Vir­tual re­al­ity lets pa­tients ease stress and pain

The Myanmar Times - Weekend - - Weekend | Health -

DE­SPITE be­ing in and out of hos­pi­tals since the age of 16, one of Har­mon Clarke’s big­gest fears is hav­ing an in­tra­venous line in­serted into his arm. The 34-year-old res­i­dent of Los An­ge­les has had more than 30 surg­eries re­lated to his Crohn’s disease, but get­ting stuck with an IV nee­dle has never got­ten less stress­ful.

“Be­cause of my Crohn’s I get re­ally de­hy­drated, which makes it re­ally chal­leng­ing to get an IV in,” Clarke said. “One time, lit­er­ally eight dif­fer­ent IV nurses had come into my room try­ing to get a line in, and I’m in tears. I can’t do my pro­ce­dure or surgery un­til we get this done, and it was just like a night­mare.”

So that day he tried an ex­per­i­ment. As part of a re­search project at Cedars-si­nai Med­i­cal Cen­ter, Clarke had been given a vir­tual-re­al­ity head­set at the bed­side to use when he felt pain. It was pro­grammed with im­mer­sive, mul­ti­sen­sory 3-D con­tent de­signed to dis­tract pa­tients from pain. Clarke popped the VR head­set on, and his bustling hos­pi­tal room was im­me­di­ately re­placed with the nat­u­ral, calm­ing beauty of Yel­low­stone Na­tional Park. He re­laxed - and a nurse was able to get an IV started for him in no time.

Since then, he has used the VR head­set for IV in­ser­tions, blood draws, break­through pain be­tween sched­uled doses of med­i­ca­tion and even in­som­nia.

Erin Mar­tucci, 42, tried vir­tual re­al­ity for the first time in a very dif­fer­ent but also in­cred­i­bly painful sit­u­a­tion: Dur­ing la­bor. For the birth of her sec­ond child, she told her ob­ste­tri­cian that she wanted a nat­u­ral birth, with­out an epidu­ral or any pain med­i­ca­tion. But as her la­bor quickly pro­gressed, fear and anx­i­ety be­gan to take over.

“I could tell the con­trac­tions were com­ing quicker, and . . . I started pan­ick­ing a lit­tle bit,” said Mar­tucci, of New Hamp­ton, New York. “I started tee­ter­ing, like, ‘Oh, my God, I’m not go­ing to be able to do this.’ “

Be­fore go­ing for­ward with an epidu­ral, her doc­tor of­fered her a VR head­set.

The doc­tor “put the ap­pa­ra­tus on me, and I was im­me­di­ately in a beach scene and be­ing com­forted by the au­dio of a woman’s voice go­ing through the breath­ing with me,” she said. “Hav­ing the vis­ual and nar­ra­tion def­i­nitely calmed me down and took away that anx­i­ety, and I knew that I could do it with­out the epidu­ral.”

Af­ter al­most two hours of la­bor, the doc­tor re­moved the head­set. It was time for Mar­tucci to push and de­liver her baby. Within a minute, she gave birth to a healthy girl.

“I was, like, ‘What’s go­ing on? Why are you tak­ing this away now?’ Be­cause we didn’t talk ahead of time what was go­ing to hap­pen, I re­ally thought that I was go­ing to use these gog­gles as I’m push­ing my baby out!” she said. The VR “helped me get through what I was so fear­ful of - like that I wasn’t able to do it - and I de­liv­ered my baby with­out any as­sis­tance of drugs.”

Clarke and Mar­tucci rep­re­sent a grow­ing num­ber of pa­tients treated with vir­tual-re­al­ity dis­trac­tion for pain in a hos­pi­tal set­ting. Cedars- Si­nai has used the tech­nol­ogy on more than 2,500 pa­tients since 2016, more than any other hos­pi­tal in the world. Mar­tucci’s ob­ste­tri­cian-gy­ne­col­o­gist, Ralph An­der­son, who prac­tices at Orange Re­gional Med­i­cal Cen­ter in Mid­dle­town, New York, has helped more than 50 women ease pain dur­ing child­birth with VR. And Los An­ge­les-based Ap­pliedvr, a com­pany that sells a VR kit and cre­ates its own ther­a­peu­tic con­tent, has part­nered with more than 100 hos­pi­tals, in­clud­ing Inova Mount Ver­non Hos­pi­tal, Bos­ton Chil­dren’s Hos­pi­tal and Chil­dren’s Hos­pi­tal Los An­ge­les.

“Vir­tual re­al­ity is part of our cul­ture now, so it’s not as alien of a tech­nol­ogy as it once was. I think peo­ple look at it as an op­por­tu­nity to de­liver bet­ter pa­tient care,” said Jef­frey Gold, di­rec­tor of the Pe­di­atric Pain Man­age­ment Clinic at Chil­dren’s Hos­pi­tal Los An­ge­les, which be­gan us­ing VR in 2004. “Maybe VR can com­ple­ment a lower dose of pain med­i­ca­tion or will elim­i­nate the need for medicine al­to­gether for some pa­tients, which would be op­ti­mal.”

