The quest for a better life may be going virtual. (Copyright Firsthand Technology Inc. www.firsthand.com)

Gaming medicine: Virtual reality is bringing real-time relief for chronic pain

Jo Marchant
Virtual reality isn’t just for video games anymore. It’s revolutionising medicine, including the way we manage pain.

‘It’s like a crawly feeling inside,” says Judy*. “You get hot, then chilled, and you feel like you want to run away.” The grey-haired 57-year-old wears a haunted expression as she sits with her right leg balanced up on her walking stick, rocking it back and forth as she speaks.

Judy explains that she suffers from constant, debilitating pain: arthritis, back problems, fibromyalgia — a disorder characterised by widespread aches — and daily migraines. She was a manager at a major electronics company until 2008, but can no longer work.

She often hurts too much to even make it out of bed.

She takes about 20 different medications daily, including painkillers, antidepressants, sedatives and a skin patch containing a high dose of the opioid drug fentanyl. The patch didn’t significantly help her pain so her physician had to wean her off the powerful drug. Then, in addition to pain, she also faced withdrawal symptoms: the chills and crawling dread.

Over the past few decades, United States doctors have tackled chronic pain problems by prescribing ever-higher levels of opioid painkillers — drugs such as oxycodone, which belong to the same chemical family as morphine and heroin. These medications have turned out to be less effective for treating constant pain than thought — but far more addictive. The surge in prescriptions has fed spiralling levels of opioid abuse and tens of thousands of overdoses, the US Centers for Disease Control reports.

Efforts to curb opioid prescriptions and abuse are starting to work. But with the spectacular failure of a drug-centric approach to treating chronic pain, doctors desperately need alternatives to fight a condition that blights millions of lives. Ted Jones, the attending clinician with the Pain Consultants of East Tennessee (PCET) clinic in Knoxville, Tennessee is trying one seemingly unlikely technological solution: virtual reality.

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Opioid painkillers were previously used only in exceedingly special cases but campaigns for pain to be treated more aggressively — as well as marketing from pharmaceutical companies, claiming that newly approved opioid drugs such as OxyContin were effective and nonaddictive — resulted in doctors prescribing them much more widely.

“We were told pain was undertreated,” says Joe Browder, a physician and senior partner of PCET. “There was no upper limit.”

The new drugs turned out to be highly addictive.

Browder says he realised more than a decade ago that ever-higher drug doses weren’t the answer. Instead of trying to eliminate pain with narcotics and sedatives, Browder and his colleagues decided to prioritise patient function

“It’s all about getting people to do more in their life with the pain they have,” PCET medical director James Choo explains.

They reduced the amount of opioids they prescribed, emphasising other medical interventions such as steroid injections to lessen inflammation and joint pain. The clinic also started offering physical and occupational therapy. Psychologists, including Jones, provided counselling in proven pain-relief techniques such as cognitive behavioural therapy (CBT), a common type of talk therapy that involves changing the way people think — and respond to — difficult situations, the US health research organisation Mayo Clinic explains. The technique is sometimes combined with mindfulness, which teaches patients how to develop an awareness and understanding of their own thought processes, to manage pain.

The shift follows decades of research that found that patients with chronic pain who received CBT in addition to traditional care reported better mood, social functioning and coping skills for dealing with their pain than those who only got conventional treatment, a 1995 research review published in the journal Pain shows.  These kinds of studies in which groups of people are arbitrarily assigned to either a new treatment or standard care are considered to be the best way to evaluate how well new medicines or treatments work. This is because randomisation ensures that the two groups — those getting the new medicine or intervention and those not — are virtually alike and can be compared.

PCET staff also started to employ methods to distract patients from the pain they were feeling — something that’s worked to varying degrees with children receiving injections or having blood drawn, a 2017 research review published in the Journal of Pediatrics Review argues.

But persuading patients to embrace more diverse approaches wasn’t easy. Some of the techniques work but they take practice, and Jones says they struggled to attract patients to multi-session courses.

A few people will do it but, in general, life gets in the way, he says.

People don’t want programmes, agrees Choo.

“They just want to take a pill.”


