Introduction: important questions for an important problem.
- Can one be distracted from pain?
- How powerful a distraction would be needed to be effective?
- If such a distraction were to be incorporated into the traditional protocols for pain, would it be antagonistic or synergistic? Productive or counterproductive?
- Would the clinical benefit justify the investment in such a new technology?
We are what we think. We are where we immerse.
For all of us, our universe is contained within our minds as an immersion of all of the sensations we perceive, experience, and navigate, and these are all based merely on information passing through our consciousness.1 The human brain is—to use a computer analogy—a graphic user interface (GUI) much like a browser displays meaningful images on a screen that comes to it as packets of data and code. Our sense organs are designed, likewise, to receive information in the form of light waves, auditory oscillations, temperature differences, and stimuli varying from light touch to noxious.
Essential to our survival is the very nature of our minds, a consortium of synapsing groups and regions that construct our reality. For example, a tree is not the green, bushy-topped thing we see blowing in the wind: it is the delivery of light at specific wavelengths to rods and cones in the retina, relayed to the “associative” areas of the brain, which then interpret them and assign them meaning based on memories, emotions, and constructs that make sense to us.
Pareidolia is a term meant to describe how our minds tend to construct meaning out of random patterns. It is why we see faces in the veins of marble, shapes of animals in the clouds, or even a “Martian” face on the mountainous topography of Mars. While pareidolia seems to originate in the fusiform gyri of the temporal lobe,2 the whole human brain tends to make meaning out of even unfamiliar things, and from this innate, primitive talent comes face recognition and calling a tree a tree. The dark side, however, is feeling pain, when such sensation originates as the firing of pain receptors (nociceptors) designed to propagate action potentials from noxious stimuli (acute pain) or from less-than-noxious stimuli—the pathological condition known as chronic pain.
Your pain is all in your head.
Physicians who are unable to make sense of someone’s pain will dismiss a patient occasionally by insinuating the pain is “all in your head.” While this is an unethical retreat, the physician who says this is right, but for reasons different from what was meant: until pain is perceived and felt in the brain, it is just signal. However, pain is not an arrow aimed at a target in the head, but involves the concept of a neuromatrix: “…pain is an amalgam of affect, cognition, and sensation mediated through diverse brain regions.”3 Translated: pain is complex. To date, medical science attempted to address pain by targeting specific areas that mediate pain, such as nociceptors on neurons, neurotransmitters between synapses, amplification signals, inhibitory pathways, and even the innate immune system. These approaches all represent piecemeal attacks in hopes of a collapse of the entire pain process, as if pain were a Jenga tower or a house of cards.
Swapping out immersions.
Virtual reality (VR), the use of computer technology to render a substitute immersion in lieu of the universe normally perceived (with its trees, cloud shapes…and pain) has recently proven effective in distracting pain patients enough to align themselves with a different universe, one in which the pain is reduced or eliminated. This makes more sense than the one-shot stand-alone approaches of narcotics, anti-inflammatories, and antidepressants. Furthermore, as the practice of “rational polypharmacology” ushers in the added risk of potentiating toxicity, the increase in mortality has become a political crisis pitting doctors against bureaucrats and law enforcement and academicians/scientists against media sensationalism.
Long gone are the days when we believed that neuron damage was permanent and unalterable. The discovery among stroke patients that the brain can heal itself4 by rerouting the neuromatrix has been bolstered by VR in a variety of acute and chronic pain conditions, specifically, fibromyalgia, phantom limb pain, and regional pain disorders.5 There has been enough activity in the medical application of VR to garner meta-analyses documenting its effectiveness. The results indicate that “virtual reality distraction is a highly effective pain intervention.”6,7
Where does Virtual Reality fit into Clinical Reality?
If all pain is perceived in the brain, then it makes sense to change what the brain perceives, that is, retrain the brain to think differently. Neuronal tracts can be altered and rerouted when a different reality, a painless reality, is constructed well enough to get the pained brain to suspend disbelief. The 3-dimensional portrayal rendered by VR is such a successful construction; and eliminating the distractions of the real world (via immersion—stereoscopic goggles and dedicated sound) allows for the VR to distract the patient from the pain in his/her real word.
Clinically, this can see a reduction in the use of controlled substances, the overhead required to follow legislated protocol for them, and their associated morbidity and mortality. VR is more than mitigating pain—it makes the mitigation of pain interesting for the patient, and the milieu of each new universe is as varied as the human imagination. And its production and delivery is via code—easily presented as the VR and easily modified on a patient-to-patient basis. Whether it be in a hospital environment for VR acute pain therapy (i.e., wound care, burn care, physical therapy, etc.) or the institutional settings of physiatry, pain management, or psychological treatment, one thing a medical facility is pre-fabricated for is computer connectivity. This means a minimum of investment for a maximum clinical and human impact.
As of now, VR has been proven effective in phobias, anxiety states, depression, and many other “mind” abnormalities other than pain.7 It can also be adjunctive; while it can be valuable as an independent approach to pain and other mental conditions, it can also be integrated seamlessly into the conventional approaches underway in patients already receiving traditional care.
VR is in its infancy, but already there has been great success in clinical practice. As Moore’s Law (doubling of capacity of computers) increases the capabilities of the digital word exponentially, what becomes clear is that VR’s most advantageous aspect is that there is no disadvantage to it. There is no downside. Mental conditions cost the USA over $193B per year in lost earnings8 and over £105.2B in the UK,9 but these figures cannot include the intangible losses from overdose deaths and broken families, nor the extra law enforcement/cost of incarceration required. Pursuing a non-pharmacological strategy makes sense now more than ever, considering these financial and human costs.
Lanza MD, Robert, Berman, Bob. Beyond Biocentrism. Benbella Books, Dallas, Texas. 2016.
Stefano Triberti, Claudia Repetto, and Giuseppe Riva. Cyberpsychology, Behavior, and Social Networking. 17:6. Jun 2014.
Doidge, Norman. The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science. Penguin Group. 2007.
Pourmand, A., Davis, S., Marchak, A. et al. Curr Pain Headache Rep (2018) 22: 53.
Kenney, M. P., & Milling, L. S. (2016). The effectiveness of virtual reality distraction for reducing pain: A meta-analysis. Psychology of Consciousness: Theory, Research, and Practice, 3(3), 199-210.
Nexhmedin Morina, Hiske Ijntema. Katharina Meyerbröker, Paul M.G.Emmelkamp. Can virtual reality exposure therapy gains be generalized to real-life? A meta-analysis of studies applying behavioral assessments. Behaviour Research and Therapy. Volume 74, November 2015, Pages 18-24.