Re­searchers be­gan to ex­plore vir­tual re­al­ity as a ther­apy for pain in the late 1990s, but the ex­pen­sive and bulky equip­ment pre­vented it from gain­ing popularity. To­day’s VR sys­tems are more af­ford­able, light­weight, smaller and com­fort­able. Many use a smart­phone for the dis­play and hard­ware, which can cut costs. This wave of new and im­proved de­vices - along with a grow­ing opi­oid epi­demic that has left physi­cians scram­bling for bet­ter op­tions for pa­tients ex­pe­ri­enc­ing pain - has sparked a re­newed in­ter­est in VR dis­trac­tion ther­apy.

“We’re in­ter­ested in un­der­stand­ing how we can use dif­fer­ent tech­nolo­gies to im­prove the pa­tient ex­pe­ri­ence in ways that don’t re­quire more drugs, and VR is one of them,” said Bren­nan Spiegel, di­rec­tor of health ser­vices re­search at Cedars-si­nai.

A num­ber of re­cent stud­ies have at­tempted to pro­vide ev­i­dence that VR dis­trac­tion ther­apy works. In 2017, Spiegel and col­leagues pub­lished a con­trolled trial test­ing the ef­fects on pain of a 3-D VR ex­pe­ri­ence vs. a 2-D na­ture video on a TV screen in 100 hos­pi­talised pa­tients. Al­though both meth­ods low­ered per­ceived pain lev­els, pa­tients in the VR group re­ported a greater re­duc­tion in pain, on av­er­age, than the TV group.

Also last year, a ran­domised con­trolled trial by Gold and col­leagues found that, out of a group of 143 chil­dren, the half who wore a VR head­set dur­ing blood draws re­ported ex­pe­ri­enc­ing less pain and anx­i­ety than the half who didn’t. Other stud­ies, which have fo­cused on pa­tients with cancer, fi­bromyal­gia, chronic pain and burn in­juries, have found sim­i­lar re­sults.

“I have worked in burn care for 18 years and come to the con­clu­sion that nar­cotics are not enough,” said Theresa Mcsherry, a nurse prac­ti­tioner at the Ore­gon Clinic in Port­land. “One par­tic­u­lar pa­tient was a real chal­lenge, a young man who had burned 100 per­cent of his body, and the drugs weren’t work­ing for him. There wasn’t a whole lot I could do for him, and that un­for­tu­nate ex­pe­ri­ence re­ally chal­lenged me to look out­side the box for fu­ture pa­tients.”

Mcsherry con­nected with VR re­searcher Hunter Hoff­man at the Univer­sity of Wash­ing­ton, who be­gan test­ing VR for pain ap­pli­ca­tions in 1996. He helped her ac­quire equip­ment to test with pa­tients need­ing wound care. The pain level of these some­times hours­long pro­ce­dures - re­mov­ing old dress­ing, clean­ing the wound and ap­ply­ing new dress­ing - is ex­tremely high.

As a form of dis­trac­tion, her pa­tients put on VR gog­gles and played “Snow­world,” a game that im­merses pa­tients in an icy po­lar world where they can throw vir­tual snow­balls at pen­guins and snow­men. The en­vi­ron­ment is meant to be a cool­ing an­tithe­sis to the pa­tients’ burns, while the game as­pect dis­tracts them from the pain.

In a study in­volv­ing 18 pa­tients, Mcsherry and col­leagues found that VR re­duced the amount of opi­oid med­i­ca­tion re­quested from pa­tients by 39 per­cent dur­ing wound-care pro­ce­dures com­pared with a con­trol con­di­tion with­out VR. The clinic still uses VR reg­u­larly to man­age pain in both in­pa­tients and out­pa­tients.

“VR is not go­ing to re­solve the opi­oid cri­sis, but it’s use­ful to have in our tool­box to help peo­ple be less de­pen­dent on med­i­ca­tion in the early stages,” she said. “This is a tool with po­ten­tial to teach pain de­sen­si­ti­sa­tion and cop­ing that may al­low a burn sur­vivor to re­turn to a bet­ter func­tional sta­tus.”

Ac­cord­ing to VR’S sup­port­ers, the idea is not for pa­tients to wear a head­set when­ever they feel pain - which, for some, would mean a life­time im­mersed in a vir­tual world. In­stead, VR ap­pli­ca­tions can teach peo­ple to man­age their pain in the real world. Clarke, for in­stance, has learned enough re­lax­ation skills through VR that he can forgo the head­set for mi­nor pro­ce­dures. Al­though some pro­grams, such as “Snow­world,” are meant to sim­ply dis­tract, Ap­pliedvr of­fers mod­ules that each cover a dif­fer­ent topic, such as breath­ing tech­niques, mind­ful­ness and pos­i­tive think­ing. These mod­ules also in­cor­po­rate heart-rate and breath-sen­sor data to pro­vide users with biofeed­back.

