It's hard to overstate just how painful a process treating burn victims is – for burn victims, air itself is excruciatingly painful. They have to undergo weeks of undressing wounds, cleaning the tender skin of debris, slathering the area with ointment, and redressing it with new bandages, and it is considered one of the most physically painful treatments in medicine. To combat this, most patients rely on consistent and heavy opioid usage.
But in 2008, University of Washington researchers published the first study of its kind using virtual reality (VR) to mitigate the use of the highly-addictive drugs. The researchers replaced the clinical hospital setting with a computer-generated snowtopia where patients could throw snowballs with penguins and snowmen through a VR headset as doctors washed the treatment area. It worked, and the study concluded that VR could replace part of an opioid dose.
A decade later, VR medicine has taken off, spawning a clutch of companies and a new field of study for what is considered one of the most promising and powerful noninvasive tools to treat pain. It's now a growing part of an $885.7 million VR health care industry.
In the eyes of Jeffrey I. Gold, a pain management doctor at the Children's Hospital Los Angeles, it's the future of medicine, as virtual reality has the potential of eliminating the need for billions of dollars worth of drugs.
If Gold is right, as researchers are increasingly finding, this could have a ripple effect across the healthcare industry eventually lowering health care costs as patients rely less on drugs to offset pain.
"That's really where VR needs to go, is into the place where you can start reducing the need for certain types of medicines that may have side effects." Gold said.
How VR Works to Mitigate Pain
Conventional pain management techniques rely on distractions like blowing bubbles with younger patients or administering pain relievers or sedation. Unlike those, VR has the unique ability to manipulate how the brain processes pain by engaging the senses with powerful immersive experiences.
Gold published a study looking at how VR impacted pain in children. Researchers gave children aged 12 to 17 who were getting blood drawn VR headsets and instructed them to play a game made specifically to soothe pain. Once they put on the set, health care workers drew blood.
They then compared the experience to children who were given traditional distraction methods like bubbles or reading a book, and soothing techniques.
The study found children who used VR during their procedures felt less pain and anxiety than children who didn't.
"People always talk about, 'you're just distracting the kid like, 'hey, look over here'.' Well, that's not what we're doing," Gold said. "It's a little bit more involved with regards to immersion, presence, something we call cognitive load."
One way to think about pain is like an "alarm" the brain sets off. VR directs the brain to set off more relaxing "sounds" in the form of a visual and audible world that forces the senses to experience something else. This drowns out that "alarm" created by the pain. The brain, effectively, does not register the needle placement as as painful as it would be without VR.
The study confirmed what researchers have been seeing for years. But what excited Gold was its potential for children: By making procedures more engaging and less painful, children with chronic conditions may become less fearful about treating their condition, he said.
"For a child to have a positive experience on a routine procedure, that can be a game changer for that kid."
Other researchers looking at the use of VR are finding that not only does the technology engage the patient's senses, but in some cases it can act as a support network, much like a family. Another study by Cedars Sinai Los Angeles used VR to assist women going into labor with painful contractions. Researchers put a headset on women in labor showing them soothing animated scenes of nature that pulsated, almost as if the elements were breathing. A calm voice used words of encouragement to help the mother through contractions.
Women who used the VR reported lower levels of pain and anxiety, much like the children.
"What I think was so impactful about this particular intervention, actually, is that what they were hearing was very much the same things ... you might hear from a doula" said Dr. Melissa Wong, maternal-fetal medicine specialist at Cedars-Sinai Los Angeles who led the study.
'A Pharmacy of VR'
Wong's study at Cedars-Sinai indicated VR could be an alternative to epidurals or nitrous oxide – two common pain management solutions used during labor. But, even more than that, it pointed to a slew of history that shows pain is not just an acute or chronic sensation in the body that causes your brain to raise alarm, it's also the environment around you.
Wong said one of the strongest indicators of whether or not patients ask for epidurals during labor is whether or not they have a birth support person in the form of a partner, family member or doula. Patients that don't are more likely to need an epidural.
"So it's suggesting, again, that [pain] is sort of the entire way in which everything is being approached, rather than just literally the pain fibers," said Wong.