Pain. When it won’t stop, it can change everything and pills alone aren’t always the answer. (Parkin Parkin)

One winter day, Jones came to work to an empty clinic; heavy snowfall had kept many patients at home. He filled time by surfing the internet, and stumbled across the website of a US start-up called Firsthand Technology.

For the company’s chief executive, Howard Rose, virtual reality — or VR — is nothing less than a superpower, or as the company website puts it, a “high-bandwidth channel” into our brains that can transform how we see ourselves and the world.

Within a few generations, he predicts, VR will be woven into every aspect of our lives. He’s starting with how we manage pain

Rose began working in VR more than 20 years ago, at the University of Washington in Seattle’s Human Interface Technology Lab (HITLab). There, Rose and his colleagues created VR worlds for everything from treating spider phobias to teaching Japanese. One of their most successful products was SnowWorld, developed by cognitive psychologist Hunter Hoffman to ease burns patients’ pain.

Burns patients have to undergo regular wound-care sessions so painful that they can be excruciating even with high doses of painkillers. SnowWorld was designed as a kind of souped-up distraction method for use during these sessions, to divert patients’ attention away from their pain. Adapted from flight simulation software, it creates the experience of flying through a virtual ice canyon while exchanging snowballs with penguins and snowmen.

Over the past decade, Hoffman and his colleagues have shown in several trials — including on army veterans burnt by explosive devices in Iraq and Afghanistan — that this works. Playing SnowWorld during wound-care sessions eases patients’ reported pain up to 50% in addition to the relief they get from drugs — significantly better than other distractions, such as music or video games, according to a 2015 research review in the journal Annals of Behavioral Medicine.

Research also shows that SnowWorld reduces activity in areas of the brain associated with pain perception, a 2006 study published in Cambridge University’s CNS Spectrums found.

The researchers believe that VR’s sense of immersion — feeling physically present in the virtual location — is crucial.

“VR becomes a place you are, not something that you are watching”, Rose says.

VR immersion has since been shown to reduce reported pain and distress during a range of medical and dental procedures, from chemotherapy to taking blood.

Rose and his colleague Ari Hollander left academia to form Firsthand Technology where they built Cool!, which Rose describes as “a sort of next generation of what we learned in SnowWorld”.

Featuring more interactivity and a wider variety of environments, it’s more open-ended, he says, “a kind of playground”.

I tried it myself at the PCET clinic. A few seconds after slipping on the headset, I was floating along a river with grassy banks. There were mountains in the distance, and a blue sky with scattered clouds. Along the water’s edge, fluffy brown otters stood greeting me on their hind legs. Using two hand-held controllers, I threw fish to them and they rolled over in delight, changing colour to zebra stripes or flamingo pink.

To my brain, this world wasn’t simply something I was watching, but a place I was actually in.

When I passed under a rocky bridge, I flinched.

When snow fell, I felt the exhilaration of clear, cold air.

VR is undoubtedly effective at shifting attention, but Rose argues that it works on other levels too.

We know that if people feel anxious and helpless then their suffering from the pain is much greater,” he says. Mentally taking people to a distant, safe place reduces their anxiety, he says, while interactivity — the ability to move around an environment and throw snowballs, for example — helps them to feel more in control.

He’d wondered whether these attributes might help patients with chronic conditions too — those suffering from pain, anxiety and helplessness in daily life. Then he received an email from Jones in Tennessee. “We’ve got patients; you’ve got a product,” Jones said.

A few months later, Rose flew to Knoxville and dropped off his equipment. But would it work?

Virtual reality — if you thought it was the stuff of video games, think again. (Parkin Parkin)

Christine* smiles.

“Mmmm,” she says. “You can almost feel the petals hitting you.” The 69-yearold is sitting in Jones’s green leather armchair, her eyes hidden by a bulky black visor.

Jones’s laptop shows Christine’s field of view as she floats down the stream. She looks around from the otters to some mysterious balls of dancing coloured flame, then scrunches up her face as she brushes past the blossom-laden branches of a grove of cherry trees.

Christine has led an active life: she used to run a tour company in Mexico before becoming a chef at her local synagogue. But she now finds it difficult to focus on anything but her pain. Since 2007 she has suffered from an autoimmune condition that attacks her nerves, causing burning pain down both legs and across the soles of her feet. She is also recovering from back surgery. She has resisted opioids and stopped taking other drugs because they interrupted her thinking and speech.

