Can Virtual Reality become a solution to adherence and pain management?
This article provides an insight into the possible applications of virtual reality in healthcare, specifically when it comes to the prevention, adherence and pain management in patients with acute or chronic pain conditions.
We are going to have a look at:
- the process of analgesic in the human body — the pain pathway and the role of opioids
- the neurobiological mechanisms underlying VR
- latest published papers and use cases of VR applications for pain management
The Pain Path and Traditional Solutions
Perception of pain is a complex process. Assessment and management can be a challenge. Opioid use for the management of chronic pain has been associated with increased morbidity, mortality, and healthcare resource utilisation. (source)
Types of Pain
- Acute pain is caused by an injury to the body. It warns of potential damage that requires action by the brain, and it can develop slowly or quickly. It can last for a few minutes to six months and goes away when the injury heals
- Chronic pain persists long after the trauma has healed (and in some cases, it occurs in the absence of any trauma). Chronic pain does not warn the body to respond, and it usually lasts longer than six months.
The physiologic mechanisms involved in the pain phenomenon are termed nociception. Nociception can be divided into four stages: transduction, transmission, perception, and modulation.
- Transduction is the process of converting painful stimuli to neuronal action potentials at the sensory receptor.
- Transmission refers to the movement of action potentials along neurons that make their way from the peripheral receptor to the spinal cord and then centrally to the brain.
- Perception occurs when the brain receives pain signals and interprets them as painful.
- The complex mechanism whereby synaptic transmission of pain signals is altered is called modulation.
It is clinically useful to conceptualise pain physiology according to these four processes because each stage provides an opportunity for intervention in the pain experience.
Narcotic and non-narcotic analgesics
Medical treatments include three basic drug forms to treat pain (analgesics):
- non-opioid drugs — acetaminophen (Tylenol and others), aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen/Motrin/Advil, naproxen/Aleve)
- opioid drugs — tramadol (Ultracet, Ultram), morphine, hydromorphone (Dilaudid and others), codeine (Tylenol and others), hydrocodone (Vicodin, Lortab), methadone, meperidine (Demerol), pentazocine (Talwin), propoxyphene (Darvon), and butorphanol (Stadol).
- drugs that are used to complement other analgesics — muscle relaxants, antidepressant medications, anti-seizure medications, nerve blocks with anesthetics.
The role of opioids in pain transmission
Opioid (also called narcotic) analgesics work by binding to receptors on cells mainly in the brain, spinal cord and gastrointestinal system and inhibiting the pain signal at multiple steps in the pathway.
Opioid medications are so effective at treating pain because they attack it from every possible angle.
Alternative Therapies for Pain Management
Mental control techniques rely on the ability of the mind and emotions to control and alleviate pain through descending neural pathways. They include relaxation techniques, hypnosis, biofeedback and distraction techniques.
VR Analgesia/Alternative Treatments for Pain
The role of VR in Pain Management — Supporting clauses
- Melzack and Wall proposed the Gate Control Theory, which suggests that factors such as the level of attention paid to the pain, the emotion associated with the pain and past experience of the pain all play a role in how the pain will be interpreted. (Melzack R, Wall PD Science. 1965 Nov 19; 150(3699):971–9)
- McCaul and Malott expanded this theory to state that human beings have a limited capacity of attention and an individual must attend to a painful stimulus in order for it to be perceived as painful. (McCaul KD, Malott JM Psychol Bull. 1984 May; 95(3):516–33)
- Wickens proposed the Multiple Resources Theory, which states that resources in different sensory systems function independently (Wickens CD Hum Factors. 2008 Jun; 50(3):449–55). This supports the nature of VR technology, which is based on integrating multimodal (visual, auditory, tactile and olfactory) sensory distractions.
- Recently, Gold et al. hypothesised that VR analgesia originates from intercortical modulation among signalling pathways of the pain matrix through attention, emotion, memory and other senses (e.g., touch, auditory and visual), thereby producing analgesia. (Gold JI, Belmont KA, Thomas DA Cyberpsychol Behav. 2007 Aug; 10(4):536–44)
Use of VR in Acute Pain Management — Positive Findings
- Das et al. conducted a randomized control trial, comparing standard of care (analgesia) with analgesia plus VR for children (5–18 years old) during burn wound care. Analgesia coupled with VR was more effective in reducing pain and distress than analgesia alone. (Das DA, Grimmer KA, Sparnon AL, McRae SE, Thomas BH BMC Pediatr. 2005 Mar 3; 5(1):1)
- Sharar et al. reported results across three studies and concluded that VR in addition to standard analgesia reduced pain intensity, unpleasantness and time spent thinking about pain. (Sharar SR, Carrougher GJ, Nakamura D, Hoffman HG, Blough DK, Patterson DR Arch Phys Med Rehabil. 2007 Dec; 88(12 Suppl 2):S43–9)
- Patterson et al. studied VR as a means of delivering hypnosis to patients with burns during wound care in a clinical case series of 13 patients. These patients reported lower levels of pain and anxiety. (Patterson DR, Hoffman HG, Palacios AG, Jensen MJ J Abnorm Psychol. 2006 Nov; 115(4):834–41) For this study, Patterson used a VR distraction sequence, SnowWorld©, developed by Hoffman, which allows users to glide through a 3D icy canyon while throwing snowballs at virtual snowmen, igloos, robots and penguins.
