Can Virtual Reality treat Chronic Pain? | 24
Virtual Reality Cognitive-Behavioral-Therapy holds great promise for "curing" fibromyalgia, but a few challenges stand in the way...
My mom has fibromyalgia (a chronic pain disorder), which led to me trying to understand more about the illness. While doing this, something that really piqued my interest was how some companies were using virtual reality as a way to alleviate the pain and its symptoms. I wrote this article to learn more about fibromyalgia and the possibilities and challenges that come with trying to treat it using VR.
I hope you enjoy reading this and learn a little more about this topic along the way!
I. Understanding the Problem
What is Fibromyalgia
You know that feeling when there’s a knot in your shoulder and you have no clue what to do? You don’t know how to stretch it out or how to make it go away. It just sits there, bringing an aching feeling that comes in waves, over and over again. Now try to multiply that by ten and imagine that you feel this all over sporadic locations in your body. You never know when it’s going to arrive, or how long it’s going to stay. All you know is that it has a few favorite spots and you’ve lived with it for far longer than you can remember. This is just an inkling of what it feels like to have fibromyalgia. Over 500 million people worldwide suffer from this illness, and even celebrities that you know suffer from it too.
Fibromyalgia is a condition that can leave people feeling stiff and sore unexplainably, with aching joints, sore muscles, and tendons that trigger widespread pain. This constant feeling of discomfort and chronic pain comes with psychological challenges as well, with symptoms of anxiety and depression added into this blender of debilitating conditions1 . As if that’s not enough, other symptoms of fibromyalgia include:
brain fog
PMS (premenstrual syndrome)
painful menstruation periods
restless sleep
inexplicable fatigue
irritable bowel syndrome
sensitivity to touch, light, and sound
Not a joy, and certainly not fun. Lots of people who suffer from fibromyalgia find their condition to be extremely demoralizing and devastating. But where does fibromyalgia actually come from and why does it occur?
🧪 The Science Behind Fibromyalgia
The curious thing about fibromyalgia, and what makes this disease so interesting is that there’s no tissue damage. None! This means that contemporary medicine struggles heavily to treat (and even in certain cases, accept) an illness where pains seem to be rooted in the mind or brain rather than a bodily injury.
The culprit causing these symptoms is most likely the body’s pain system–– which is also called the “nociceptive system”. It becomes high-strung, firing electrical signals left and right in the patient when fibromyalgia is present. This guarantees that the person experiences a much higher intensity of pain than the average person. This state of increased pain sensitivity is dubbed “central sensitization.” Injury or pain can cause sensitization meaning that the nerves that send pain signals fire more easily and at inappropriate times. Interestingly, these misfirings happen more within the peripheral nervous system (ie. the nerves outside of the brain and spinal cord).
To add to this, people who struggle with fibromyalgia also undergo changes to their overall brain structure, which sometimes leads to pain at rest. Changes to neurotransmitter levels, the molecules in the body that lessen pain, and the nerve fibers associated with pain have been recorded by numerous studies about fibromyalgia.
Whew, all this talk about pain can be exhausting, but it pales in comparison to the constant fatigue that people with fibromyalgia must endure. Imagine feeling all this pain, and then having some people question whether this pain is even real! Thankfully, technology has progressed far enough that statements like this can be easily dismissed: with studies proving how fibromyalgia exists through machine learning and AI, as well as experts in the pain field validating and confirming its existence.
“There’s not much uncertainty among people in the pain field who read this literature,” says Daniel Clauw, a professor at the University of Michigan and director of the school’s Chronic Pain and Fatigue Research Center. “But in the general medical field there are still providers who don’t understand it or think it’s real.”
— https://qz.com/1349854/ai-can-spot-the-pain-from-a-disease-some-doctors-still-think-is-fake
Who is affected by Fibromyalgia + Why is solving it such an important problem?
→ Fibromyalgia affects about 4 million US adults, about 2% of the adult population.
→ Fibromyalgia has a worldwide presence affecting nearly 1 in 20 people globally.
1 in 20 people worldwide amounts to about 500 million people worldwide experiencing debilitating pain daily.
