The Daily - The Sunday Read: ‘Can Virtual Reality Help Ease Chronic Pain?’

Episode Date: May 22, 2022

Chronic pain is one of the leading causes of long-term disability in the world. By some measures, 50 million Americans live with chronic pain, in part because the power of medicine to relieve it remains inadequate.Helen Ouyang, a physician and contributing writer for The New York Times Magazine, explores the potentially groundbreaking use of virtual reality in the alleviation of acute pain, as well as anxiety and depression, and meets the doctors and entrepreneurs who believe this “nonpharmacological therapy” is a good alternative to prescription drugs.A lush forest, a snow-capped mountain, a desert at sunset — could these virtual experiences really be the answer for managing chronic pain?This story was written by Helen Ouyang and recorded by Audm. To hear more audio stories from publications like The New York Times, download Audm for iPhone or Android.

My name is Helen Ouyang. I'm an emergency room doctor in New York City, and I've been fascinated by chronic pain for a long time. When we touch a hot stove, we feel pain and pull our hand away. This is our body's alarm system. But chronic pain is when the whole alarm system goes haywire. The body is just in a state of alarm all the time, and we don't have any good treatments for

that. There's one incident that really sticks with me. A man had driven to five different emergency rooms looking for his missing son, and it turned out, actually, that the son had died in our ER just about an hour earlier. The father explained how his son had undergone foot surgery and was prescribed Percocet. He got hooked and went on to use other drugs like heroin, which is what ultimately killed him. I heard recently that people were using virtual reality to treat chronic pain. Around 50% of our brain is used in visual processing. So if you're wearing a headset that's totally immersive and bombarding you with visuals, then you can transport the brain to a new reality,

possibly one without pain. The first time I tried VR, I just stood in my living room and was moving around this fantastical world. There were these canyon scenes with huge mountains and beaches, plants that grew into trees, that moved with the rhythm of my breathing. It was completely transporting.

I reached out to a doctor named Brendan Spiegel at Cedars-Sinai Medical Center because I knew he was running one of the most comprehensive academic programs focused on VR. I watched him use virtual reality on his patients and I saw how they had these deep, profound reactions, really unexpected ones.

So here's my article, Can Virtual Reality Help Ease Chronic Pain? Read by Emily Wu Zeller. from The New York Times, The New Yorker, Vanity Fair, The Atlantic, and other publications on your smartphone. Download Autumn on the App Store or the Play Store. Visit autumn.com for more details. After an hour and a half bus ride last November, Julia Monterosso arrived at a white Art Deco building in West Hollywood, just opposite a Chanel store and the Ivy, a restaurant famous for its celebrity sightings. Montorosso was there to see Brennan Spiegel, a gastroenterologist and researcher at Cedars-Sinai who runs one of the largest academic medical initiatives studying virtual reality as a health therapy. He started the

program in 2015, after the hospital received a million-dollar donation from an investment banker on its board. Spiegel saw Monterosso in his clinic the week before and thought he might be able to help alleviate her symptoms. Monterosso is 55 and petite, with youthful bangs and hair clipped back by tiny jeweled barrettes. with youthful bangs and hair clipped back by tiny jeweled barrettes. Eighteen months earlier, pain seized her lower abdomen and never went away. After undergoing back surgery in September to treat a herniated disc,

and after the constant ache in her abdomen worsened, she had to stop working as a house cleaner. Eventually, following a series of tests that failed to reveal any clear cause, she landed in Spiegel's office. She rated her pain an 8 on a 10-point scale, with 10 being the most severe. Chronic pain is generally defined as pain that has lasted three months or longer. It is one of the leading causes of long-term disability in the world. By some measures, 50 million Americans live with chronic pain, in part because the power of medicine to relieve pain remains woefully inadequate.

