatar and are quizzed at the end of the modules.
Figure 2. Trainees begin their explorations of nerve anatomy through the Male and Female Peripheral Nervous System overview modules. These modules allow for a dissection through muscle and connective tissues and the location of nerves throughout the human body. Individual nerves can be located, and their respective functions observed. Module captured with permission from BioDigital.
Target audience-appropriate experiences provide detailed, game-based learning on peripheral nerve disorders and appropriate treatment. Over 25 modules focus on individual nerve disorders such as brachial plexus compression/injury, facial pain and headache, facial palsy, joint denervation, and pelvic pain of neural origin. In addition, trainees can learn about peripheral neuropathy due to diabetes, leprosy, or chemotherapy. Trainees are briefed on a patient case and then interact with a patient avatar to learn the appropriate diagnostics - including physical exam maneuvers and electrodiagnostic testing - to diagnose and treat the patient [Figure 3]. Trainees gain competency in how to medically treat nerve injuries and learn when surgical intervention is necessary. Surgical intervention modules demonstrate the principles of nerve decompression, nerve repair, nerve reconstruction, and neuroma treatment.
Figure 3. Individual nerve disorders, such as Bell’s Palsy featured here, use game-based learning to train students on appropriate diagnostics and treatment. Trainees interact with avatars and learn to identify the signs and symptoms of over 25 peripheral nerve disorders. Module captured with permission from BioDigital.
We are developing a high-fidelity operating room (OR) experience capable of both a single and multi-player format to allow surgical residents and advanced trainees to learn how to perform the peripheral nerve surgeries described. Patient case and OR simulations will be done under the guidance of a virtual coach to provide real-time feedback. The simulations will be followed by a debriefing and constructive, personalized discussion of the simulation and the trainee’s decisions.
The VPNA’s data and analytics dashboards allow trainees to assess skill improvement and identify specific learning needs. The built-in learner management system facilitates easy integration into any existing curricula. The infrastructure of the VPNA supports reconfiguration and customization to address the training needs of different audiences - thus allowing the platform to be used to train healthcare professionals at any level as well as patients.
The VPNA is accessible by mobile device or computer using any Internet Web browser. It can be used with a VR headset and data gloves to allow for an immersive, hands-on experience, and real-time haptic feedback.
We are developing the first pilot course to assess the efficacy of the VPNA in enhancing medical student competency in the peripheral nervous system. Our pilot team consists of experts in the field, curriculum leaders and other stakeholders at the Johns Hopkins School of Medicine, and the BioDigital platform. Following the Office of Medical Student Curriculum’s (OMSC) Process for Curricular Enhancement, the feasibility of curricular integration was first discussed with the OMSC and the Medical Student Senate (MSS). The VPNA team was approved to conduct a needs assessment to evaluate areas within the existing curriculum that did not address or could be enhanced by the content of the VPNA. First, the VPNA team assessed student and faculty impressions of the existing content to identify themes for improvement. Themes gathered from two groups of ten participants consisting of plastic surgeons and medical students in an informal setting included general nerve physiology, individual nerve function, nerve disorders, and appropriate diagnostics/treatment. Surgeons expressed a need for early diagnosis and referral from primary care and other specialties as they frequently saw patients with delayed care. This was similarly noticed by medical students during their clinical exposure. Medical students within their preclinical years also described a large focus on the central nervous system over the peripheral nervous system within their neuroscience curriculum. From these themes, 65 individual topics (i.e., ulnar nerve, carpal tunnel syndrome) were then listed. Individual topics underwent two rounds of pretesting with five participants consisting of plastic surgeons and medical students in an informal setting.
The VPNA team then conducted a lecture-by-lecture assessment of the medical student curriculum at Hopkins to characterize if and how these individual topics were covered. The team worked closely with curriculum leaders to ensure nothing was missed. Among the courses searched were Anatomy, Pre-clinical Neuroscience, and Neurology Clerkship. Of the 40 topics assessed, 29 (72%) were present within the curriculum. However, the topics were most often briefly described (i.e., one slide within a lecture) or were only included within a graphic or table. Upon completion of the needs assessment, the VPNA was approved for implementation as both a supplement to existing topics and an avenue for new topics. Based upon our needs assessment of the Johns Hopkins School of Medicine curriculum, we have deemed the VPNA would be appropriate and beneficial to be included as a component of the Pre-clerkship Curriculum and the neurology clerkship. We have partnered with the course directors of the Pre-clerkship Curriculum to utilize the small group sessions already built within the curriculum to test the VPNA against the standard educational content. During the neuroscience core, half of the small group sessions will have unlimited access to the VPNA, while the remaining half will complete the standard course material. At the end of the core, there will be an assessment of learner satisfaction with the course material and a quiz on content specific to the peripheral nervous system. Final course exam scores will also be compared. We hypothesize that the VPNA will greatly improve overall course exam scores as well as provide a more enjoyable learning experience.
