“Can Virtual Reality Help Ease Chronic Pain?” — by Helen Ouyang, The New York Times Magazine, April 26, 2022
Would you like to take a cyberdelic to enter a special trance within a brilliant, virtual world, in which your pain can’t find a foothold? No doubt many would. Soon you might be able to.
As physician Helen Ouyang explains in a recent article in New York Times Magazine, business startups have begun to create virtual reality headsets to treat pain. By interesting coincidence, this technical development comes right on the heels of the discovery that a psychological technique, Pain Reprocessing Therapy, has been scientifically shown to cure chronic pain completely.
As they say, the world is large. One might argue about which type of treatment is better and for whom, yet I suspect that as with all treatments, it depends on the patient. I’m intrigued about the powers and limits of this new technology.
A Brief History of Pain Management
The Times article by Dr. Ouyang is well-written and does an excellent job of quickly detailing how we arrived at our present understanding of chronic pain:
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 Wall’s and 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 Woolf, 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.”
Woolf 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,” Woolf 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. 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 Woolf’s experiment. A. Vania 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.”
My clients, of course, know this emotional cloud very well. It’s this cloud, like a set of glasses that have become dirty, that we target in Pain Reprocessing Therapy. We transform that lens into a “lens of safety”.
For us as conscious beings, becoming habituated to pain is a mental and emotional, psychological process. But part of the substrate beneath those thoughts and feelings is an organic brain process that is now much better understood. As the article further explains:
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 or virtual reality — in theory could undo chronic pain.
Psychedelic vs. Cyberdelic
The pace of the use of psychedelics to treat mental illnesses such as depression and PTSD has been quickening; people can find that even a single experience, if it’s the right one, can be life-changing. The psychedelic experience itself can, in the best case, provide people with insights into their lives and concerns that last and change the nature of how they see themselves. One interesting question that arises here is whether these VR systems provide an experience, like psychedelic, or a training, or both?
The article presents a client, Julia Monterroso, with chronic back pain. She slips on a headset and as the author describes it,
Monterroso 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. [Dr.] 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.”
In this case the experience helped her process her grief, regardless of the initial intent of the session. And that — according to PRT principles — will most definitely decrease the latent distress in her nervous system that can spark and contribute to chronic pain. We also know that the brain is extraordinarily visually dominated — almost 50 percent of the cortex is involved in visual processing. So if we can commandeer the brain’s computer time with something other than pain, this is, at the very least, an extraordinary distraction technique. Which is a very necessary and useful tool in your toolbox. In some sense, VR replaces the previously conditioned production of pain sensations with new sensations related to the immersive world being experienced. That’s great, but what might the patient learn in that new space, if they were to engage in a training?
What Principles are Behind VR Pain Management Therapy ?
The virtual reality field in mental health is just on the cusp of widespread offerings. One leading company is called AppliedVR. To date they’ve raised more than $70 million in funding. Their product, RelieVRx, is soon to be on the market.
Patients’ breathing patterns can by tracked by the device in real time and the patient is given immediate feedback. The Times article quotes Todd Maddox, a cognitive neuroscientist and AppliedVR’s vice president for research and development. “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.”
So this is real-time learning spiced with a feeling of reward. It’s basically operant conditioning, following principles developed by B. F. Skinner in the 1950s, but with an interesting biofeedback twist.
My initial response to reading this is: “Wonderful, this stuff will work!” But I had the same concern as expressed in the article by University of Washington professor Hunter Hoffman, who noted, “We can definitely reduce your pain while you’re in the helmet, but you can’t stay in there all day.”
As it turns out, the average session lasts only seven minutes, and patients are directed to do just one a day for eight weeks. This is an interesting bit of information. In a short part of a session, a psychotherapist can play a role analogous to a VR headset by engaging the client’s imagination, rather than vision, during a meditative exercise. This may require a little more effort for the client and therapist initially, but the possibilities of tailoring the “imaginal world” to the client’s needs are fascinating.
How Did We Get Here?
You’ve no doubt heard about phantom-limb pain, the 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 in an injured or abnormal state. The abnormality registers as dangerous — painful.
The famous neurologist V.S. Ramachandran invented “mirror therapy” in the 1990s by placing the arm of an amputee or stroke patient into an open box with a mirror down the middle so that the patient, peering down through the top, saw the reflection of an intact, functioning arm on the affected side.
The brain was trained to see that missing limb as a healthy limb. And this — if we use the PRT understanding that pain is a danger signal sustained by fear and distress — might be why the pain could be trained away.
From Mirror Therapy to Virtual Reality Therapy
Now what if you could play a movie in the mirror, in which the patient could begin to exhibit what are, for them, special powers? With the same effort, for example, they could move much further. They could bend and twist in exquisite ways and feel no pain. They would be able to watch themselves do this, feel that they were doing this, and yet, because of the immersive power of the virtual environment they were in, where all their normal queues for pain are absent—that dreaded work chair, those familiar steps, that particular keyboard—they could have entirely new, pain-free experiences.
This is imaginal therapy based on graded motor imagery and currently being offered by San Francisco’s Karuna Labs. According to the article, 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 brains’ predictive coding — or what they expect to happen when they move.” The brain makes pain by predicting that an action will be painful, and according to CEO Lincoln Nguyen, if the brain predicts that an action will be painful, then “it’s going to send that threat signal out ahead of time.” The article concludes, “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.”
These are fascinating new technologies, and in the times we live in, solutions like pills, magic mushrooms, or VR headsets often garner more interest and dollars than a talking cure — regardless of what the science shows. It seems to me that these will be part of the future of treatment for pain. For some, the “talk” alone in the talking cure can itself melt pain away. But for most, there are skills — like somatic tracking or leaning in to positive sensations — to learn and train. These are wonderful life skills whose effects can reach far beyond merely curing pain. Some people are naturally attracted to such a path, but it’s a little like learning meditation. Some would like to learn, but others would rather take a pill if they could — and that is also fine! We will see mixes of approaches as well. Karuna Labs adds health coaches as part of their program.
There’s one other point to consider regarding virtual reality. In 2022 some may believe that people “can’t stay in there all day,” but many suspect that this is a future we are heading towards. I think it’s wise to consider our roles in encouraging and shaping that future.
My hope is that as we use these devices, they will, like cameras or musical instruments, help us to develop our own curative powers, imaginal qualities and aesthetic interests as we experiment with them. Many of us have already experienced that light and color, the imagination, as well as music, can be exceptionally soothing, even healing. What if we used these tools like training wheels to discover what is most effective for us, not only to de-condition pain, but to further explore conscious and aesthetic experience itself?