As Daniel Klaue, who runs the Chronic Pain and Fatigue Research Center at the University of Michigan, put it in a 2019 lecture, there isn't any drug in any chronic pain state that works in better than one out of three people. He went on to say that non-pharmacological therapy should instead be front and center in managing chronic pain, rather than opioids, or for that matter, any of our drugs. Virtual reality is emerging as an unlikely tool for solving this intractable problem. is emerging as an unlikely tool for solving this intractable problem. The VR segment in healthcare alone, which according to some estimates is already valued at billions of dollars,

is expected to grow by multiples of that in the next few years, with researchers seeing potential for it to help with everything from anxiety and depression to rehabilitation after strokes to surgeons strategizing where they will cut and stitch. In November, the Food and Drug Administration gave authorization for the first VR product to be marketed for the treatment of chronic pain. Spiegel, who has the slim build of someone who runs marathons, he has finished 18 of them, fastened a black VR set onto Monterosso's head. It was wired to a computer, behind whose monitor sat Omir Laron, a psychiatrist and self-taught programmer who created the virtual worlds for this use.

The beauty of doing everything here is that I can very quickly change things with patient feedback, Laron told me. If we outsourced it, it would be pretty much impossible, he said, or at least slow and expensive. The week before, Spiegel and Laron started collecting various biometric data from patients while they were in virtual reality. Laron's computer showed what was happening to Monterosso's heart and eyes and to her cognitive load, or mental effort,

while a two-dimensional version of what she was seeing in the headset played on another screen. Monterosso sat in a plastic chair under fluorescent lights, but in virtual reality, she stood on a footbridge in a lush forest. As she looked around at the giant trees, she trembled and tears suddenly started streaming down her face. Her cognitive load, shown as a pink line on the computer, started to increase. I feel like I'm there with my son, she said in Spanish. Her 21-year-old son died in a car accident in June. They loved visiting Yosemite together, and in these virtual woods, she felt as if she were hiking with him again.

Spiegel reassured her that such intense reactions are very common, then leaned over to whisper to me, She's doing her own therapy right now. As her tears dried, Monterosso slowly moved her head to look over a menu of choices. moved her head to look over a menu of choices. Selecting a beach scene option with her gaze, she found herself beside a placid sea, under a brilliant blue sky. A mandala moved toward and away from her, sinking her breathing rates to a relaxation-inducing tempo. Her cognitive load and heart rate slowed, and her pupils became less dilated, all signs of relaxation. After a while, she headed to the mountains,

where goats trotted by. Welcome back, Spiegel said as Monterosso removed the headset. He pulled up some of her measurements on the computer monitor. He explained that larger pupils, for example, indicate stress.

In the forest, they're big. Because my emotions were very strong then, Monterosso replied. In the mountains, the pupils were smaller because you were relaxed, Spiegel continued, his finger tracing a downward sloping line on the screen. I've tried breathing exercises before, she said, but this is much more relaxing. She rubbed her abdomen. I don't have pain in my stomach now. Next, Monterosso entered

another virtual environment that Leron built specifically for patients with chronic gastrointestinal symptoms. In this setting, unlike the previous one, Monterosso used hand controls. Inside a virtual clinic, a robot named Maya, short for Mixed Reality Artificial Intelligence Assistant, guided her to a young blonde woman who expressed frustration with abdominal symptoms. Monterosso examined the patient with her virtual hands, placing a stethoscope on her stomach to listen to the sounds of digestion. Maya explained how the brain and the gut worked together. As she spoke, an image of a brain popped up, connected to intestines by a yellow flashing line.

When the brain became stressed, it turned fuchsia in color, and the yellow line to the gut metamorphosed into a stream of fire. A pounding heart appeared. Because the program is in English, Spiegel translated Maya's speech into Spanish. When you have a lot of stress, the heart beats faster, the intestines can move faster, and oxygen in the body goes to the brain, away from your intestines. This really helped me to understand how the brain and the intestines work together, because after the accident of my son, I've been very sad, Monterosso told Spiegel after her VR session.