Within the Neurology core, half of the rotating students will be granted, randomly, access to the VPNA. At the end of the core, all students will take the standard National Board of Medical Examiners (NBME) Neurology core exam. Scores will be compared between the VPNA and standard education students. We hypothesize that students who can study with the VPNA will achieve higher scores on their NBME exams. Although not intended to be studied during the pilot course, it is our hope that repeated exposure to the VPNA during the pre-clerkship curriculum and neurology clerkship will lead to better retention of knowledge on the peripheral nervous system.
Upon conclusion of these pilot studies, we aim to have the support to permanently implement the VPNA at the Johns Hopkins School of Medicine and to expand to other medical schools.
The Virtual Peripheral Nerve Academy aims to provide an immersive platform for medical students to learn about the peripheral nervous system and gain competency in treating real-life nerve pathologies. This training can be easily integrated into existing medical school curricula. By increasing medical students’ knowledge of how to identify and treat peripheral nerve disorders at both pre-clerkship and clerkship levels, we hope to create a lasting familiarity with the peripheral nervous system regardless of their residency choice. In doing so, we hope to reduce barriers in access to care for patients with peripheral nerve injuries by increasing the number of healthcare professionals versed in their care. The Virtual Peripheral Nerve Academy began pilot evaluation in March 2022, and data collection will continue through December 2022. Following pilot completion and iterative refinement, it will be released with all components to the public in July 2023.
We thank the BioDigital team for their collaboration on this project.Authors’ contributions
Made substantial contributions to conception and design of the Virtual Peripheral Nerve Academy: Lee EB, Podsednik A, Khoo K, Cheema A, Cabrejo R, Shen C, Rosen J, Dellon AL
Designed and established pilot program: Lee EB, Dellon ALAvailability of data and materials
Not applicable.Financial support and sponsorship
None.Conflicts of interest
All authors declared that there are no conflicts of interest.Ethical approval and consent to participate
Not applicable.Consent for publication
© The Author(s) 2022.
1. Taylor CA, Braza D, Rice JB, Dillingham T. The incidence of peripheral nerve injury in extremity trauma. Am J Phys Med Rehabil 2008;87:381-5.DOIPubMed
2. Campbell WW. Evaluation and management of peripheral nerve injury. Clin Neurophysiol 2008;119:1951-65.DOIPubMed
3. Jeffcoate WJ, Chipchase SY, Ince P, Game FL. Assessing the outcome of the management of diabetic foot ulcers using ulcer-related and person-related measures. Diabetes Care 2006;29:1784-7.DOIPubMed
4. Miscio G, Guastamacchia G, Brunani A, Priano L, Baudo S, Mauro A. Obesity and peripheral neuropathy risk: a dangerous liaison. J Peripher Nerv Syst 2005;10:354-8.DOIPubMed
5. Callaghan BC, Gao L, Li Y, et al. Diabetes and obesity are the main metabolic drivers of peripheral neuropathy. Ann Clin Transl Neurol 2018;5:397-405.DOIPubMed PMC
6. Hashemi S, Cheikh I, Dellon AL. Prevalence of upper and lower extremity Tinel signs in diabetics: crosssectional study from a united states, urban hospital-based population. J Diabetes Metab 2013;4:3.DOI
7. Ducic I, Moxley M, Al-Attar A. Algorithm for treatment of postoperative incisional groin pain after cesarean delivery or hysterectomy. Obstet Gynecol 2006;108:27-31.DOIPubMed
8. Khoshmohabat H, Panahi F, Alvandi AA, Mehrvarz S, Mohebi HA, Shams Koushki E. Effect of ilioinguinal neurectomy on chronic pain following herniorrhaphy. Trauma Mon 2012;17:323-8.DOIPubMed PMC
9. Lee CH, Dellon LA. Surgical management of groin pain of neural origin1. Journal of the American College of Surgeons 2000;191:137-42.DOI
10. Dellon AL, Mont MA, Krackow KA, Hungerford DS. Partial denervation for treatment of persistent neuroma pain after total knee arthroplasty. Clin Orthop Rel Res 1995;316:145-50.DOI