What’s even more interesting is that the ratio of people who suffer from fibromyalgia is much higher in women than in men. Although men may be affected by this condition, women are seen to be 7 times more likely to develop fibromyalgia.
Recognition, education, and stigma are also worse with functional diseases in many poorer countries, meaning that many people from lower-income backgrounds simply accept pain and discomfort (like the pain that comes from Fibromyalgia) as normal in their everyday lives.
II. The Problems with Current Fibromyalgia Cures
How is Fibromyalgia currently treated?
Besides recommendations and suggestions for improving mood and pain sensitivity through gentle exercise, a healthier diet, and promoting overall well-being, currently, fibromyalgia is primarily treated with medication (ex. opioids, antidepressants, muscle relaxants etc,) Cognitive Behavioral Therapy (CBT), and talk-therapy.
Other common approaches to managing symptoms include:
mindfulness practices
nutrition changes like switching to an anti-inflammatory plant-based diet
medical cannabis and cannabidiol (CBD)
💊 The Issues with Medication
Currently, only pregabalin, duloxetine, and milnacipran are FDA-approved for use specifically as fibromyalgia treatments. Sometimes, other opioids, antidepressants, and painkillers2 are also prescribed which leads to chronic fibromyalgia patients typically taking more medication than the average patient.
Studies suggest that for some people living with fibromyalgia, the medications either didn’t provide relief or were stopped due to side effects3 These side effects include weight gain, swelling, dizziness, and drowsiness, among others. Both duloxetine and milnacipran have been known to cause nausea, drowsiness, dry mouth
Doctors are hesitant to prescribe medication as a form of treatment for fibromyalgia patients for this reason
“Both physicians and patients should have realistic expectations about the potential benefit of these drugs,” says Winfried Häuser, MD, an associate professor of psychosomatic medicine at the Klinikum Saarbrucken in Germany. “Although patients may initially experience symptom relief with good tolerance, the majority will ultimately discontinue therapy because of inadequate response or unacceptable side effects.”
“Even though I have had a few patients experience modest benefits from them, I rarely prescribe these medications,” says Robert Keenan, MD, MPH, an assistant professor of rheumatology at Duke University School of Medicine. “Many of my patients experience significant weight gain and other side effects that counteract any benefit they might see otherwise.” The issues with Talk Therapy— athritis.org
The Issues with Cognitive Behavioral Therapy
A Brief Introduction to CBT
When it comes to chronic pain, the theory behind Cognitive Behavioral Therapy (CBT) is that if you can change the way you think, you can change the way you respond to what’s physically happening in your body. You’re essentially learning new strategies to manage your discomfort by shifting your focus and perspective, even if the pain doesn’t go away.
CBT may actually lead to a physical change in the way certain pain receptors (nociceptors) respond to stimuli, which leads to a reduction in the amount of pain that people experience.4
🔎 The issue is that with current CBT methods is that…
You get CBT of varying quality: Some CBT practitioners rely more on behavioral interventions, making the treatment variable from one practitioner to the next
It can be time-consuming and expensive. In general, CBT sessions can range from $100 to $200 per session, and a typical course of treatment may involve 8 to 12 sessions5
It requires a motivated and committed patient.
It may not be effective for all types of pain6
Though it’s been seen to improve the fibromyalgia of many, CBT doesn’t work on every single fibromyalgia patient.
There is no one-size-fits-all approach to treating Fibromyalgia…
Treating fibromyalgia usually requires a combination of changes in lifestyle, CBT, and, in extreme cases, medication.
“Drugs alone are not sufficient,” Dr. Gota says. “You have to look at the whole patient and combine treatment with aerobic exercise and a comprehensive approach that includes cognitive-behavioral therapy and occupational therapy.”
III. A Possible Cure to Fibromyalgia: Virtual Reality
VR-CBT (Virtual-reality-assisted Cognitive Behavioral Therapy) for Fibromyalgia
In this scenario, Virtual Reality and its ability to hyperstimulate the brain and whisk the user into a different world and far away from their current reality turns out to be a positive trait. If you’ve tried a VR headset on before, you know just how immersive and realistic it can be and seem. If you’ve never tried a VR headset on before, just watch these videos and see how immersive VR can trick people into thinking that what they’re experiencing is the real thing.