She looked around the room, seemingly surprised to see everyone. I didn't even notice the people here, she said. That's because people can't live in two realities at once, Spiegel said. He was describing VR's unique ability to convey a sense of just being there, wherever there happens to be. As he puts it in his book, VRX, How Virtual Therapeutics Will Revolutionize Medicine. All of its revolutionary potential tumbles out of its ability to compel a person's brain and body to react to a different reality. Humans may use roughly 50% of our brains in visual processing,

Spiegel writes, so bombard the eyes with spectacular and dynamic visions, and next thing you know, those three billion neuronal firings per second will ricochet through half the brain to process the overwhelming load of visual data. In this reality, Monterosso no longer experienced pain. What we saw today with Julia was like a cyberdelic,

as if she took a psilocybin, Spiegel told me, referring to the hallucinogen. She had explosive insights into how to modify her own life. Her amygdala was on fire, he added, referring to the almond-shaped structure in the brain that processes emotions. The real-time biodata helped her connect the dots between brain and body, while Maya taught her how she could potentially turn the pain off. Even though Spiegel tried to explain all this to her the week before, she did not grasp it until she tried VR. I almost don't even care what the mechanism is of how it's working, Spiegel told me. And indeed, its impact on chronic pain still isn't fully understood.

What really matters to him is the answer to his question, is it clinically working or not? I began looking into novel treatments for chronic pain because, as an emergency room doctor, I've long grappled with caring for patients at the extremes of persistent suffering. I've seen what happens when our medical treatments turn deadly. Years after telling a man that his son had died of an opioid overdose, which resulted from an addiction to prescription painkillers following foot surgery,

I can still hear his wails and recall how they brought my hospital's bustling ER to near silence. The opioid epidemic, an American tragedy, has no clear end in sight. Drug overdose deaths, most of them from opioids, rose 30% during the first year of the pandemic. While illicit fentanyl is largely to blame, the healthcare system is also complicit in this harrowing statistic. At one point, 80% of those who were using heroin first misused prescription opioids. Patient-rated pain scores in siren red used to be a regular feature on my ER's dashboard, having gained the same importance as other vital signs like oxygen levels and blood pressure, until they quickly disappeared after Purdue Pharma became implicated

in the unethical marketing of opioids. The healthcare system, confronted with evidence that these drugs were being overprescribed and even harming some patients, then began cutting them off abruptly in some cases, instead of tapering their use or offering alternative treatments. The patients who haunt me nearly as much as those who have succumbed to the opioid crisis are the ones I send away,

often in as much pain as when they first arrived. When I meet patients with chronic pain in the ER, they narrate their years of suffering, and I respond with remedies that I know, and they know that I know, they've tried before with no success. This is when I feel the most futility as a physician. Figuring out chronic pain can be mystifying for doctors. In MRI studies of people's spines, disc herniations

have been found in half of those subjects who nevertheless report feeling no pain. Age-related degenerative findings also show little correlation with symptoms. Some patients with knee osteoarthritis continue to have pain after joint replacement surgery. to have pain after joint replacement surgery. While chronic pain may flummox the usual scans and tests, the condition is very much real, causing immeasurable suffering. We have at least come to recognize that acute pain resulting from damage to tissues

is not the same as chronic pain, which is now considered a distinct disease. How we came to this understanding can be traced back to a serendipitous experiment in London in the early 1980s. Before then, scientists knew that the brain has some control over pain, but that insight was mostly confined to the situations described by Patrick Walls and Ronald Malzak's gate control theory, which helps explain why, walls in Ronald Melzack's gate control theory, which helps explain why, say, a person running from a house on fire may not realize that she sprained her ankle until she is a safe distance away. The brain, so intent on escaping the fire, shuts the gate, blocking pain signals coming up

the spinal cord from the ankle. You could close the gate, says Clifford Wolfe, a neurobiology professor at Harvard Medical School who worked in Wall's lab. But essentially, there was nothing about the opposite possibility, which is that the brain, independent of the periphery, could be a generator of pain. Wolfe was conducting his own experiment in Wall's lab, Wolf was conducting his own experiment in Wall's lab, applying painful stimuli to rats' hind legs. The animals developed large fields of pain that could easily be activated months later with a light tap or gentle warmth,

even in spots that weren't being touched directly. I was changing the function of the nervous system, such that its properties were altered, Wolff says. Pain was not simply a measure of some peripheral pathology, he concluded. It could also be the consequence of abnormal amplification within the nervous system. This was the phenomenon of central sensitization. Before this discovery, he says, the feeling was always pain is a symptom that reflects a disease, and now we know that pain often is a consequence of a disease state of the nervous system itself.

