On a particularly stressful November day three years ago, Erin Martucci found herself on a beach with waves lapping up against a sandy coastline, birds flying overhead and a calming voice guiding her through breathing exercises.
Just minutes before, she was on a hospital bed experiencing painful contractions that threatened her commitment to having an epidural-free birth.
“When we got to the hospital though, I was wavering and thinking ‘Can I do this or can I not?’” recalled Martucci in a recent interview.
She ended up using a virtual reality experience — a term she had barely heard of before — for two hours before being jarred out of the idyllic environment by her doctor. It was time to deliver her baby. While aware of her body, the technology made the pain bearable and seemed to magically narrow the timeframe she was actually in labor, Martucci said. This phenomenon is known as time contraction in the VR world.
“I had no idea that I had worn it as long as I did and that I had progressed through the stages of labor and it was time to push,” Martucci said. “It definitely suited its purpose in helping me have a medical-free birth and we had a beautiful experience.”
She is currently pregnant with her third child and plans to go into the delivery room again armed with a VR headset.
Martucci is just one of thousands of patients who have used digital-based VR therapies in medical situations like labor, burns, blood draws and IV insertions. Startups and providers are developing the evidence to apply the technology in clinical settings and try and win reimbursement.
Early studies into the use of VR as a potential pain therapy and surgery training tool dates back to the 1990s, but widespread adoption was hampered by bulky systems that were too expensive and difficult-to-use outside of a research setting. In the past few years, however, a number of consumer friendly devices developed by companies like Oculus, Samsung and HTC have entered the market, reigniting interest in the use of VR for clinical applications. New research and investment are also fueling the field.
But while a clinical evidence base continues to grow supporting VR’s use in healthcare, industry leaders face the unenviable challenge of integrating the emerging technology into the healthcare system.
Mapping out the VR pharmacy
The first time Dr. Brennan Spiegel used a VR headset, he died virtually by jumping off a window-washing rig, elevated high over a sprawling cityscape. The anecdote provides an unlikely origin story for someone who has become one of the leading evangelists for the technology’s use in healthcare.
The terrifying experience was able to crystallize an understanding of VR’s potential to shift a person’s mental state even in the relative safety of a carpeted conference room.
“We’ve never evolutionarily had a requirement to live in two realities at once; we just take for granted the reality that we’re in,” said Spiegel, the director of health services research at Cedars-Sinai in Los Angeles. “My whole reaction was that if we can use this for evil, we must be able to use this for good.”
As an organizing framework for thinking about the future of the technology, Spiegel has proposed an evidence-based VRx or a virtual reality pharmacy that classifies the digital therapies into a few large therapeutic buckets.
Two of the categories he posits are high exteroception — where too much attention is paid to the outside world as in anxiety or phobia — and high intraception, where too much attention is being turned inward as in the case of chronic pain or IBS. Virtual reality can be used in exposure therapy to combat phobias or as a distraction tool in helping people dampen the problem of chronic pain.
On the opposite end of the spectrum is low extraception and low interoception, where there’s a detachment to the outside world as in the case of schizophrenia, or a disconnection to the inner body like with patients suffering from eating disorders or recovering from stroke. By modifying the experienced world through VR, the theory is that the technology can get people back in touch with the reality around themselves or enhance healthy body attention.
Since 2016, Cedars Sinai has used VR technology on more than 3,000 patients and conducted studies showing the tool’s positive effects on managing pain and its potential cost savings through shorter hospital stays.
The hospital held the second iteration of its Virtual Medicine symposium to a sold out crowd earlier this year pointing to the growing enthusiasm for the field.
“I can say it was the first time in my life that I’ve gone to an academic conference where people were scalping for tickets,” Spiegel said, chuckling.
Not surprisingly, a raft of startups has sprung up to commercialize VR therapies for patients. Spiegel estimates that over 5,000 papers have been published exploring the connection between virtual reality and healthcare. That proliferation requires a framework to evaluate and validate new therapeutics.
He helped to form VR-CORE, an international working group, which has created a modified three-phase structure to research and develop clinical VR therapies that mirrors the clinical trial structure used by the FDA.
The model — which was published in JMIR — focuses on content development in coordination with patients and providers before moving to initial feasibility, acceptability and tolerability tests, and finally to a third stage of randomized controlled trials.
Putting the mind at ease
Pain management remains the most highly researched and common clinical use case for VR in healthcare. The science behind the VR’s analgesic effects are not completely understood, but researchers have discovered the technology dampens both physical and emotional brain response to pain by creating what is known as “inattentional blindness” and time contraction through distraction.
VR pain management has focused on acute pain settings like in labor and delivery or for burn victims, who suffer through an extremely painful healing and wound care process. One experience developed by researchers at the University of Washington known as SnowWorld puts burn victims in an icy and wintry scene and arms them with snowballs to launch at targets leading to 35 to 50 percent less pain for users.
Increasingly though, a focus for VR has been chronic pain. That trend line has been driven in part by concerns about the opioid epidemic killing more than 40,000 Americans annually and driving billions of dollars in additional healthcare costs.
Bob Jester believes he could have been well on the way towards being a statistic if not for VR.
Jester, a volunteer firefighter, chimney sweep and retired science teacher, was climbing up to work on a roof when he fell and landed on a concrete slab, breaking 19 bones and severely damaging his spine in 2016.
The next few weeks were a whirlwind of hospital stays and emergency surgeries that left him numb from the waist down. Gregarious by nature, Jester found himself beset with dark thoughts and waves of crippling pain, only relieved by opioids that muted his personality and sense of humor.
