Wearing virtual reality goggles and experiencing the excitement of swimming with dolphins eased Amanda Greene’s chronic pain. The author of LA Lupus Lady blog, Greene has been fighting lupus, rheumatoid arthritis, fibromyalgia and osteoarthritis since she was a young adult. She suffers serious pain from one or all of her conditions on a daily basis. As a result, she has tried almost every type of treatment to find relief. In 2017, Greene heard about a free trial offer from a California-based company called Applied VR that was testing virtual reality among people with chronic pain. “They sent me the headset and mobile phone with an app and I got to try it for eight days,” said Greene. “By day five, I went out and bought my own headset, knowing that I wanted to continue this after the trial offer was over.”
She was able to reduce her number of pain medicines halfway through the experiment, and by day eight, she stopped taking pills altogether. “Virtual reality helped immerse my mind in something other than my pain. One minute you’re swimming with dolphins, the other minute you’re walking along the beach in Hawaii. You’re so busy enjoying the environment around you that you’re not thinking about the pain,” said Greene.
Virtual reality (VR) has a come a long way since it was first developed in the 1960s by the U.S. Air Force. Once thought of as a sci-fi gimmick with static and monotonous visuals, VR now features high-definition images that use dynamic light. Many VR technologies use dramatic and immersive sound, and some systems even monitor breathing so they can guide users through deep-breathing exercises.
Mainstream use of VR in entertainment and teaching has led to its increased popularity. Sleeker and lower-cost versions have revolutionized VR technology and made them more accessible. Oculus Go from Facebook is the most popular VR technology because the headsets are light, well built, easy to use and more affordable than those for its predecessor Oculus Rift.
In the medical community, VR has been used for decades to help people overcome phobias and anxiety disorders. One of its first applications was developed in the mid-90s to distract burn victims from the agonizing pain of changing their wound dressings. A virtual environment called SnowWorld was developed by cognitive psychologist Hunter Hoffman to ease the pain from severe burns.
VR research has focused on both acute and chronic pain and has been tested in people with post-traumatic stress disorder, idiopathic facial pain and complex regional pain syndrome (CRPS), among other pain conditions.
More than 100 hospitals across the country are assessing the use of VR, including well-known medical centers like Hospital for Special Surgery in New York, Cedars-Sinai Medical Center in Los Angeles and Boston Children’s Hospital. Cedars-Sinai has been on the cutting edge of using VR to treat people with pain. The VR program, led by gastroenterologist Brennan Spiegel, MD, has treated about 3,000 patients over the past three years.
Spiegel conducted a study with 100 patients suffering from pain due to a variety of causes. Researchers found that the group that experienced VR technology reported a 24 percent drop in pain scores. The other 50 patients who watched a standard, 2D nature video with relaxing scenes on a nearby screen experienced only a 13.2 percent reduction in pain.
“Virtual reality has been shown to reduce pain when used within the hospital in a variety of studies,” said Brandon Birckhead, MD, a project scientist at Cedars-Sinai researching immersive technology with Spiegel. “Now, we’re looking to see if a digital pain reduction kit, including virtual reality, used at home for 60 days can help patients improve quality of life and reduce their need for opioids. This will likely be the longest study using VR.”
New opioid alternative
Looking for options to opioids is an important goal for many doctors. One of these doctors is Ted Jones, PhD, a pain psychologist with Pain Consultants of East Tennessee in Knoxville. He explained that alternatives to opioid drugs are needed, especially in the heart of the opioid-abuse epicenter like Tennessee and the Southern Appalachia area, where he has seen firsthand the abuse and overuse of opioids.
Psychological therapies like cognitive behavioral therapy and mindfulness are effective, but few providers can offer these services, and they require significant time and effort from patients. “VR can be an alternative to these,” said Jones. “VR technology has become easier to use and patients like using [it].”
Jones led one research program in which 30 patients with chronic pain were exposed to VR technology for five minutes. In the treatment sessions, patients wore the Oculus Rift headset and virtually travelled a preset route in a computergenerated fantasy world, where they encountered small otters and fish. The study showed a 60 percent reduction in pain from pre-session pain scores to post-session, and 10 participants, or 33 percent, reported 100 percent pain relief during the VR session.
“We could be on the verge of a new era of pain treatment in which medications are rarely used, and VR is a primary treatment modality,” Jones said.
Despite the excitement around VR and its promise for managing pain and potentially reducing the need for opioids, the exact mode behind how VR impacts pain remains unknown. Some experts speculate that VR creates a non-medicated form of analgesia by changing the activity of the body’s pain modulation system, whiles others postulate that VR serves as a “pain distraction” that reduces the perception of pain by absorbing and diverting attention away from the pain.
The effectiveness of VR for chronic pain has yet to be established through well-controlled clinical studies. The technology is some years away from the government approval it would require to be used as an approved medical device. Reimbursement for VR therapy is limited, but physical therapists can get paid for using VR devices during rehabilitation sessions.
Andrea Stevenson Won, PhD, believes in the potential of VR technology, but she also recognizes the need for more studies. Won became interested in virtual reality and how it could be used as a treatment option for patients living with physical pain and has led studies examining the use of VR to ease the pain in people with complex regional pain syndrome and persistent idiopathic facial pain.
“In the past, there were very few labs that were working in VR because it was so expensive and technically challenging, but once consumer equipment became available, many more researchers started envisioning new potential applications for virtual reality,” said Won, director of the Virtual Embodiment Lab at Cornell University in Ithaca, NY, where she is an assistant professor of communications with the College of Agriculture and Life Sciences. “There’s huge potential for VR as a therapeutic option, but we don’t want this to be oversold and people to get excited about VR treatments before they are proven effective.”
Doctors are also looking into the potential side effects of VR, including whether it could be addictive. “It’s probably unlikely to be addictive in its current form and, in fact, we have not seen abuse among our patients who are using it for therapeutic purposes, though in the future this will be something to consider in the areas of gaming or entertainment,” said Birckhead.
The most common side effect for some patients, according to Birckhead, is “cybersickness,” the feeling of dizziness and nausea when the patient is wearing a VR headset. Patients also have experienced side effects such as blurred vision, eye strain and headache. He said less than 5 percent of patients experience these effects, but they usually disappear when the headset comes off and can decrease with subsequent treatment sessions.
The explosion of interest in VR technology seems endless. The American Academy of Pain Medicine organized a session on virtual reality treatment for both acute and chronic pain at its 2018 conference. Cedars-Sinai hosts an annual conference (virtualmedicine.health) with top experts to share best practices and discuss the future of medical VR.
Many companies throughout the country are entering the field to discover the next generation of VR systems that go beyond it being a distraction therapy that focuses the brain away from pain. One company, CognifiSense, is working on a completely new type of VR therapy, which they have dubbed “VR neuropsychological therapy.” This new approach is different from traditional VR therapy because it aims to change how the brain perceives pain and create a lasting reduction in pain.
CognifiSense co-founder and CEO Tassilo Baeuerle envisions that the technology may offer an alternative or adjunct to pain medicines. “We hope one day it can be used to avoid prescribing opioids, particularly strong opioids, to patients at high risk of addiction,” he explained. “It could then also be used to help wean addicted patients off opioids or enable a chronic pain patient already on opioids to avoid taking a higher opioid dose.”