Some ailments, like rheumatoid arthritis, can exhibit both peripheral pathology and central sensitization. and central sensitization. Others, like fibromyalgia, characterized by pain throughout the body, are considered solely a problem of the central nervous system itself. A better grasp of how chronic pain changes the central nervous system has emerged since Wolf's experiment. A. Vanya Apkarian's pain lab at Northwestern University found that when back pain persists, the activity in the brain shifts from the sensory and motor regions to the areas associated with emotion, which include the amygdala and the hippocampus. It's now part of the internal psychology, Apkarian says,

a negative emotional cloud that takes hold. The brain itself morphs. Patients with chronic pain can show a significant loss of gray matter in the prefrontal cortex, the attention and decision-making region of the brain that sits behind our foreheads, as well as in the thalamus, which relays sensory signals. Both areas are important in processing pain. Excitatory neurotransmitters increase, and inhibitory ones decrease, while glial and other immune cells drive inflammation. The nervous system, unbalanced, magnifies and prolongs the pain. The system goes haywire, like an alarm that keeps blaring even when there's no threat, even when the pain isn't protective anymore.

Instead, it just begets more pain. And the longer it lasts, the more deeply systemic it becomes and the harder it is to resolve. There's a popular saying in neuroscience that as neurons fire together, they begin to wire together, an example of neuroplasticity in action. But if our brains really are plastic, what is shaped there can be reshaped. Therapies that target the brain instead of the aching back or the sore knee, whether through psychology, drugs, direct stimulation of the brain instead of the aching back or the sore knee, whether through psychology, drugs,

direct stimulation of the brain, or virtual reality, in theory could undo chronic pain. In the 1990s, Hunter Hoffman, a cognitive psychologist at the University of Washington, began to use VR to provide relief to burn patients who were having their dressings changed, provide relief to burn patients who were having their dressings changed, an excruciating ordeal that is difficult to medicate. Nobody was using virtual reality to reduce the pain of patients before us, he says. In his VR program, called Snow World, patients who tumbled through the wintry scene, chucking snowballs at penguins, reported that their relief was similar to what they got from intravenous opioids. Brain scans confirmed these findings. VR and opioids each resulted in remarkable reductions

in neural activity in pain-related areas. Unlike most drugs and surgical procedures, VR has far fewer side effects, mostly nausea and motion sickness. Headsets now cost a fraction of what they once did, and graphics are markedly improved, resulting in more immersive experiences and fewer potential side effects.

What's more, Hoffman says, all the major computer companies are pumping billions of dollars into virtual reality as a kind of internet. What Mark Zuckerberg called an embodied internet when he announced last fall that Facebook was becoming meta. A few months later, Microsoft unveiled plans to acquire Activision Blizzard to provide building blocks for the metaverse, the company said. The downstream effects of all this technological ferment, Hoffman predicts, is that VR therapies, powered by private sector investments,

will swiftly develop into a standard treatment for pain. On August 8, 2016, Robert Jester, a retired high school biology teacher in Greenport, New York, who was moonlighting as a chimney sweeper, both to support his family and to enjoy the magnificent views, drove to a nearby neighborhood for a quick job. The ladder he took was too short, but it seemed like a simple sweep, so he decided to go ahead with the work anyway. He climbed to the top, the ladder slipped,

and he fell to the hard ground below. The pain in his back was so intense that he couldn't make out the rescue workers bending over him. He could see only white light. A broken spinal cord means he can't walk today, and his legs constantly feel as if they're submerged in boiling water. Frequently, they also feel as though knives are stabbing them up and down their length. He fractured his molars from clenching down during these episodes. The first year after his accident, the pain was so unbearable that he almost enacted his step-by-step suicide plan a dozen times.