Over 2000 studies and 30 years of research have shown how immersive virtual reality (VR) can significantly reduce pain-related brain activity by simultaneously modulating key areas of the brain related to pain (emotional, cognitive, experiential, behavioral, and sensory).7 Virtual reality has been used for many years to treat acute pain–– for instance, for young children after in-patient medical procedures due to this successful immersive phenomenon
Now, while VR has typically worked very well by distracting patients from their pain, VR-CBT helps people with chronic pain by teaching them to self-regulate outside the headset. Cognitive Behavioral Therapy by itself has been known to be extremely helpful when treating fibromyalgia, so in theory, VR-CBT could result in a more immersive and successful extension of this phenomenon. VR-CBT could also address clinical challenges around cost and accessibility as well as potentially reduce the need for opioids.
How exactly does VR-CBT work?
CBT for Fibromyalgia Syndrome (FMS) usually involves three phases:
Education: This phase involves ensuring the patient knows the facts about the condition rather than inaccurate or conflicting information that is common with Fibromyalgia Syndrome (FMS). This includes the possible causes, things that help sustain the illness, and how important it is for the patient to be actively involved in the treatment process. This phase can also include specific skills to help you learn how to adapt to life with FMS.
CBT skill sets: This phase focuses on giving you skills for reducing pain. These may include relaxation techniques; graded-activation, which helps you gradually increase activity levels while avoiding the "push-crash" cycle that's common in FMS; improving sleep habits; changing thoughts about pain; and dealing with other functional or emotional aspects of living with chronic illness.
Real-life application of skills: This helps you apply what you've learned in the day-to-day realities you face. It typically involves homework assignments focused on the skills from phase 2, and allows them to be tailored to your specific needs.
VR-CBT provides treatment based on these cognitive behavioral therapy skills and other evidence-based behavioral methods for patients. This immersive VR experience helps patients learn skills that modulate multiple brain systems. VR-CBT builds upon these phenomenons to induce neuroplasticity, modulating neural regions associated with pain for long-lasting change.
A Virtual Reality version of Cognitive Behavioral Therapy can lead to a more enjoyable and sustainable therapy practice as well. People who have fibromyalgia might even look forward to playing games that promote their physical and psychological well-being. If you’ve ever played a VR game, you know just how enjoyable it can be.
📝 Evidence supporting VR-CBT
Multiple papers show how the use of VR-CBT has better results when compared to audio-only CBT. For example, a study was conducted where 97 adults between 18- and 75-years-old (67% male) with self-reported low back pain (LBP or fibromyalgia were randomly assigned to one of two unblinded groups. The program consisted of 21 days of four to eight sessions (either VR or audio only) lasting from 1 to 15 minutes.
………. The results?
🔎 Pain scores were reduced significantly over time with results strengthening after two weeks. Although both groups experienced a reduction in all measures of pain, the effect was stronger in the VR group, particularly over time. Patients in the VR group reported >30% reduction in pain intensity and a 37% reduction in pain interference measures. These improvements strengthened over the course of treatment.
Because both groups received the same treatment program – only the presentation format differed, Dr. Darnall from Stanford University concludes:
“We were able to demonstrate that VR had greater analgesic benefit and was superior in reducing pain-related interference to the exact same treatment delivered in a different form. It was a very high bar to exceed.”
Using VR as a treatment for fibromyalgia has also shown promising results in several studies, including:
One study by Won et al. (2017) explored the use of immersive VR for pediatric pain and found that it can be effective in reducing pain.
Another study by Pourmand et al. (2018) reviewed the application of VR therapies for pain management and found that VR can be beneficial for various acute and chronic pain conditions, including fibromyalgia.
In addition to pain management, VR has also been found to improve mobility and balance in fibromyalgia patients. Collado-Mateo et al. Ahern et al. (2020) conducted a study on adult fibromyalgia patients and found that a combined program of physical exercise and non-immersive VR improved their mobility, balance, and fear of falling. Furthermore, VR has shown potential in improving outcomes for spinal pain, which is often associated with fibromyalgia.
