Target Health Blog

Pain Management with Virtual Reality and Video Games

May 6, 2019

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Quiz
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Young children can indicate their level of pain by pointing to the appropriate face on a children's pain scale
Graphic credit: Robert Weis - Own work, CC BY-SA 4.0,
https://commons.wikimedia.org/w/index.php?curid=39242682

Pain management, pain medicine, pain control or algiatry, is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with chronic pain. The typical pain management team includes medical practitioners, pharmacists, clinical psychologists, physiotherapists, occupational therapists, physician assistants, nurses. The team may also include other mental health specialists and massage 1) ___. Pain sometimes resolves promptly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as analgesics and (occasionally) anxiolytics. Effective management of chronic (long-term) pain, however, frequently requires the coordinated efforts of the management team.

Medicine treats injury and pathology to support and speed healing; and treats distressing symptoms such as pain to relieve suffering during treatment and healing. When a painful injury or pathology is resistant to treatment and persists, when pain persists after the injury or pathology has healed, and when medical science cannot identify the cause of pain, the task of medicine is to relieve 2) ___. Treatment approaches to chronic pain include pharmacological measures, such as analgesics, antidepressants and anticonvulsants, interventional procedures, physical therapy, physical exercise, application of ice and/or heat, and psychological measures, such as biofeedback and cognitive behavioral therapy. Pain can have many causes and there are many possible treatments for it. In the nursing profession, one common definition of pain is any problem that is “whatever the experiencing person says it is, existing whenever the experiencing person says it does“. Different sorts of pain management address different sorts of pain.

Physical medicine and rehabilitation employs diverse physical techniques such as thermal agents and electrotherapy, as well as therapeutic exercise and behavioral therapy, alone or in tandem with interventional techniques and conventional pharmacotherapy to treat pain, usually as part of an interdisciplinary or multidisciplinary 3) ___. The Center for Disease Control recommends that physical therapy and exercise can be prescribed as a positive alternative to opioids for decreasing one's pain in multiple injuries, illnesses, or diseases. This can include chronic low back pain, osteoarthritis of the hip and knee, or fibromyalgia. Exercise alone or with other rehabilitation disciplines (such as psychologically based approaches) can have a positive effect on reducing pain. In addition to improving pain, exercise also can improve one's well-being and general health. Physical activity interventions, such as tai chi, yoga and Pilates, promote harmony of the mind and body through total body awareness. These ancient practices incorporate breathing techniques, meditation and a wide variety of movements, while training the body to perform functionally by increasing strength, flexibility, and range of motion. Physical activity and exercise may improve chronic pain (pain lasting more than 12 weeks), and overall quality of life, while minimizing the need for pain medications.

A sophisticated distraction technique is being used to help patients of all ages cope with pain, both acute and chronic. The method, called Virtual Reality Therapy, goes beyond simple distraction, as might result from watching television. Rather, it totally immerses the patient in an entertaining, relaxing, interactive environment that so occupies the brain, it has no room to process pain sensations at the same time. More than a distraction, it's like an endogenous narcotic providing a physiological and chemical burst that causes you to feel good, according to the pediatric pain management clinic team, at Children's Hospital Los Angeles. It's different from reading a book or playing with a toy. It's a multisensory experience that engages a person's attention on a much deeper level.

Virtual Reality Therapy is the new tool in the kit, for pain management, now gradually growing in use as the opioid epidemic continues to soar and the price of the needed equipment has plummeted. VR, as it is called, has been most widely and successfully used so far to help children and adults weather acute pain, as can accompany an IV insertion or debridement of burns. But it can also enhance the effectiveness of established techniques like physical therapy, hypnosis and cognitive behavioral therapy to treat debilitating chronic pain. A therapist suggested that a patient try VR as part of her treatment for persistent, life-inhibiting pain following a motorcycle accident. Months after suffering a concussion and extremely painful bruising when a car struck her motorcycle, the prediction of getting better with time wasn't happening. Then the patient spent 10 or 20 minutes in a dark room while a head-mounted 3-D screen transported her to a very relaxing place, taught her about the nature of pain, how oxygen travels through the body, then how to breathe, focus on breathing, relax the body and think of nothing else. The device engages multiple senses, essentially flooding the brain with so much input that it cannot register pain signals. The usual pain messages don't get through.