Opioids softened the agony, but they also changed his mood. He stopped telling jokes. And if he no longer had his sense of humor, he thought, what was the point of living? Before the accident, Jester got his students so excited about biology that they wanted to work on their science projects long after school, frustrating the custodians who were trying to clean his classroom in the evening. During fire drills, his students would form a conga line, chanting, D-N-A, deoxyribonucleic acid. He also volunteered as a tutor to kids in town. One of them had a father named Bob McInnes,

whom Jester met while cleaning the family's chimney. McInnes happened to have seen an internet video about a company in Los Angeles called Applied VR. At the time, in the spring of 2017, Applied VR was focused on treating anxiety and acute pain in those who had to undergo hospital procedures, especially children. McInnes went to the company's website

and filled out a general contact form with information about Jester's situation. Is there anything that your device might be able to do to help him? He typed. Just thought I'd throw it out, given how much pain he's in. He didn't expect to hear back.

Three hours later, an email from Josh Sackman, one of the company's founders, arrived in McInnes' inbox. A headset soon appeared in Jester's mail. Sitting in a plush brown recliner, his beef stroganoff dinner on a tray before him, Jester tried VR for the first time. He got so caught up viewing a farm scene

that he tried to shoo away a cow that came over to lick him and knocked the noodles all over his living room wall. He was hooked. Next, he flew with the Wright brothers, controlling the plane by looking in different directions. Applied VR has stopped using this module. Jester realized that he was so focused on keeping the plane upright that he was no longer dwelling on his pain anymore.

He wondered if he could use VR to distract himself and reduce his reliance on OxyContin and other pain medications and eventually stop altogether. He started charting his opioid use in a little blue notebook while continuing daily VR sessions. After two months, he was off narcotic painkillers. Now, Jester told me recently, I use the training right away when the pain comes on. He squeezed his eyes closed and breathed in deeply. I can refocus myself for a minute, he said, imagining one of

the special VR plants whose bare branches become full of leaves when his breathing is slow and steady, as detected by a sensor on the headset. When Sackman and his co-founder Matthew Stout heard about Jester's success with VR and opioid tapering, they redesigned their product. EaseVRX, renamed Reliever in February, would provide therapy for chronic pain. Beth Darnell, a psychologist and director of Stanford's Pain Relief Innovations Lab, is the company's chief science advisor. She describes the breath-fed tree as a way for visual elements to reflect back to the user the changes that are occurring in their own physiology. She adds, it's a powerful way to teach principles and concepts that extend well beyond what we do in traditional didactic cognitive

behavioral therapy. The sort of biometric data that Spiegel and Laron captured with their graphs are here distilled into an aesthetically appealing format that delivers immediate, actionable feedback without interrupting a patient's immersion in virtual reality. Because Jester left his headset at the facility where he did physical therapy, he was unable to use it for more than a year during the pandemic. But he discovered that he had retained the lessons he learned in VR. This is the kind of lasting, real-world effect that VR

experts see as their ultimate goal. After all, as Hoffman, the University of Washington professor, points out, we can definitely reduce your pain while you're in the helmet, but you can't stay in there all day. Reliever also has modules that prompt patients to redirect their attention through gameplay, or by allowing scenes, waves washing onto a sunny coast, say, to soothe their nervous systems. The average session lasts seven minutes, and patients are directed to do just one a day for eight weeks. Unlike the sort of VR that's popular in gaming, Reliever tracks only patients' head movements, meaning Jester can't go up to the tree and grab a branch or chase cows away. The product is designed to be easier to use than an iPhone. You just strap on the headset and press the power button. It's easier to use than an iPhone.

You just strap on the headset and press the power button. Todd Maddox, a cognitive neuroscientist and Applied VR's vice president for research and development, explains how Reliever works with an example. I am rewarding you with a tree that flourishes for generating an appropriate breathing pattern. I didn't tell you to read a PDF or count in your head. But by using VR to engage the brain in experiential learning, he says, I have just set you on a path for behavioral change. To date, Applied VR has raised more than $70 million. Much of this money has been directed toward product development and clinical trials. A recently published study by researchers affiliated with the company, for which they recruited subjects during the pandemic through Facebook ads and pain organizations, reported an average drop in chronic back pain by nearly 43% for the reliever group, compared with 25% for the control group.