11. Wan EL, Goldstein AT, Tolson H, Dellon AL. Injury to perineal branch of pudendal nerve in women: outcome from resection of the perineal branches. J Reconstr Microsurg 2017;33:395-401.DOIPubMed
12. Wang E, Inaba K, Byerly S, et al. Optimal timing for repair of peripheral nerve injuries. J Trauma Acute Care Surg 2017;83:875-81.DOIPubMed
13. Gordon T, Tyreman N, Raji MA. The basis for diminished functional recovery after delayed peripheral nerve repair. J Neurosci 2011;31:5325-34.DOIPubMed PMC
14. Höke A, Brushart T. Introduction to special issue: challenges and opportunities for regeneration in the peripheral nervous system. Exp Neurol 2010;223:1-4.DOIPubMed PMC
15. Carlson BM, Billington L, Faulkner J. Studies on the regenerative recovery of long-term denervated muscle in rats. Restor Neurol Neurosci 1996;10:77-84.DOIPubMed
16. Höke A. Mechanisms of disease: what factors limit the success of peripheral nerve regeneration in humans? Nat Clin Pract Neurol 2006;2:448-54.DOIPubMed
17. Scheib J, Höke A. Advances in peripheral nerve regeneration. Nat Rev Neurol 2013;9:668-76.DOIPubMed
18. Kadakia RJ, Tsahakis JM, Issar NM, et al. Health literacy in an orthopedic trauma patient population: a cross-sectional survey of patient comprehension. J Orthop Trauma 2013;27:467-71.DOIPubMed
19. Way CW Jr. Is there a surgeon shortage? Mo Med 2010;107:309-12.DOI
20. Doescher MP. The crisis in rural general surgery: can research drive policy change? WWAMI rural health research center; 2009. Available from: https://familymedicine.uw.edu/rhrc/presentations/the-crisis-in-rural-general-surgery-can-research-drive-policy-change/ [Last accessed on 14 Jul 2022].
21. Lee CH, Dellon AL. Prognostic ability of Tinel sign in determining outcome for decompression surgery in diabetic and nondiabetic neuropathy. Ann Plast Surg 2004;53:523-7.DOIPubMed
22. Garrison DR, Akyol Z. Role of instructional technology in the transformation of higher education. J Comput High Educ 2009;21:19-30.DOI
23. Moro C, Štromberga Z, Raikos A, Stirling A. The effectiveness of virtual and augmented reality in health sciences and medical anatomy. Anat Sci Educ 2017;10:549-59.DOIPubMed
24. O’Sullivan DM, Foley R, Proctor K, et al. The use of virtual reality echocardiography in medical education. Pediatr Cardiol 2021;42:723-6.DOIPubMed
25. Shetty S, Zevin B, Grantcharov TP, Roberts KE, Duffy AJ. Perceptions, training experiences, and preferences of surgical residents toward laparoscopic simulation training: a resident survey. J Surg Educ 2014;71:727-33.DOIPubMed
26. Mitrousias V, Varitimidis SE, Hantes ME, Malizos KN, Arvanitis DL, Zibis AH. Anatomy learning from prosected cadaveric specimens versus three-dimensional software: a comparative study of upper limb anatomy. Ann Anat 2018;218:156-64.DOIPubMed
27. Bartlett J, Kazzazi F, To K, Lawrence J, Khanduja V. Virtual reality simulator use stimulates medical students’ interest in orthopaedic surgery. Arthrosc Sports Med Rehabil 2021;3:e1343-8.DOIPubMed PMC
28. Qualter J, Sculli F, Oliker A, et al. The biodigital human: a web-based 3D platform for medical visualization and education. Stud Health Technol Inform 2012;173:359-61.PubMed
29. Kantar RS, Alfonso AR, Ramly EP, Diaz-Siso JR, Flores RL. Educational resources in craniofacial surgery: the case for user-friendly digital simulators. J Craniofac Surg 2020;31:931-3.DOIPubMed
30. Stern C, Oliker A, Napier Z, et al. Integration of surgical simulation in plastic surgery residency training. Stud Health Technol Inform 2012;173:497-9.PubMed
31. Smith DM, Aston SJ, Cutting CB, Oliker A. Applications of virtual reality in aesthetic surgery. Plast Reconstr Surg 2005;116:898-904; discussion 905.DOIPubMed
Lee EB, Podsednik A, Khoo K, Cheema A, Cabrejo R, Shen C, Rosen J, Dellon AL. The virtual peripheral nerve academy: education for the identification and treatment of peripheral nerve disorders. Plast Aesthet Res 2022;9:46. http://dx.doi.org/10.20517/2347-9264.2022.11