As a tool for overcoming pain and fear of an injection or IV insertion, for example, children may strive to earn points by launching Nerf balls at teddy bears on one VR program. Kids may say ?When are you going to do it?' and the medical procedure has been done five minutes ago. One of the first VR programs, called SnowWorld, was designed for treating burn patients, who often say “getting their wounds cleaned is like being burned again.“ The virtual snowy environment is a stark contrast with the cause of their burns. Of course, if the treatment of persistent pain only involved virtual 4) ___, once the headset and its computerized program are removed, the pain can and would return. If a patient is taught within a virtual environment, they're more likely to retain it, engage with it and comply with what they've been taught. When they're fully immersed in a 5) ___ environment, they can't be engaged in anything else. Too often, patients with chronic pain become afraid to move, which can actually make their problem worse. Various VR programs get patients to gently exercise their injured body parts and extend their range of motion while blocking their brain's ability to register pain. Using VR as an adjunct, therapists can teach coping skills, techniques patients can use on their own that will help diminish chronic pain. Learning, itself, changes the brain and gives patients something that continues to work when they take the helmet off. When 6) ___realize their pain isn't inevitable, they're more receptive to doing physical therapy exercises and more likely to move on their own.

A University of Washington researcher who pioneered the combined use of VR and hypnosis, said that the techniques can foster mindfulness, enhancing patients' ability to come into the moment rather than pay attention to their pain. Mindfulness can train the brain not to react to thoughts or emotions associated with suffering. Pain may be inevitable, but suffering isn't. Mindfulness teaches the mind how to quiet the body and nervous system through breathing and focusing on one's breath. Thoughts may come into your head but then go out. You don't obsess about them or catastrophize. At this time, VR is not yet ready for prime time to treat chronic pain, nor should it be considered a replacement for medication. Pilot studies are underway using different kinds of VR content to help patients learn skills for managing their pain and be less quick to grab medication. With VR headsets now priced around $300 or $400, patients may be able to use them at home several times a day. A number of companies are developing various software programs that create therapeutic virtual environments, with the ultimate goal of using the mind to change the brain - like learning to play the piano or ride a bike. VR is not a panacea or silver bullet, but a tool to teach many different things. Unlike opioids, patients don't become dependent on VR. Rather, they learn skills that can generalize into life without VR. It's a tool for breaking the cycle of pain and stress that drives the nervous system through the roof. You can learn to think yourself well instead of thinking yourself sick. An article published in Physical Therapy journal, in 2018, was the first-of-its-kind study to investigate the effectiveness of self-managed home-based video game exercises in people over 55 years using a Nintendo Wii-Fit-U.

Low back pain (LBP) is the most disabling and costly musculoskeletal condition worldwide with most of this burden among older people who develop chronic symptoms. Chronic LBP becomes more severe and disabling with 7) ___, and can have a significant impact on physical functioning such as balance, strength and walking speed. Home-based video game exercises are a valuable treatment option for older people suffering from chronic low back pain as participants experienced a 27% reduction in pain and a 23% increase in function from the exercises. Participants practiced flexibility, strengthening and aerobic exercises for 60 minutes, three times per week at home without therapist supervision, and the effect of the 8-week video-game program was comparable to exercise programs completed under the supervision of a physiotherapist. Structured exercise programs are recommended for the management of chronic LBP, but there is poor compliance to unsupervised home-exercises. Our study however had high compliance to video-8) ___ exercises, with participants completing on average 85% of recommended sessions. Video-game exercises are interactive, have video and audio instructions, provide feedback on a patient's technique and scores them on the basis of their performance. These features are extremely motivating and likely explain why compliance to this program was much higher than other trials that have instructed patients to exercise without supervision. These exercise programs could be a unique solution to increase older people's motivation to self-manage their chronic LBP through home-exercise and improve their ability to continue with their daily activities despite having 9) ___. This home-based program has great potential as supervised physiotherapy visits can be costly and people who live in remote or rural areas can face barriers accessing these services. Older people with poor physical functioning also prefer home-based exercises as travelling to treatment facilities can be difficult.

Given the enormous global cost of chronic low back pain, increasing an individual's capacity to self-manage their pain, while reducing the need for therapist supervision, should be a priority. Home-based video-game exercises could be a solution to this problem as they reduce reliance on a healthcare system with scare resources. Units are low cost at around $200 and patients wouldn't need to travel to treatment clinics. These programs could be implemented under the current Medical Benefit Scheme (MBS) chronic pain care pathway in Australia, with only one session needed to set up the program and teach patients how to use it. Traditional exercise programs require many more sessions than are funded by MBS. This study highlights the potential cost-effectiveness of this new approach to the management of low back pain, particularly since it can be implemented on a large-scale and to people in remote communities with limited access to treatment providers. This study shows a promising new direction in the treatment of older people suffering from low back pain, which is particularly important given the majority of treatment options for low 10) ___ pain have not been tested in older people. The global population of people over 60 years old is expected to triple by 2050, so more research on this population is extremely important.

Sources: The New York Times, Jane E. Brody; Wikipedia; NIH.gov; University of Sydney; ScienceDaily.com

ANSWERS: 1) therapists; 2) suffering; 3) program; 4) reality; 5) virtual; 6) patients; 7) age; 8) game; 9) pain; 10) back

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