For those who used Reliever, pain also interfered less with their activity and sleep. Three months after the last VR session, these gains were mostly found to endure, and sometimes they persisted for six months. If these numbers hold up, they would indicate that users had retained the coping skills they learned inside the virtual world, as Jester did.

Maddox hypothesizes that the program alters structure and function of the brain. While acknowledging that he does not have concrete evidence, he says, you don't get changes in patient-reported outcomes without changes in the brain. In mid-November, the FDA gave applied VR authorization to market what is now Reliever for chronic lower back pain, a regulatory first that may pave the way for the agency to okay similar VR products, in large part because the side effects are minimal compared with those of pharmaceuticals. Medical device regulation is not drug regulation,

a senior official at the FDA told me. For VR, some of those technologies and some of the uses we need to see before they can be marketed, but we can also envision and imagine there are some where that's not necessary. Applied VR was founded by two entrepreneurs with expertise in business and marketing, not healthcare veterans. Sackman claims their backgrounds give them an advantage.

The first questions he says he asked when he learned about VR were, if this stuff is so powerful, why is it sitting in an academic lab? Why don't more people know about it? Why aren't people using this in clinical practice? He answered the questions himself. It's because there aren't people productizing it.

There's not a business model. Leron, at Cedars-Sinai, concedes the point. We aren't businessmen, he told me. He and Spiegel intend to keep their own VR products in-house The way we make money here is grants That's our currency, Spiegel says I don't want this to be suddenly sold and licensed commercially And now I can't get an NIH grant

Apart from a small one-time payment in 2016 In 2016, Spiegel says, he doesn't earn money from Applied VR, but he occasionally advises the company, and he uses its products in some of his federally funded research. He says that is mainly because there is nothing better right now for chronic pain. Cedars-Sinai itself, which first invested in applied VR six years ago through the hospital's tech incubator, may someday opt to commercialize its own VR efforts. Still, Spiegel recognizes the value of startup funding and the freedom that comes with it. The initial $1 million directed toward some of his work helps him and Laurent take VR to the bedsides of hospital patients. toward some of his work helps him and lauren take vr to the bedsides of hospital patients that sort of funding spiegel says gives his group extra support and flexibility to be innovative

including the creation of their own vr programs and making them available without cost i met one of these hospitalized patients misty williams-year-old chef who has long suffered debilitating pain episodes caused by sickle cell disease, Williams relies on Dilaudid, a strong narcotic, but not while she's catering, because if anything happens on the job, they're going to ask you what you're taking, and so I don't, she says. After her inpatient VR session, she concluded that the headset was better than Dilaudid. What would be most helpful, she pointed out, would be using VR during her breaks at work. Spiegel's program helped her during her hospitalization, but it won't do so after she goes home. Applied VR is considered the pioneer, and the company that is most likely furthest along in getting devices to patients,

according to Amanda DiTrollio, a healthcare technology analyst at CB Insights. But several other companies are also closing in. Karuna Labs, a startup based in San Francisco, has created a hybrid model that mixes VR with aspects of telehealth. We're neuroscience people, with whiz-bang technology, says Lincoln Nguyen, its founder. He is reluctant, however, to call his firm a VR company because he considers coaching sessions to be central to what Karuna does. Patients are paired with a pain coach, who makes weekly video calls to supplement the self-guided VR modules that patients go through daily for three months.

John Weinberg, Karuna's chief operating officer, emphasizes that the human engagement is essential. The coaching curriculum falls under the purview of Howard Schubiner, director of the MindBody Medicine Center at Ascension Providence Hospital in Michigan and a clinical professor at Michigan State University's College of Human Medicine, and Christine Beebe, Karuna's lead pain coach and physical therapist. Schubiner is a protege of the late John Sarno, a controversial pain doctor who taught patients that their pain was caused by repressed emotions. Schubiner recognizes the limitations of Sarno's work and what he got wrong.