“Vir­tual re­al­ity can train and con­vince a per­son that they have gov­er­nance over their body and their ex­pe­ri­ence. It demon­strates that the brain’s re­sponse to in­juries can be ma­nip­u­lated in a pos­i­tive way,” Spiegel said.

A VR sys­tem con­sists of spe­cialised gog­gles that cover your eyes com­pletely, re­plac­ing your view of the real world with a com­puter-gen­er­ated en­vi­ron­ment. The head­set tracks your head move­ments, so you can freely look around the vir­tual world. Some­times it in­cludes head­phones for full au­dio­vi­sual im­mer­sion or hand­held con­trollers that al­low you to ma­nip­u­late ob­jects. In the best-case sce­nario, all these in­puts add up to a sense of pres­ence. In other words, VR can make you feel as though you’re re­lax­ing on the beach when you’re re­ally sit­ting in a hos­pi­tal room.

“The brain is re­ally bad at liv­ing in two re­al­i­ties at once. Evo­lu­tion­ar­ily, we’ve never had to think about liv­ing in two re­al­i­ties, and ev­ery­thing about our brain and our body is de­signed to live in this re­al­ity,” Spiegel said. “So if we’re in vir­tual re­al­ity, the brain now has a sub­sti­tute re­al­ity, and the brain takes it as real be­cause it can’t eas­ily also think of the other re­al­ity.”

De­spite the grow­ing ex­cite­ment, a num­ber of chal­lenges and bar­ri­ers re­main for vir­tual re­al­ity as a pain man­age­ment tool. The cost of equip­ment, while steadily de­creas­ing, re­mains high for a largely un­proven tech­nol­ogy.

For in­stance, Face­book-owned Ocu­lus re­cently re­leased a stand­alone VR head­set for use in gam­ing at home with a start­ing price of $199 - a sub­stan­tial drop from a pre­vi­ous model, which orig­i­nally sold for $599. Cheaper VR head­sets use your smart­phone’s dis­play and hard­ware for less than $20, but they lack the qual­ity and fea­tures of their more ex­pen­sive coun­ter­parts.

More im­por­tant, re­searchers say not enough large stud­ies have been done to prove VR’S ef­fec­tive­ness.

“If you have a se­ri­ous med­i­cal prob­lem, you want the ev­i­dence to know that this tech­nol­ogy is go­ing to work, es­pe­cially for pa­tients who just have to buy the equip­ment out­right,” said Anita Gupta, an anes­the­si­ol­o­gist and pain spe­cial­ist at Prince­ton Univer­sity. “I think there’s more that has to be done re­gard­ing re­search, and we need to in­ves­ti­gate whether or not this is truly a vi­able tool in the in­pa­tient set­ting.”

A few years ago, Gupta be­gan to search for pain man­age­ment so­lu­tions that didn’t in­volve opi­oids. She ini­tially was drawn to VR, given its non­in­va­sive and non­phar­ma­co­logic ap­proach, but she quickly ran up against prac­ti­cal is­sues such as the high cost of equip­ment and side ef­fects. (Older pa­tients, in par­tic­u­lar, had dif­fi­culty han­dling the de­vice and were more prone to headaches, nau­sea and dizzi­ness.)

“Def­i­nitely the older peo­ple tend to be a lit­tle more sus­pi­cious and re­sis­tant. They’ll say things like, ‘I’m too busy’ or ‘I’m too tired.’ Or they’ll say, ‘Hey, are you try­ing to ex­per­i­ment on me? Is this like a mind ex­per­i­ment?’ “Spiegel said. “How­ever, the para­dox is that we’ve ac­tu­ally seen older pa­tients have more pro­found pain re­duc­tion [us­ing VR] than younger peo­ple.”

VR dis­trac­tion ther­apy may not be for every­body or work for ev­ery con­di­tion, but pa­tients such as Clarke and Mar­tucci swear that the tech­nol­ogy has been a gamechanger for their pain. Mar­tucci rec­om­mends vir­tual re­al­ity to moth­ers-to-be in her com­mu­nity and would hap­pily use it again if she were to have another baby. And Clarke loves what VR does for him, though he still ex­pe­ri­ences pain daily.

“Pain medicine is def­i­nitely a ne­ces­sity. It’s a part of my life right now, while we’re get­ting this thing un­der con­trol,” Clarke said. “But I also do ev­ery­thing from acupunc­ture to mas­sage ther­apy to aquather­apy. I’m on the con­stant look­out for some­thing al­ter­na­tive with no side ef­fects, and so this vir­tual re­al­ity was a true bless­ing for me be­cause it re­ally helps.”

– The Wash­ing­ton Post

Photo: The Wash­ing­ton Post

A child uses VR gog­gles while get­ting his blood drawn. Such de­vices al­low pa­tients to re­lax de­spite the stresses of treat­ment.

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