- A study by Schneider and Workman examined 11 children (aged 10–17 years) receiving chemotherapy with and without VR. A total of 82% of the children stated that treatment with VR was better than previous treatments and that they would like to use VR during future treatments. (Schneider SM, Workman ML Pediatr Nurs. 2000 Nov-Dec; 26(6):593–7)
Use of VR in Acute Pain Management — Negative Findings
- Konstantatos et al. examined the efficacy of VR relaxation in addition to morphine for pain reduction during burn wound dressing changes. Instead of using a distraction type program, such as SnowWorld, the researchers developed a VR relaxation sequence prepared by psychologists and based on hypnotherapy theory. This provided calming visual scenery, which instructed the participant to concentrate on a moving spiral. Contrary to previous results, this study found an increase in pain intensity for participants receiving VR with morphine during wound care. (Konstantatos AH, Angliss M, Costello V, Cleland H, Stafrace S Burns. 2009 Jun; 35(4):491–9)
Use of VR in Acute Pain Management — Neutral Findings
- Sander Wint et al. investigated VR use during lumbar puncture with a sample of 30 adolescents (aged 10–19 years). Although pain scores were lower in the VR condition, differences were not statistically significant. (Sander Wint S, Eshelman D, Steele J, Guzzetta CE Oncol Nurs Forum. 2002 Jan-Feb; 29(1):E8-E15)
Use of VR in Chronic Pain Management — Positive Findings
- Sato et al. investigated the use of VR for treating complex regional pain syndrome in adults. In this pilot study, a VR mirror visual feedback system was created and applied to the treatment of complex regional pain syndrome in five adult patients (46–74 years old). This was a nonimmersive form of VR, as participants were not engaged in VR through an HMD. In the study, patients participated in five to eight outpatient sessions, resulting in four of the five patients demonstrating at least 50% reduction in their pain intensity scores. (Sato K, Fukumori S, Matsusaki T, Maruo T, Ishikawa S, Nishie H, Takata K, Mizuhara H, Mizobuchi S, Nakatsuka H, Matsumi M, Gofuku A, Yokoyama M, Morita K Pain Med. 2010 Apr; 11(4):622–9)
- Sarig-Bahat et al. investigated VR’s ability to treat chronic neck pain in 67 patients (22–65 years) with and without symptoms. The investigators used a VR environment, which encouraged patients to increase their range of motion by ‘spraying’ flies with a virtual spray canister. In theory, the more they engaged in the activity, the greater their range of motion would become. The investigators found that a single session of VR resulted in increased cervical range of motion and decreased neck pain. (Sarig-Bahat H, Weiss PL, Laufer Y Spine (Phila Pa 1976). 2010 Feb 15; 35(4):E105–12)
- Hoffman et al. explored whether immersive VR could help reduce pain during repeated physical therapy sessions for burn victims. During three sessions, seven patients (9–32 years of age) came to perform range-of-motion exercises under an occupational therapists’ direction. Participants spent an equal amount of time during the session with VR distraction and without. The investigators found that pain ratings were significantly lower when patients were immersed in VR and the magnitude of pain reduction did not decrease over multiple sessions. These findings are promising as they indicate a potential for VR to be applied to long-term physical therapy. (Hoffman HG, Patterson DR, Carrougher GJ, Sharar SR Clin J Pain. 2001 Sep; 17(3):229–35)
- Similar to mirror box therapy, VR can give patients the illusion that limbs are not in pain. Through cortical reorganisation (neuroplasticity), visual inputs (using VR in this case) are used for sensory and motor reprogramming representations of pain. So instead of treating or distracting users from pain, this method leverages the brain’s ability to reorganise itself by forming new neural connections that compensate for pain. Utilising VR expands on the mirror box method, while a software solution provides the capability to map data from physical tracking, which in turn produces personalised therapy with insights at scale. This is exactly what Karuna Labs is working on — VR software to treat chronic pain through cortical reorganisation.
There is scientific concern that individuals may habituate to VR and, therefore, lose its benefits over repeated exposures.