“It spoiled my life,” she says. Now she gets by on ibuprofen and pain-dulling lidocaine patches, which she wears on her legs during the day and on her feet at night, but the pain never goes away.

“It’s all you think about,” she says. When she arrives in Jones’s office, Christine rates her pain as 7/10. Then she puts on the headset and headphones for her third session of VR. “I’m already relaxing,” she says. After the cherry trees, she follows the river into a cave, its rocky walls covered with strange drawings and sparkling gems.

I ask how her pain is.

“Oh,” she says as if surprised to be reminded of it. “Zero. It’s gone.”

Compared with other forms of distraction, such as colouring in a drawing or watching TV, VR “works a whole lot better,” Jones says. “It grabs your attention. You just put the helmet on and you are gone.”

Jones had completed two small clinical trials of Cool! by 2017, which together involved 40 participants receiving between them about 60 sessions of VR. Only one person didn’t report reduced pain, he says. Overall, the patients reported that their pain fell by 60% to 75% compared with baseline measurements during their VR session, and by 30% to 50% immediately afterwards, according to a 2016 study published in the journal Plos One.

The best morphine does is 30%.

It’s early research, but a few other studies of chronic pain have found similar results. In 2017, Diane Gromala of the Pain Studies Lab at Canada’s Simon Fraser University, and her colleagues reported on a VR game called Cryoslide — inspired by SnowWorld — which involves sliding through a snowy landscape and an icy cave while throwing snowballs at fantasy creatures.

When chronic pain patients played it for 10 minutes, their pain reduced significantly compared with those asked to use other distraction strategies such as meditating, reading or playing games on a phone. A review of the study was published in the 2016 book Medicine Meets Virtual Reality.

Elsewhere, Brenda Wiederhold and colleagues at the US Virtual Reality Medical Center found that chronic-pain patients immersed in virtual scenes such as forests, beaches and mountains reported significantly reduced pain, a 2014 study in the journal Cyberpsychology, Behavior, and Social Networking shows.

They also had a reduced heart rate and raised skin temperature, suggesting that they were more relaxed.

No long term or large-scale randomised controlled trials have yet investigated whether VR is helpful for managing chronic pain in the long-term.

But the research so far provides the first proof of principle that VR can ease pain in chronic conditions. It isn’t possible or desirable to immerse patients all the time, of course, but even short sessions might provide respite for patients who are otherwise always in pain.

Jones says that, compared with techniques such as mindfulness that require long-term effort and training, “with VR you put a visor on their head and they’re there”.

He hopes that the effects last at least a little longer than the session.

In his trials, patients reported that their pain relief lasted for between two and 48 hours after the VR session. This supports the idea that it might be triggering the release of pain-relieving hormones called endorphins, for example, which ease symptoms even after the headset is removed.

Perhaps it also demonstrates to patients that their pain “is not intractable, it can be influenced”, Browder suggests.

In other words, it shows people with grinding, constant pain that there is hope.

There is increasing interest in using VR to teach long-term coping skills that patients can use in their daily lives, or as Rose puts it, “to change that relationship with the pain”.

But many hospitals and clinics are wary of adopting unfamiliar technology.

Even when the research evidence is strong — in burns patients, for example — VR pain relief is still not widely used. Jones describes how PCET raised funds for a nearby children’s hospital, and demonstrated to one of the nurses how VR could help children going through medical procedures.

She wasn’t impressed.

“It’s frustrating,” Jones says. “We gave her $15 000 and she’s going to buy more colouring books.”

For Jones, there won’t ever be one answer to chronic pain. But VR could be a tool.

As well as providing a non-pharmacological alternative to treating pain, it might help people who are on opioids to minimise their dose, giving them something active they can do instead of popping extra pills.

“With opioids, you just take it, sit and wait”, he says. “That’s why people end up taking more pills than they need — they just want to do something to help their pain.”

*Not their real names. 

This is an edited version of an article first published by Wellcome on Mosaic and is republished here under a Creative Commons licence. Sign up to the newsletter at mosaicscience.com/#newsletter

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