Meeting Report: Virtual Reality Pain 2016

New technology opens a virtual world for pain treatment. Image credit: leungchopan/123RF Stock Photo.

Editor’s Note: This article is adapted from a meeting report that originally appeared on the Pain Research Forum.

When Dave Thomas initially talked to people at the National Institutes of Health (NIH) about funding research on virtual reality (VR) back in 2004, most were skeptical or dismissive. “They said it seemed like Weird Science,” Thomas said, referring to the 1985 sci-fi comedy in which two nerdy teenagers digitally create their perfect woman and bring her into reality. “But things have changed since 2004,” Thomas said.

Thomas, a program officer at the National Institute on Drug Abuse (NIDA) and a member of the NIH’s Pain Consortium, Bethesda, US, was addressing —via Skype—an audience keenly interested to hear what he had to say. Gathered in a ballroom of a downtown Los Angeles hotel were about one hundred researchers, entrepreneurs, artists and programmers all focused on developing and studying VR. The meeting, held September 19, 2016, was focused specifically on how VR might be used to treat pain. Funding for the event was provided by The Mayday Fund, a family foundation dedicated to alleviating pain. Several presenters spoke about research using VR as a therapy for post-traumatic stress disorder (PTSD), one of the first clinical uses of VR. Others spoke about using VR to reduce pain and anxiety in a variety of ways. The following is a summary of selected talks from the meeting.

What is VR?
What makes an experience truly VR? There are blurred lines in the industry, but the consensus is that VR is a three-dimensional, interactive, and immersive experience. VR often takes the form of a game or journey. Just as you might be immersed in a pool of water, when immersed in VR, you inhabit that virtual world, which is much different from simply looking at a screen. When you turn to look around in the world, your view of the world moves with you. And when you take actions, the world reacts to you. VR machines accomplish that with sophisticated sensors to track movements and update the worldview within milliseconds.

The technology that allows for today’s relatively sophisticated VR systems has only recently been developed. The field of VR research is itself in its infancy, dating back just 25 years to 1991, when VR machines became commercially available. Before then, they were used only by the US military to train fighter pilots. Although VR burst into public consciousness in the 1990s, the technological development of hardware lagged, and so did investors’ enthusiasm for VR. But a few researchers continued to study the technology and its potential for improving health.

Among them was Hunter Hoffman, who still runs the Human Interface Technology (HIT) laboratory at the University of Washington, Seattle, US. At the meeting, Hoffman described his work dating back to 1999, when he first used a VR game called Snow World to distract patients with severe burns during wound care. Patients using VR saw significant reductions in pain and anxiety during the procedures, compared to a traditional video game.

Diane Gromala, now a professor and VR researcher at Simon Fraser University, Surrey, British Columbia, Canada, trained at the HIT lab in Seattle in the early 1990s. “The research then was very difficult because the head-mounted displays cost from $40,000-$150,000, and you had to program everything by hand—there were no software packages. And [VR technology] companies didn’t last long, because there was no critical mass at the time,” Gromala said.

But the technology did evolve. A sea change came in March of 2014 with the announcement by Facebook co-founder and CEO Mark Zuckerberg that he would pay $2 billion for Oculus Rift, a company started by a California teenager that had successfully developed a VR headset deemed worthy of the massive investment. “That was an undeniable cue that VR was not just hype this time,” Gromala said. Today, Oculus Rift VR systems are available to the public for under $2,000, making research much more feasible.

Can researchers develop VR to treat pain?
VR research has accelerated since then, exploring how it might be used medically, including as pain treatment. Walter Greenleaf, Stanford University, California, US, an organizer of the meeting, told attendees, “Medical applications will be one of the biggest verticals for VR,” meaning they will likely attract significant investment for development in the coming years. He described four areas in which VR might be used medically: for assessing patients, delivering interventions, training healthcare providers, and for everyday health and wellness apps, which might be used on a cell phone. Very soon, he said, “VR is going to be a major part of our lives.”

VR is poised to be a big part of pain care, too. Beginning with Hoffman’s pioneering work, many studies by multiple research groups have established that VR approaches provide clear improvements for acute pain. For example, VR has been used to distract patients during a variety of painful medical procedures, and doctors at Cedars Sinai Hospital in Los Angeles offer patients a VR-like movie experience to reduce pain and anxiety during their stay. Researchers are still unclear on how VR helps reduce pain, but most agree that distraction is key. Rather than paying attention to their pain, patients escape to a virtual world. “We can use VR to direct as much of a patient’s cognitive capacity as possible away from pain,” Gromala said. “We think that is what might account for some of the effect.” But how might VR be used to help patients with chronic pain?

Gromala’s work is focused squarely on that question. It will require a different approach, she said, because people with chronic pain can’t be distracted from their pain twenty-four hours a day, seven days a week. “If that’s not possible,” she asked, “what is possible?”

Gromala and her team created a VR experience specifically for chronic pain patients called the Virtual Meditative Walk. The researchers began with two treatments for chronic pain that have long been shown to have beneficial effects: biofeedback and Mindfulness-Based Stress Reduction (MBSR). The therapies “both have at least 20 years of validation,” Gromala said. “So that seemed like great place to start.” The researchers then used VR to enhance the delivery of the treatments. Patients wear a VR headset and walk through a forest—either actually walking on a treadmill, or simply “virtually” walking while remaining seated—while they listen to an interactive recording of an MBSR training. Biofeedback sensors record data from patients’ skin and heart, and the conditions in the forest change to mirror the biofeedback signals. For example, when someone slows his or her breathing or heart rate, the fog in the forest lifts, the wind in the trees calms, and sounds and visuals become sharper. Early studies suggest that patients using the Virtual Meditative Walk experienced better pain reduction than patients who simply listened to the MBSR training and had conventional biofeedback, Gromala said in her presentation.

One factor will be crucial to VR’s success when it comes to treating chronic pain, Gromala said: a VR experience for chronic pain patients will have to look and feel very different from a typical game for entertainment. She and her colleagues spent a lot of time along the way studying potential barriers to the use of VR among chronic pain patients. “We have to take that seriously when designing an approach for these patients,” she said. For example, many patients are not able to walk on a treadmill, and some have trouble even sitting for twenty minutes. Other patients may not tolerate the head-mounted apparatus because of allodynia [when normally innocuous stimuli, such as the brush of a feather against the arm, become painful]. Games for entertainment often feature loud sudden noises, flashing lights and movements, and other highly stimulating features that might be insufferable for pain patients. All of these factors must be considered in developing VR for pain treatment.

Sean Mackey, a pain researcher and clinician at Stanford University, delivered an address at lunch outlining the current problem of chronic pain in the US. He told attendees he could see the potential for VR to fit into the multi-pronged approach espoused at Mackey’s Stanford pain clinic. “I believe there will be a convergence [of current therapies] with new technologies—like VR, biofeedback, and rTMS [repetitive transcranial magnetic stimulation, a procedure in which a magnetic field generated outside the head alters neuronal circuit activity inside the brain]. The technique itself might not be the end-all, but we can use technology to augment learning,” he said, such as the improved learning of MBSR and biofeedback signals seen in Gromala’s study.

Mackey and others agreed that much more research will be necessary to determine the best way to use VR to treat pain or to enhance existing therapies, who it might work best for, and to determine any potential risks. With the equipment now readily available, the pace of that research may well now accelerate, bringing VR closer to real-world clinics.

Stephani Sutherland, PhD, is a neuroscientist, yogi, and freelance writer in Southern California.