Virtual Reality Ventures Into Real World of Chronic Pain

Nancy A. Melville

May 27, 2016

AUSTIN, Texas — Virtual reality (VR), already shown to have important benefits in the treatment of acute and procedural pain, shows preliminary evidence of also reducing symptoms in chronic pain, according to new research.

"Our pain providers desperately need effective nonopioid treatments for chronic pain, ones that patients will adopt and use," Ted Jones, PhD, from the Behavioral Medicine Institute at Pain Consultants of East Tennessee, in Knoxville, told Medscape Medical News.

"Virtual reality offers very good analgesia in a way that could be easy and motivating for chronic pain patients to adopt and use on a daily basis."

The immersive 3-dimensional technology has been shown to have a powerful effect in distracting patients in acute pain situations, such as in burn units, or after painful procedures, more so than observed in playing video games or passive TV or movie viewing.

However, VR use in chronic pain has not been well documented, with just one other early study from Belgium looking at the effects.

Because the technology has been prohibitively expensive, its use has mainly been restricted to hospitals, but the introduction of new, more affordable technology is extending reach to the outpatient setting.

For the new research, presented here at the American Pain Society (APS) 35th Annual Scientific Meeting, Dr Jones and colleagues worked with DeepStreamVR, the creators of the VR program, called "Cool!," to test its efficacy on patients.

They conducted two studies, the first involving 30 patients with a variety of chronic nonmalignant paint conditions receiving a single-treatment, 5-minute session. Participants had a median age of 50 years and included 10 men and 20 women.

In that study, 9 patients reported 100% pain relief, while 3 reported no pre–post pain relief. Patients' pain scores decreased by an average of 33% from before to after the session (P < .001) and decreased 60% from presession to during the session (P < .001).

The second study, looking at the effects of multiple sessions, is ongoing, but Dr Jones reported on data of 7 patients with neuropathic chronic nonmalignant pain were recruited to three 20-minute sessions.

In that study, pain scores reportedly decreased by an average of 57% from before to after the session and by 75% during the session (both P < .001).

None of the patients in either study reported dizziness, headache, or nausea.

Importantly, most patients reported that the analgesic effect of the VR experience persisted after the treatment session ended, with reports of effects lasting from 2 to 48 hours.

"One of our most exciting early results is that the analgesia from virtual reality lasts after the session is over, sometimes days afterwards," Dr Jones said.

"About 10% of subjects said it did not help, while 30% said it gave them complete pain relief while doing virtual reality."

The VR program, which was used with the Oculus Rift DK2 VR display goggles, was specifically designed to help with chronic pain and was developed by some of the engineers who had also worked on "SnowWorld," the original virtual reality experience for acute pain patients.

"You can think of 'Cool!' as a second-generation tool that has its roots in the original VR-pain world," Dr Jones said.

"It uses several specific principles to help get and keep a patient's focus on the virtual reality environment, such as using several tunnels and entrances to engage the viewer and draw focus and attention."

The program was developed by DeepStreamVR, which worked with Dr Jones' clinic to provide the virtual reality; however, neither Dr Jones nor the coauthors have any financial interests with the company or any other VR program developers.

According to the company's website, the "Cool!" program includes biofeedback components to "enhance mindfulness and resilience training."

"Biosensors help induce flow state by controlling the intensity of the experience to maximize benefits," the company says.

Dr Jones said that while ongoing studies are looking to determine which patients may best benefit from the sessions, initial signs point to those who simply become more engaged.

"My initial impression is that the analgesia seems to be more pronounced, not surprisingly, in subjects who 'get into the game' more," he said.

"So regardless of gender, age or amount of depression, if someone allows themselves to be involved in the VR experience, it has pronounced analgesia."

While the technology is still too expensive for most pain patients to use VR at home, Dr Jones said he expected that to change within the next few years.

"I can envision a day when pain patients will be using a program similar to 'Cool!' on their smartphones at home on a daily basis on a very affordable basis and having great results," he said. "We just need to do some more research and development to get there."

Previous studies have shown benefits of VR for pain conditions, including fibromyalgia, dental experiences, and combat-related burn injuries.

The latter study used the program "SnowWorld," with imagery of an icy canyon and river, intended to represent the extreme opposite experience of fire. Though the study was small — just 12 patients — the results showed greater reduction in pain when the burn patients used the technology along with morphine, compared to morphine alone.

In a review of 17 studies, involving 337 patients, on VR in acute pain in children and adults, researchers reported finding "strong overall evidence for immediate and short-term pain reduction, whereas moderate evidence was found for short-term effects on physical function. Little evidence exists for longer-term benefits."

Coauthor of that review, Bernie Garrett, PhD, an associate professor at the University of British Columbia School of Nursing, Vancouver, Canada, said he was surprised by the results seen in Jones and colleagues' study.

"Although we also found some impact on chronic pain with virtual reality, we found no persistent effect," he told Medscape Medical News

"As these are pilot studies it is really too early to say as the research is immature, and the numbers too small to claim significant findings yet. There does seem to be some effect though."

Dr Garrett also noted an important potential caveat experience with his patients that was not seen in Jones and colleagues' study: "cyber-sickness."

"The effects of cyber-sickness should not be underestimated," he cautioned.

"Over half of our patients experienced this to some degree. Several dropped out of the study as a result, and one person had to lie down for 3 hours after a 10-minute exposure before they felt better."

Dr Jones, the study coauthors, and Dr Garrett have disclosed no relevant financial relationships.

American Pain Society (APS) 35th Annual Scientific Meeting. Abstract #512. Presented May 13, 2016.

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