VR Applications in healthcare areas
VR technology has been shown to provide meaningful improvements in 5 key areas:
- Prevention: promoting wellness, stress management, and addiction behaviour;
- Improved pain management: distraction experiences as alternatives to pain-killers;
- Improved training: includes clinical skills training and surgical skill training;
- Improved adherence: the heightened sense of experience and game-like features of VR training help motivate patients and engage them more fully in the treatment process;
- Telemedicine: cellphone-based or standalone VR systems can be used to extend the reach of the clinician, provide healthcare access to underserved populations, support managed home recovery, enhance chronic disease management and protocol adherence, and facilitate for aging in place.
Available Applications/Case Studies
- BreatheVR, a virtual mindfulness and breathing tool, promotes mental and physical relaxation with vibrant VR imagery of rolling hills, flowers, grass, trees and nature sounds like birds and calming music. The Gear VR, the app’s compatible headset, has a microphone that tracks your breath and influences the virtual landscape to move right along with your breath. A small trial of pain sufferers who used the app went from a pain rating of 7 to a 3.5 out of 10 and had a fifty percent reduction in pain.
- Karuna — Chronic Pain Management; Karuna contains modules for upper limb, lower limb, cervical and lumbar spine.
So how could VR be used in patients with chronic or acute pain?
- Pain Management — Various researches were showing that it is possible to efficiently reduce acute and chronic pain by using virtual reality headsets with special programs as a distraction. Those who have participated in such studies have been able to lower their addiction to opioids. The theory is based on the gate control theory of pain, which postulates that pain perception can be reduced by refocusing the brain’s attention away from the pain.
- Progressive Relaxation
- Focused Breathing
- Pain Neuroscience Education
- Adherence — can help address adherence by telling the story of patient journeys through scientifically accurate, deep visualisations of conditions, disease states and therapies.
- Virtual reality may be used as a distraction therapy to manage and reduce acute and chronic pain management, as well as psychiatric and pain/physical rehabilitation over the next 5–10 years (as costs associated with VR technology decrease and the flexibility/customisability of the gaming environments increase).
- As part of a healthcare providers toolkit, VR may be integrated into a variety of medical settings: routine painful medical procedures, physical therapy, pain rehabilitation, chronic pain management and to treat a variety of psychiatric conditions (i.e., anxiety, post-traumatic stress disorder and substance abuse) etc.
- The neurobiological mechanisms underlying VR are still not fully understood.
- Dan M McEntire, Daniel R Kirkpatrick, Nicholas P Dueck, Mitchell J Kerfeld, Tyler A Smith, Taylor J Nelson, Mark D Reisbig, and Devendra K Agrawal, Pain Transduction: A Pharmacologic Perspective, Expert Rev Clin Pharmacol. 2016 Aug; 9(8): 1069–1080.
- Angela Li, Zorash Montaño, Vincent J Chen, and Jeffrey I Gold, Virtual reality and pain management: current trends and future directions, Pain Manag. 2011 Mar; 1(2): 147–157.
- Melzack R, Wall PD Science. 1965 Nov 19; 150(3699):971–9
- McCaul KD, Malott JM Psychol Bull. 1984 May; 95(3):516–33
- Wickens CD Hum Factors. 2008 Jun; 50(3):449–55
- Gold JI, Belmont KA, Thomas DA Cyberpsychol Behav. 2007 Aug; 10(4):536–44
- Das DA, Grimmer KA, Sparnon AL, McRae SE, Thomas BH BMC Pediatr. 2005 Mar 3; 5(1):1
- Sharar SR, Carrougher GJ, Nakamura D, Hoffman HG, Blough DK, Patterson DR Arch Phys Med Rehabil. 2007 Dec; 88(12 Suppl 2):S43–9
- Patterson DR, Hoffman HG, Palacios AG, Jensen MJ J Abnorm Psychol. 2006 Nov; 115(4):834–41
- Schneider SM, Workman ML Pediatr Nurs. 2000 Nov-Dec; 26(6):593–7
- Konstantatos AH, Angliss M, Costello V, Cleland H, Stafrace S Burns. 2009 Jun; 35(4):491–9
- Sander Wint S, Eshelman D, Steele J, Guzzetta CE Oncol Nurs Forum. 2002 Jan-Feb; 29(1):E8-E15
- Sato K, Fukumori S, Matsusaki T, Maruo T, Ishikawa S, Nishie H, Takata K, Mizuhara H, Mizobuchi S, Nakatsuka H, Matsumi M, Gofuku A, Yokoyama M, Morita K Pain Med. 2010 Apr; 11(4):622–9
- Sarig-Bahat H, Weiss PL, Laufer Y Spine (Phila Pa 1976). 2010 Feb 15; 35(4):E105–12
- Hoffman HG, Patterson DR, Carrougher GJ, Sharar SR Clin J Pain. 2001 Sep; 17(3):229–35