At the 11th Annual CyberTherapy 2006 Conference: Virtual healing: Designing Reality, on June 12, 2006 in Gatineau, Canada, a workshop was held titled “Virtual Reality and Pain Reduction,” chaired by NIH Pain Consortium member David Thomas Ph.D. and Jeffrey Gold Ph.D. (Keck School of Medicine, University of Southern California; USC). The purpose of this workshop was to review the current use of virtual reality (VR) for the treatment of pain, and also to explore other potential applications of VR in the treatment and prevention of acute and chronic pain. The National Institutes of Health (NIH) Pain Consortium was briefed on the conclusions from this workshop by David Thomas at the June 28^th, 2006 Pain Consortium meeting. 

The speakers at this workshop were David Thomas, Ph.D. (National Institute on Drug Abuse, NIH), Brenda Wiederhold, Ph.D., MBA (The Virtual Reality Medical Center), Hunter Hoffman, Ph.D. (University of Washington), Belinda Lange, BScB Physio Hons (University of South Australia), and Jeffrey Gold, Ph.D. (USC).

David Thomas discussed the make up and function of the NIH Pain Consortium.  He then overviewed the current pain program at NIDA, including pain research in VR.  He discussed funded research looking at VR and dental pain, burn wound care pain, and physical therapy pain. He also discussed the research of Christopher deCharms et al. who use VR with fMRI to give subjects biofeedback of brain activity in specific brain regions involved in pain control. Using this feedback, subjects can increase activity in these areas and reduce perceived pain. 

Brenda Wiederhold discussed some of her and the collaborators work using VR to distract patients from various types of pain, including dental pain and burn wound treatment pain.  In the treatment of burn wounds, she reported a 76% reduction in perceive pain intensity using one of their VR worlds (South Pole Fantasy) versus controls.  Measures of anxiety related to painful dental procedures were also significantly reduced.  Further, in a pilot study, migraine headache, fibromyalgia and chronic back pain were also reduced in a relaxing VR environment.  

Hunter Hoffman described some of his work using VR during burn wound care (both changing dressing and stretching the skin during physical therapy).  VR produced a significant reduction in pain measures during these procedures, compared to control subjects that were playing video games.  These reductions in pain corresponded to changes in brain activity as measured by fMRI.   Further, anxiety related to these procedures dropped dramatically.  This resulted in less morphine being needed to treat patients that received VR treatment.  

Belinda Lange described the use of VR in children who received venipuncture or wound care.  Children who received VR had significantly less distress compared to controls that were watching a movie.   At this point in this study, both groups had similar pain ratings.

Jeffrey Gold also discussed research related to painful and stressful medical procedures in children.  During i.v. placement, VR was found to reduce pain in children, as indicated by both the child’s and the parent’s report of the child’s pain.  Anxiety of the children was also substantially reduced.  Further, he found that the caregiver were much more satisfied with the VR treatment than the control treatments. 

Future Directions:

The clinical use of VR in the treatment of disease is a new but rapidly growing field. In terms of pain treatment, many successes have recently been realized in the treatment of acute pain.  However, there are likely a multitude ways to extend and improve how VR is used in the treatment of acute pain, and expand its use to the treatment of chronic pain. The participants in this workshop (including the audience), worked on describing these opportunities, with the aim of informing the VR pain research and treatment fields, as well as to help alert the NIH Pain Consortium about ways that VR might be used to reduce pain. 

In terms of acute pain, it was concluded that research that seeks to determine the characteristics of VR environments that work for distracting patients from various types of pain in of importance. For example, research is needed to determine if “cold” VR environments, including things like snow and penguins, works better on burn wound pain than other environments.  In contrast, research is needed on whether other types of pain (e.g. acute arthritis pain) respond better to a VR environment that depicts a warm scene.  It may be the case that numerous VR worlds will be needed, each tailored to the specific types of pain being treated.   

Further, VR worlds likely will prove to be more powerful if they are individualized to various patient characteristics.  Factors like age, gender, and personal interests likely impact how effective various VR worlds are at producing distraction from pain.  Designing and matching VR worlds to various patient characteristics would likely result in much greater pain distraction and patient acceptance. 

Along these lines, basic research on general properties of the VR worlds and how these relate their effectiveness is needed.  This research could address if more realistic worlds produce more distraction or if simple cartoon-like graphics are sufficient or even superior.  Various types of head mounted displays (HMD) are used to present VR visual stimuli. Research could help determine which types of displays are the most effective.  A sense of “presences” in the VR is often sited as essential for the VR experience to be effective.  Research on what this sense really is, how it can be produced, and if it impacts pain perception are also of importance.     

It was also acknowledge that VR alone for acute pain in many cases may not suffice.  Research on how VR can be used with other types of treatments may allow more effective treatment of acute pain, where less drugs are needed in situations where pharmacotherapies are currently the treatments of choice.  

While acute pain is a serious problem, approximately 50 million Americans suffer from chronic pain, and this type of pain can be debilitating, greatly reducing quality of life.  The use of VR in the treatment of chronic pain is just beginning to be explored.  Obviously, a person cannot be distracted from pain at all times by wearing a HMD.  However, chronic pain typically varies over time.  With the advent of less expensive VR equipment and software, it is possible for patients to use VR away from the clinic to treat bouts of pain.  This may include a set up where data about the treatments could be electronically forwarded to caregivers, who could monitor progress and change the treatment if needed.  By treating bouts of chronic pain in this way, there also may be less “wind-up” pain, where a person’s pain puts them in more of a hyperalgesic state. It may also reduce reliance on opioids, which is important because there is evidence that chronic opioid treatments can actually result in a hyperalgesic state (opioid-induced hyperalgesia).

Biobehavioral methods have efficacy in the treatment of chronic pain, where people learn to cope with their pain, and are enabled to pursue more activities.  VR is very suited for various biobehavioral treatments, and has been shown to be very effective at reinforcing various behavioral, social, and cognitive skills. Adapting VR protocols to promote a better quality of life in chronic pain patients is important. These protocols would likely include “serious games,” where the patient plays a game in VR that teaches them about their pain conditions, and how to cope with and overcome their disease. 

A further area of opportunity raised at this workshop is the use of simulated VR people (avatars) to help teach pain treatment professionals. These simulated people can be programmed to present with various symptoms including pain. The clinician interacts with these avatars and establishes a diagnosis. This type of technology could be used in the pain treatment field as a means to allow clinicians to practice and improve their diagnosis skills.  It could also be used to help train clinicians to be able to distinguish between people in pain and drug-addicted individuals faking painful symptoms in order to obtain opioids. 

Summary:

VR is a being shown to be a powerful technology in the treatment of acute pain. It is envisioned that VR could be used with much greater efficacy in the treatment of acute pain in the future. Further, there is great potential for VR in the treatment of chronic pain. Lastly, VR might be a useful as a tool to train clinicians to more accurately diagnose types of pain, and differentiate between patients in pain and drug addicted individuals seeking drugs.  In this, “The Decade of Pain Research and Treatment,” exploiting the power of technologies like VR in the treatment of pain will help our country greatly alleviate pain in millions of individuals.