Being angry at your mother about your childhood isn't likely to cut off blood flow to your back, but he maintains that treating chronic pain requires a rewiring of the brain, which can involve recognizing emotions and difficult life events. Not some kind of woo-woo new age thing, Schubiner told me. This is just straight neuroscience. Schubiner, who is not involved in the VR aspect of Karuna's program, instructs the patients in his own clinic in Michigan to imagine that they are taking part in activities without experiencing pain, like the athlete visualizing the perfect shot

so that they engage the corresponding but dysfunctional neurons. Karuna tries to do the same thing by using VR instead of requiring patients to rely on their imagination. In an interactive virtual setting, Karuna's head sensors and hand controls determine how the body moves. Patients with back pain, say, might be asked to bend as far as they can without discomfort, then make both their body and their avatar gradually increase their spinal

flexion. Archery games help patients recover movement in their back as they pick up arrows, or their shoulders as they draw back the bowstring. In other modules, designed to facilitate the resumption of routine tasks, patients push around a virtual vacuum that cleans up colorful stars. The patient's performance is transmitted to their coach. Karuna is based on existing chronic pain treatments, though some of the company's explanations for how VR trains the brain are more heuristic than settled science. We don't have any hypotheses born in VR, Weinberg says. According to Nguyen,

the brain, transported to a different world in VR, learns to stop associating routine motions with the usual pain. I've seen the body moving in VR in ways that it can't move in real life, he told me. You're tricking your brain, using the visual system to move more so that we have bottom-up, top-down synergistic effects that can help people to change. If you can vacuum in virtual reality, then maybe you can vacuum in your living room too. Karuna also uses mirror therapy to trick the brain. This is how Nguyen first became interested in VR and chronic pain. Nguyen discovered it as an adolescent

when he was looking for remedies for his father, who was in extreme pain after two debilitating strokes. The therapy was invented in the 1990s by V.S. Ramachandran, a neurologist, to treat phantom limb pain, a phenomenon in which someone who has lost a leg or an arm still feels pain in the missing limb because the brain continues to perceive it as being present, but also in an abnormal state. Ramachandran would place the arm of an amputee, or a stroke patient in the case of someone like Nguyen's father, into an open box with a mirror down the middle, so that the sufferer, peering down through the top, saw the reflection of an intact, functioning arm on the affected side.

reflection of an intact, functioning arm on the affected side. Eventually, the thinking goes, the visually dominated brain sees a normal, healthy limb and reduces the pain signals, a crude form of virtual reality. In chronic pain, the body part that hurts may be undamaged and even seem healthy. What's altered is the area of the brain that corresponds to its anatomical location. Karuna extends the idea of mirror therapy so that patients not only see

their afflicted body part as healthy and pain-free in virtual reality, they also get to move it in complex ways. In one module, patients pick up lotus flowers with their healthy arm and toss them into a serene infinity pond surrounded by mountains. The VR mirrors the action but shows the opposite arm doing the motions. Seeing themselves perform this novel action in an unfamiliar environment that has no associations with pain seems to create new neural connections that eventually help repair the dysfunctional parts of their brains. At times, Karuna's VR program

exaggerates bodily movements, so patients see themselves moving more extensively in the virtual world than in actuality. This further disrupts their brain's predictive coding, or what they expect to happen when they move. If the brain predicts that an action will be painful, then it's going to send that threat signal out ahead of time, Nguyen says.

But if people experience themselves maneuvering more easily and with greater range in VR, then their brains may begin to recognize that increased movement as safe, and, Nguyen hopes, eventually pleasurable. To that end, patients also score points, accompanied by lights and dings, as in video games, in order to activate the reward centers in their brains. We're not trying to turn you into a zombie that doesn't experience pain, Nguyen says. But at some point,

the brain has gotten so good at making this pain signal, it's very vigilant, constantly looking for danger signals. There's no point in developing a technology just because it's cool, says Leonardo Angelone, who heads a program at the National Institute on Drug Abuse that oversees, among other things, FDA-regulated medical devices. If VR therapy companies can't get their products onto patients' heads,

it doesn't matter what the machinery can do. That means a lot of people, would-be individual users as well as decision makers in the broader healthcare industry, will need to have confidence in the technology. When Carol Danen heard about VR as a therapy for chronic pain, she thought she would laugh in the doctor's face if they gave this BS. Danen has struggled with chronic pain for more than 15 years, following a series of dislocations of her kneecap. The pain spread until eventually she was diagnosed with fibromyalgia.

