Gaming pain: The quest for a better
Virtual reality isn’t just for video games anymore. It’s revolutionising medicine, including the way we manage one of the biggest concerns for patients across the world: 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 everhigher 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 Centres for Disease Control reports.
Efforts to curb opioid prescriptions and abuse are starting to work. But with the spectacular failure of a drugcentric 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.
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.
The analysis looked at the results of 25 randomised controlled clinical trials into the use of CBT in pain management. These kinds of studies in which groups of people are arbitrarily assigned either to a new treatment or to 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 who are not — are almost 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 multisession 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.”
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 woundcare sessions eases patients’ reported pain by 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