Byra & Czernicki (2020) conducted a systematic review and meta-analysis on the effectiveness of VR in patients with spinal pain and found that VR can lead to improvements in pain intensity, disability, fear of movement, patient satisfaction, and general health status.
Other studies have also reported positive effects of VR on fibromyalgia patients. Wiederhold et al. (2014) found that using VR rehabilitation can increase muscular strength in women with fibromyalgia. Adler-Neal & Zeidan (2017) conducted a pilot study on the long-term effects of VR therapy for fibromyalgia and found promising results.
It’s also important to mention, however, that though VR has shown potential as a treatment for fibromyalgia, it it is not the only approach. Mind-body techniques, such as mindfulness meditation, have also been found to be effective in treating fibromyalgia (Sephton et al., 2007; Chen et al., 2017). Because of this, a question that also really spikes my curiosity is: What could happen if we started using VR-based mind-body techniques and integrated mindfulness meditation into a VR experience?
In conclusion, VR-CBT looks like a really promising solution to help cure Fibromyalgia. But, if it’s so successful, why hasn’t it been widely implemented yet?
Main Problems with VR-CBT
1. Cost 💵
Some companies, like RelieVRx deliver VR content while incorporating biopsychosocial pain education, diaphragmatic breathing training, mindfulness exercises, relaxation exercises, and executive functioning games. But.. all of this comes at a pretty hefty price.
The standard package costs $2,588
The premium one costs $3,700
Other companies, like XR Health also use VR to treat Fibromyalgia (their company also incorporates biofeedback technology), and they offer this service to patients on a subscription model that costs around $276 to $476 per month.
These are also considered to be the most affordable and budget-friendly options. Costs increase significantly as patients start to explore more expensive alternatives. Hunter Hoffman, director of the virtual reality research center at the University of Washington’s Human Photonics Laboratory and a developer of a pain control game called SnowWorld, says the VR equipment he’s using as part of an intensive care unit pain-relief study costs $35,000. (Yikes!)
2. Lack of Studies 📚🚫
Studies on VR-CBT for fibromyalgia are simply too rare. This makes it difficult to give specific recommendations for certain timings and frequency of interventions.
A. We need more investigation into the neural mechanisms of this disorder
Studies have stated the need for further understanding of the impact of VR-CBT on the disorder. Understanding the neural mechanisms is crucial to properly studying the underlying causes and pathways involved in fibromyalgia, which can inform the development and optimization of VR-CBT interventions.
B. We need more data about the dropoff rate and long-term viability
The dropoff rate and long-term viability of VR-CBT for fibromyalgia are incredibly important considerations in the development and implementation of this therapeutic approach. Long-term studies are vital to determine if the benefits of VR-CBT persist over time or if any potential side effects or diminishing effects become evident. Evaluating the long-term viability of this treatment approach will be incredibly important as the technology matures to ensure that it continues to provide relief and support for fibromyalgia patients well beyond the initial stages of treatment.
C. Lack of including marginalized communities in VR studies
An interesting study I found showed that…. even if marginalized population groups are offered VR, the technology is currently designed to cater towards the usability and content relevancy needs of white patients with higher income. The study shone some light on the fact that only 2 studies included a significant percentage of racially marginalized patients8 despite their lower likelihood to be prescribed analgesics or more likely to be given lower chronic pain medication dosages compared to White patients9
How do we solve these problems, and what are the larger-scale implications of doing so?
→ VRCBT will become more accessible alongside normal VR
As VR becomes more and more accessible (just as phones and laptops have become for us today), more people will hopefully be able to access VR-CBT and reduce their symptoms of chronic pain
→ Brain-Computer Interfaces x Virtual Reality
A gripping vision of the future arises when we consider the possibility of merging AR/VR technology with BCIs to increase the immersiveness of AR/VR and improve the usability of BCIs for rehabilitation and control. Many of the current papers exploring this topic use custom AR/VR environments and solutions to set up sensors, input devices, and displays (check out (Putze, 2019) for an overview of emerging methods and tools and (Si-Mohammed et al., 2017) for a general overview of potential applications and main scientific challenges related to the combination of AR and BCI).