She is 50 and has had 28 operations. She takes opioids around the clock, as well as several other medications to dampen her symptoms After she tried physical therapy she was so exhausted that she slept for 10 days setting her alarm to wake her every few hours to take her pills When you're in a full flare

and you're rocking and crying into sleep in bed and your pain meds don't work virtual reality is not going to do squat, Danen says. A tech-driven solution like VR can seem insulting to someone who feels that she has tried it all. To see someone say,

oh, we'll give you VR and teach you to regulate your breathing. I'm like, didn't you think I tried that already? Other skeptical reactions include preferences for the convenience of pills over the encumbrance of headsets, or fears that the widespread prescribing of VR will mean losing access to painkillers. Nicole Hemingway, the chief executive of the U.S. Pain Foundation, views VR favorably. The more tools available, the better. But she recognizes that chronic pain patients,

who may feel that they have long been ignored by the medical community, now also face stigma and restrictions in response to the opioid epidemic. There is always a fear that something else might come in the way of the treatment you're currently on, Hemenway says. Of course, this assumes that medical providers will eventually embrace the technology. When I visited Cedars-Sinai, Spiegel had not yet been able to get the ER staff there to adopt virtual reality.

I wasn't surprised. The ER can be crushingly busy, and it's a place where expensive medical equipment often gets damaged or lost. Any extra bedside therapy feels like a significant burden in a system that is already overwhelmed. In this setting, VR seems to be one more time-consuming fantasy. Even in less intense circumstances, some doctors worry VR could exclude those who

don't speak English or who are disadvantaged and unable to get the latest technology. In applied VR's study of lower back pain, nearly all the participants were white and had at least some college education. If doctors do start prescribing VR, there's another hurdle to clear. Who will pay for it? Affordable access to VR is Hemingway's biggest worry about the future of the technology. FDA clearance is most likely necessary for the widespread adoption of any VR product. A spokesperson for one major insurer told me that the company wouldn't even consider reimbursement without the FDA's authorization. Payers also want to see clinical trials demonstrating efficacy and economic analyses showing that VR can save money by keeping patients out of the hospital and cutting down on expensive tests and treatments. This is one reason Applied VR says it prioritizes conducting studies.

Though Reliever has been authorized by the FDA, insurers still don't have to cover its cost. The company hopes that by packaging it as a single product, one that combines software and hardware, its resemblance to traditional medical equipment will lead to its acceptance by the Centers for Medicare and Medicaid Services, which currently does not cover VR services. That could change soon. In February, the CMS approved a code for FDA-cleared software for behavioral therapy, and a code is usually needed before reimbursement is considered. A month later, a bill was introduced in Congress

that would push Medicare to cover prescription digital therapeutics. Private insurers determine their own policies, but the CMS tends to set the standards. Applied VR decided early on that if its product is going to be used like a drug or a device, it needs to function within the current health coverage environment. It needs to be prescribed by doctors and paid for by insurance, Sackman says, or else this will be on the fringes for people who can afford cash pay or believe in alternative medicine. Workers' compensation insurers,

which have strong incentives to help patients return to their jobs, already provide reimbursements to Karuna, as does the Department of Veterans Affairs. Weinberg, Karuna's chief operating officer, is hoping to persuade companies to include Karuna in their benefit packages soon. The healthcare system has been slow to fully buy into VR because it's so new, Nguyen says. But our way in is, just try it out. What do you have to lose? You tried everything else.

In January, as COVID cases soared again, a man in his late 50s with chronic back pain came into the ER where I work. His painkillers were no longer providing relief. He was unsure if they ever really helped. But everything seemed worse now, he said. He had been unable to travel. He was stuck in his apartment, in pain. His doctor's appointments scrambled with each pandemic surge.

I told him all I could do was order a different formulation of one of his medicines a desperate and often useless step that doctors take when trying to alleviate chronic pain but he had come with an idea of his own have you heard of people using virtual reality for pain? he asked me eagerly how can I get that?