Imagine being in pain, but happily distracted from your suffering by being totally immersed in floating lazily down a river or tossing fish to hungry otters that pop up out of nowhere. Such scenarios of a 360-degree world are possible via virtual reality (VR), whereby a patient sits in a chair wearing a head visor connected to a computer and holds a small wireless device in his or her hand to change direction.
“Although [VR] is very early in its inception for treating painful conditions, we are hopeful that VR will interest other research and payors,” said James Choo, MD, owner and medical director of Pain Consultants of East Tennessee, in Knoxville, which conducted two clinical studies of VR. “I think there is a lot of potential for VR, especially if you marry VR to other pain treatments that are not widely available but that we know work, such as cognitive-behavioral therapy and mindfulness meditation for lower back pain.”
However, he added that few pain psychologists are practicing in the United States, and cognitive-behavioral therapy is time-consuming. “We have never had scalable treatments that work and that can be highly disseminated,” Dr. Choo said. “With VR, if you have the right software, there is an enormous potential to disseminate that type of care to millions of people rather than just a handful of patients who have access to the one pain psychologist that might be in their region.”
Similarly, mindfulness-based instruction through VR may be plausible.
“The effects of the type of VR program that we used derive from a game,” Dr. Choo said. “It is not just a passive immersive experience of looking around at the scene. You are actually playing a game—interacting with the environment itself. Besides distracting pain, VR is fun, like playing a video game.”
Dr. Choo said the immersive experience of being in a virtual environment and simply being distracted from pain are helpful. In addition, “perhaps even the immersive experience has its own analgesic effect,” he said. “But we do not understand quite yet the neuropathways that are being affected that cause the analgesic effect. Once we do, then we will be able to better target the type of VR programs that best suit the patient and their particular pain needs.”
Ted Jones, PhD, a clinical psychologist at Pain Consultants of East Tennessee, heard a conference speaker last year refer to VR as a syringe, meaning its effect “depends on the content.” He added, “Historically, since the late 1980s, VR has been used for procedural pain—basically for burn pain and injections in an inpatient setting or a burn unit. However, the majority of pain [treated by clinicians] is outpatient pain. So we are taking what has been used for inpatient procedural pain and using it for outpatient pain.”
To date, VR treatments at the clinic have been isolated to two completed studies, using software called Cool! developed by Firsthand Technology.
“What we have found is that if you give someone doses of VR, it cuts their pain dramatically,” said Dr. Jones, who was principal investigator of both trials. “However, there is no [long-term] effect. A week later, the patient is right back where he or she started, both painwise and depression-wise and stresswise. It is similar to a person coming to a pain clinic, giving them a dose of medicine and sending them home.”
The first study, conducted in 2015 and published last year in PLOS ONE (2016;11:e0167523), consisted of 30 patients with chronic pain. Participants were asked about their pain before and after a single, five-minute session of VR conducted at the clinic.
“The study decreased pain by 55% to 60%,” Dr. Jones said. “VR is like distraction on steroids, because when your brain is in a virtual world, it is like you are there. In comparison, morphine reduces pain by only one-third.”
The second study, performed last year at the clinic, involved 10 patients with neuropathic pain. The protocol was three sessions of VR, each lasting 20 minutes and spaced one week apart.
“Pain was cut by roughly 70%, due to the longer exposure sessions and multiple treatments,” Dr. Jones said. “There was also a lingering effect. Most patients reported that their pain continued to be less for about one day on average after each session.”
‘Still Out of Reach’
However, depression, anxiety, beliefs about pain and how to cope with pain did not change over time. “In other words, VR did not provide patients any emotional or cognitive benefit,” Dr. Jones said.
Dr. Jones said a single VR unit costs between $3,000 and $4,000. Although it’s a dramatic drop from the previous $8,000 cost, “it is still out of reach for most patients,” he said. “Further, many of the units currently available have a lot of wires and require a high-end machine. You cannot take it home with you—physically or financially.”
To address these shortcomings, Pain Consultants of East Tennessee and the University of Tennessee plan on conducting a pilot study of 10 to 20 patients this fall with the portable Samsung Gear VR, which has an easy-to-use headset and some pain and relaxation applications, along with a Fitbit fitness mobile device to detect activity level and record pain.
“We will determine if daily VR home use is effective, which should be the case, based on our two previous studies,” Dr. Jones said. “Using VR at home several times a day is like being prescribed a pain reliever to be taken two or three times daily. VR has the chance to replace as-needed pain medicine at home.”
The occupational therapy department at the pain clinic is also scheduled to incorporate VR into therapy for conditions such as phantom limb pain and stroke pain. “For this application, VR acts like a mirror, so patients can see and restore movement,” Dr. Jones said.
Despite enthusiasm about VR for pain, there are several hurdles and challenges to make the modality effective in the clinical space. Besides no payors yet, “we need more in-depth studies to show its efficacy for [specific] conditions,” Dr. Choo said.
Apart from employing VR as simply a game, VR may be used as a substitute therapist in certain cases, or for biometric functioning and rehabilitation. “These are completely different programs,” Dr. Choo said. “Therefore, we have to be very specific on the types of software programs we use and the way they deliver care.”
For instance, VR could be used to help patients meditate or provide biofeedback.
“One of the key [goals] is for VR to become a scalable model,” Dr. Choo said. “The unit we are using is not portable. But in the future, we envision all VR units being extremely portable, easy to use and accessible.”
Dr. Jones added, “VR has a lot of potential. We just need to match it to the right patient at the correct setting and the right cost.”
—David C. Holzman