Perhaps future research that integrates these two fields can build on this pioneering work and the resulting best practices to derive more standardized, common experiment protocols for a large variety of research questions. One of which, of course, involves understanding the neural mechanisms behind fibromyalgia and the impacts that VR-CBT has on its symptoms.
Other integrations of BCI and VR that interest me include:
BrainCo’s neurofeedback technology helps with modulating the brain’s response to emotions and assists with keeping focus along with regulating emotions, performance, and behavior. Perhaps this could be implemented alongside VR-CBT for a more enhanced version of long-term neurofeedback loop therapy.
ApolloNeuro uses vibrations to rebalance the nervous system, stimulating the parasympathetic nervous system so that the users feel calmer and more in control. Perhaps this treatment can be extended towards fibromyalgia and used alongside VR for an incredibly interactive form of relief-therapy against fibromyalgia.
→ VR-CBT’s crossover into outside fibromyalgia treatment and its significance towards other mental health issues
Cognitive-Behavioral Therapy (CBT) is known to be able to treat various mental health issues, including depression, anxiety disorders, PTSD, OCD, eating disorders, and more. Since this is the case, then improvements in Virtual Reality CBT (VR-CBT) can greatly enhance mental health tech too! It can do this by increasing engagement and making therapy more interactive, enabling controlled exposure therapy in realistic virtual environments, extending accessibility through remote delivery, offering personalized treatment approaches, and allowing data-driven adaptation for individual progress. VR-CBT has the potential to dramatically increase the quality of mental health care and outcomes across a wide range of conditions, hopefully making various forms of therapy more engaging and accessible in the future.
Conclusion
Virtual Reality based Cognitive Behavioral Therapy seems to hold much promise for the possibility of curing fibromyalgia (and making hundreds of millions of people’s lives better). Currently, the main prohibiting factor for this is cost.
I believe that the cost of VR headsets will eventually go down drastically sooner or later (just as mobile devices and personal computers have), and that this technology will eventually be in most people’s hands given enough time. However, till then, I hypothesize that for this particular type of technology, “raising the ceiling instead of the floor” could contribute most to furthering its cause.
We can do this by conducting more studies to investigate the neural mechanisms behind VR and how it affects fibromyalgia and optimizing VR-CBT through the information we gather from these studies. We should also explore avenues like vagus nerve stimulation, neuromodulation, and mindfulness techniques to see whether any of these other successful technological advancements can be used alongside VR for enhanced results in pain reduction.
As technology progresses, there has to be a way to cure and alleviate the needless suffering of hundreds of millions of people across the world.VR-CBT is a step towards solving this problem and hopefully, innovation in the treatment of fibromyalgia accelerates and helps solve the challenges within the field to make this solution a reality. Too many people learn to live with chronic pain every single day.
https://www.cdc.gov/arthritis/basics/fibromyalgia.htm
Analgesics, including tramadol (Ultracet, Ultram)
Muscle relaxants, such as cylobenzaprine (Cycloflex, Flexeril)
Fatigue medications, such as modafinil (Provigil)
https://www.arthritis.org/diseases/more-about/fibromyalgia-medications-are-not-a-cure-all
Lazaridou A, Kim J, Cahalan CM, et al. Effects of cognitive-behavioral therapy (CBT) on brain connectivity supporting catastrophizing in fibromyalgia.
https://scite.ai/reports/cognitive-behavioral-therapy-for-individuals-with-14NdzX
Eccleston, C., Crombez, G., & Williams, A. (2006). Psychological therapies for chronic pain. The Cochrane Database of Systematic Reviews, 3, CD003968.
Dascal J, Reid M, Ishak WW, et al. Virtual reality and medical inpatients: a systematic review of randomized, controlled trials. Innov Clin Neurosci. 2017;14(1–2):14–21.
Hoffman HG, Richards TL, Coda B, et al. Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI. Neuroreport. 2004;15(8):1245-1248. doi: 10.1097/01.wnr.0000127826.73576.91
Hoffman HG, Patterson DR, Carrougher GJ, Sharar SR. Effectiveness of virtual reality-based pain control with multiple treatments. Clin J Pain. 2001;17(3):229-235. doi:10.1097/00002508-200109000-00007
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10282907/#ref60
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10282907/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10282907/#ref16