Virtual Reality Therapy Is Feasible for Rheumatology Patients

whiteMocca / shutterstock.com

A recent pilot study explores the feasibility of virtual reality-based pain interventions for people with rheumatic con­ditions.¹ Although the work is in its early stages, it may someday represent a new non-pharmacological tool for patients with chronic pain.

VR for Treatment

R. Swamy Venuturupalli, MD, FACR, is an associate clinical professor of medicine at the David Geffen School of Medicine, University of California, Los Angeles, and a practicing rheumatologist at Cedars Sinai Medical Center. He is the first author of “Virtual Reality-Based Biofeedback and Guided Meditation in Rheumatology: A Pilot Study.”¹

Virtual reality (VR) uses a combination of technologies, such as head-mounted displays, headphones and specially designed software, to create compelling sensations of an alternate, interactive environment in three-dimensional space. “The premise is that each person experiencing VR is placed into an immersive environment in which the brain, in a sense, can get hijacked to believe that what is being perceived in that virtual environment is, in fact, real,” Dr. Venuturupalli explains. 

Different software for VR systems can be used to create different types of experiences. For example, some programs can take patients through a meditative mindfulness VR experience. Mindfulness meditation practices in non-VR settings have been shown to have positive psychological impacts for some patients with chronic pain.²

Similarly, VR platforms can be used to take patients through biofeedback sessions, helping them learn to control autonomic processes such as respiratory rate. 

“Biofeedback allows a person to get into a deep state of relaxation whereby their autonomic nervous system and parasympathetic nervous system in particular is firing at a higher rate,” explains Dr. Venuturupalli. “More parasympathetic activity results in a relaxed state with slower breathing and heart rate and has also been shown in numerous studies to modulate pain.”

Dr. Venuturupalli

VR may mediate its effects through a variety of mechanisms, partly dependent on the software used. For example, VR may reduce pain-related activity in the insula and the thalamus.³ Through engaging the person’s senses, VR modulates how nociceptive signals are perceived by an individual.⁴ Dr. Venuturupalli points out one of the advantages of using a VR platform to perform such potentially stress-reducing activities: “Even a novice who has never done biofeedback or meditation is able to achieve some of those results in an easy manner when using this technology.”

Dr. Venuturupalli notes that interest in VR as a treatment modality has expanded in the past 10 years. He adds that a fair amount of data have demonstrated the benefit for VR for acute pain episodes, for example, for burn victims having their dressings changed.⁵ However, less work has been done in chronic pain. The research team could find no studies examining VR specifically in an outpatient rheumatology setting. Dr. Venuturupalli and colleagues initiated a pilot study to gather preliminary information that might ultimately help them develop an intervention for people with rheumatic diseases.

Pilot Study

The team recruited 20 adult rheumatology patients from a private practice clinic in Los Angeles. The participants were primarily female and Caucasian. The most common diagnosis was rheumatoid arthritis, followed by lupus and fibromyalgia. All participants had active, but stable, disease. They all had some degree of ongoing pain as assessed by a score of at least 5 on the Visual Analog Scale (VAS) for at least four days of the preceding month. Most of the patients had some knowledge of VR prior to the study. Three participants were excluded due to medical conditions that might theoretically be aggravated by VR, such as vertigo.¹

All participants experienced two different VR environments: a guided meditation environment and a respiratory biofeedback environment. The latter provided interaction to help patients breathe at six breaths a minute. Some participants experienced the guided meditation environment first and others the biofeedback environment. Both modules provided immersive experiences in similar natural environments for 10–15 minutes.¹ 

The team also performed pre-VR, between VR and post-VR assessments using scales from the Patient-Reported Outcomes Measurement Information System (PROMIS), as well as the VAS. They also collected general impressions from the participants.¹

“I would say that the main finding of the study was that this intervention was very well tolerated by 100% of the patients,” says Dr. Venuturupalli. Only one participant found the device uncomfortable, though 44% said they would prefer to use a lighter device. All said they would be willing to participate in another VR study.¹

The pilot project was not powered to draw definitive conclusions about effectiveness. However, about two-thirds of participants reported positive responses to at least one of their two VR sessions, and the researchers found a statistically significant reduction in VAS scores after both types of VR modules. Most patients said they could see themselves utilizing VR for relaxation and pain reduction if it were available to them.¹

Looking Forward

Although much work remains to be done, Dr. Venuturupalli sees VR as a promising potential treatment modality that comes with very few risks. Since development of early VR systems, the technology has become less expensive, more portable and easier to use. Ultimately, Dr. Venuturupalli predicts that VR devices will become as ubiquitous as smartphones are today.

Many important research questions remain about how best to approach VR interventions. Dr. Venuturupalli points out that in addition to pain and anxiety reduction, VR may be used for instruction, such as teaching movement skills in elderly patients with osteo­arthritis. He notes that we need to learn about how best to dose VR in terms of how long and how often patients would use it, and how long the effects last. 

“What we need is some sort of virtual reality prescribing guide, where certain conditions are treated with certain kinds of protocols,” he says. “That will require a lot more research.” 

Dr. Venuturupalli notes that in addition to VR, other technologies, such as augmented reality and mixed reality, are being used for various medical purposes. Unlike VR, such technology does not place participants in a completely immersive environment. Instead, the external world is enhanced in particular ways to help patients build specific skills. 

The National Institutes of Health awarded Dr. Venuturupalli’s group a grant to study VR for back pain. The study will be led by Brennan Spiegel, MD. The team is also hoping to get more funding to research other aspects of the technology. The researchers would like to curate a library of VR programs that could target pain, anxiety, movement and sleep for patients with chronic rheumatic diseases. Rheumatologists could then prescribe specific interventions for their patients. 

“Down the road, the possible treatment interventions are innumerable,” Dr. Venuturupalli says.

For pain control, the need for new inter­ventions is more pressing than ever. As Dr. Venuturupalli points out, “The current opioid epidemic is making it necessary for the medical profession to find different ways to manage pain. But we don’t have very much guidance about what can work for our patients.” VR may represent one new potential tool in the pain treatment armamentarium.

Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine. She is a freelance medical and science writer living in Bloomington, Ind.

References

1. Venuturupalli RS, Chu T, Vicari M, et al. Virtual reality-based biofeedback and guided meditation in rheumatology: A pilot study. ACR Open Rheumatology. 2019 Nov 11;1(10): 667–675.
2. Ball EF, Nur Shafna Muhammad Sharizan E, Franklin G, Rogozińska E. Does mindfulness meditation improve chronic pain? A systematic review. Curr Opin Obstet Gynecol. 2017 Dec;29(6):359–366.
3. Hoffman HG, Richards TL, Van Oostrom T, et al. The analgesic effects of opioids and immersive virtual reality distraction: Evidence from subjective and functional brain imaging assessments. Anesth Analg. 2007 Dec;105(6):1776–1783.
4. Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: Current trends and future directions. Pain Manag. 2011 Mar;1(2):147–157. 
5. Sharar SR, Miller W, Teeley A, et al. Applications of virtual reality for pain management in burn-injured patients. Expert Rev Neurother. 2008 Nov;8(11):1667–1674.