Somewhat by chance, Jester was introduced to an employee at AppliedVR, a Los Angeles startup, which makes VR experiences. Neither Martucci nor Jester are paid by AppliedVR, but have provided feedback to inform product development.
Putting on the VR headset teleported him out of his wheelchair and into the ocean with a school of swimming dolphins or on a ranch surrounded by curious cows, making it possible for him to weather his bouts of pain. Using the technology, Jester was able to wean himself off the drugs and has been opioid-free for the past year-and-a-half.
“It felt like I was drowning, but just before you take your final breath someone brings you back up to air. That was what AppliedVR did for me,” Jester said. “It didn’t solve all my problems, but it gave me the tools to deal with the pain and opioids I was taking.”
San Francisco-based Karuna Labs is another company using VR in chronic pain by working to reconnect the brain to physical movement.
“There’s a big distinction between acute pain and chronic pain,” said Jon Weinberg, the chief operating officer of the company. “Acute pain is the body’s alarm system, but chronic pain is more like a broken record. It’s a product of your brain kind of rewiring itself to recreate this pain because the original stimulus was so severe.”
The company offers a number of modules to help ease neuropathic pain and assist with stroke rehab including VR-enabled mirror box therapy that helps to alleviate phantom limb pain and help to enhance movement by reflecting the pain free side of the body to look like the impaired part of the body.
But the immediate demand is for finding solutions to the opioid crisis.
“Every provider without exception that we speak to talks about the opioid epidemic and the pressure on them to find new modalities to treat chronic pain,” Weinberg said. “There’s been a big push to address the three pronged parts of chronic pain: the biological aspect, the psychological aspect and the social aspect.”
Jester agreed, stressing the mental health benefits that VR can provide.
“Where I go to physical therapy there are people lying in their bed or sitting in their wheelchair in one spot for most of the day,” he said. “VR can set you free for a while by giving you that little bit of freedom to go out and explore a different place.”
Not all fun and games
For all of its benefits, VR has its own side effects despite not being a physical drug. For instance, cyber sickness was an initial hurdle to overcome because users experienced nausea or dizziness while in motion virtually. That problem has been lessened by improvements in latency and features that allow users to “jump” around to different locations instead of walking.
Now, another important aspect to examine is the potential for dependency, especially as the solution has been positioned as an alternative to addictive drugs. Interactive experiences like video games can be hard to turn off, and the World Health Organization officially classified “gaming addiction” as an illness earlier this year.
However, experts in clinical VR say when used as a therapy, VR hasn’t statistically shown to be lead to dependence or abuse.
“In wondering about the dark side of VR, people sometimes start thinking about Ready Player One or the Matrix. But from a healthcare perspective we’ve found that people don’t love to spend an extended time in VR,” Spiegel said. “We want people to spend just enough time in VR to learn something about their mind and their body that they hopefully can take with them into real reality and have a stronger ability to govern their mind and body, just like mindful meditation or other types of cognitive behavioral therapy.”
If that is difficult, VR companies can also mimic the gaming industry tactic of locking out users for a certain amount of time or reward time away from the device, said Matthew Stoudt, AppliedVR’s CEO.
Making the jump from the lab to the bedside
How can the tech move from research studies to actual clinical practice? There are several things to consider, chief among them being economic value to a buyer.
“We really need to prioritize those ideas where there’s an actual value in which an insurance company, a hospital system, a pharma company or whoever is going to write a check consistently. Not just for a research trial, but to actually implement it,” said Omkar Kulkarni, chief innovation officer, Children’s Hospital Los Angeles.
The Children’s Hospital Los Angeles has been experimenting with VR for more than a decade, using the technology to provide pain and anxiety relief for its pediatric patients and train providers in pediatric emergency scenarios.
Two high-need cases Kulkarni pointed to were using the technology as a pain therapy to reduce medication costs and healthcare spending due to opioid overuse, as well as helping to supplement overstretched mental health providers through VR-enabled cognitive behavioral therapy.
Some institutions are already working to develop that evidence for reimbursement.
For example, the clinical trial started by Cedars-Sinai, Samsung Electronics America, Bayer, AppliedVR and insurance company Travelers to test a VR therapy for managing acute orthopedic pain, in conjunction with a Samsung wearable and a TENS device made by Bayer.
“It helped us to understand the disparate needs of different groups and how to create a win-win so everyone is able to walk away with something,” Stoudt said. “I think the biggest challenges for any digital therapeutic is to think about the ecosystem as a whole and make sure you’re thinking about the health economics angle.”
The other piece is the regulatory go-ahead that would boost the reimbursement argument. At present, no VR clinical therapy has received FDA clearance.
“It’s incredibly important that we elevate the way that both the patient and doctor perceives this to being a serious medical device,” Stoudt said. “In order for this to be successful you’ve got to have to have clinical evidence behind it, you’ve got to have doctors prescribing it and you’ve got to be integrated into the EMR.”
Then, there is the issue of workflow integration that is key to ensure that VR is considered part of the clinical continuum of care and to resist siloing the technology, experts say. Further downstream are operational issues like performing effective infection control on the hardware, developing easy charging methods and modifying headsets for specific patient populations.
But adoption of VR in clinical settings is ultimately a cultural issue. As younger doctors enter healthcare, they may be more amenable to seeing VR as part of the standard clinical toolkit.
Spiegel predicts that healthcare will have virtual specialists who will concentrate on using digital tools in medicine and understand the technology and its intersection with psychology, medicine and computer science.
“Look at radiation oncology. That’s a whole specialty that developed when we figured out that radiation helps with tumors,” Spiegel said. “We’re starting to learn whether, when and how to use (VR) and it’s getting complicated. It’s not just turn on a headset and see what happens anymore.”
Picture: exdez, Getty Images