In other words, pain isn't simply a feeling. It is also a patient's support system, surroundings and mental fitness. By taking patients out of a clinical hospital setting of linoleum floors and wheeling carts and into a magical virtual world that has its own soundscapes and therapeutic guides, their pain can appear to be far less than what it might be.
Brennan Spiegel, a doctor at Cedars-Sinai Los Angeles who oversees virtual reality programs, coined "a pharmacy of VR" -- the idea that VR therapies should be created to help specific situations, like going through labor, dressing a burn wound, undergoing chemotherapy or having an anxiety attack.
But the industry is still young and many of the devices have yet to gain full Food and Drug Administration approval. Still, there's growing demand.
Companies Are Getting Involved
Companies like seven-year-old Alameda-based KindVR are using virtual reality programs to soothe pediatric patients before an MRI and calm them before an operation. XRHealth, a five-year-old company based in Massachusetts, offers a host of applications designed to treat physical immobility and mental health.
And the six-year-old Los Angeles-based AppliedVR developed a suite of VR-based "video games" meant to soothe anxiety for veterans and treat acute pain for people giving birth and burn victims. The company has raised around $34 million to date, the most any startup in the chronic pain market has raised, and valued at over $67 million, according to Pitchbook.
Following the idea of a 'pharmacy for VR', AppliedVR has two opioid-sparing treatments -- one for patients to use to help with acute pain, and one for chronic pain. The effects of chronic pain are often long lasting stress and a feat of moving, which is why the company incorporates cognitive behavioral therapy into the treatment.
Their chronic pain product is EaseVRx, a VR device used in an eight-week program that takes patients through different educational and training modules to explain to them how stress can affect pain, how they can avoid stress, and how to utilize breathing and acceptance-based therapy to reduce pain long after taking off the VR headset.
Laura Garcia, director of research, design and product innovation at AppliedVR said the company found that patients are able to utilize the benefits of VR up to six months after taking off the headset.
"While you're in the headset, you're able to learn your skill sets and change your brain so that you're able to cope with the pain differently," she said. "So imagine having a pill that gives you benefits and relieves [pain] for the time that you use the pill for, but also six months after."
Correction: An earlier version of this misidentified EaseVRx and misstated the length of its VR training program.
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Josh Sackman, co-founder and president of AppliedVR, was born with congenital joint ligament abnormalities that left him with weak joints and introduced him early on to the world of health care.
The chronic pain sent him to hospital and doctors offices over the years. His surgeries and treatments often left him stressed and feeling isolated.
"Chronic pain is something that impacts 100 million Americans, just in the U.S. alone," said Sackman. "And [it affects] 1.5 billion people worldwide, costing $635 billion more than heart disease, diabetes and cancer combined."
Sackman recalls his eight-year-old self coming out of surgery in pain. He has had reconstructive surgery on his shoulders three times and several other related surgeries. His experiences inspired him to build a company that will lessen and make the chronic pain more manageable for others. He has had reconstructive surgery on his shoulder three times and several other related surgeries.
AppliedVR's products use virtual reality to take patients through mental exercises that help them cope. It's an option that could appeal, especially for those seeking alternatives to heavy drugs. The startup raised $29 million to continue developing products that help patients alleviate chronic pain, postoperative pain and anxiety. It's competing against companies like San Francisco-based Karuna Labs and Massachusetts-based XR Labs, which are also looking to treat chronic pain with virtual reality solutions.
"The pandemic was really disruptive [for health care]," Sackman said. "The typical care patients receive for chronic pain includes physical therapy visits with their doctors, often [also] injections, implants, surgical procedures and a number of other things that were just off access… We are addressing their quality of life, making fundamental improvements to how they're able to live their life, especially when dealing with pain, stress and isolation, more than ever."
Sackman and his co-founders Matthew Stoudt and David Sackman launched the Los Angeles-based company at the start of 2015. They had a shared interest in VR, but from a variety of perspectives. Stoudt's background was in advertising technology, and after watching a TedX talk on virtual reality, he saw a future in which screens in hospitals could do so much more than advertise. David Sackman previously worked at Lieberman Research, where he learned that VR has the ability to change behavior and build empathy.
"Virtual reality has so much promise and potential through all the studies and research we're seeing, but there were limitations around the hardware in terms of the form factor and pricing and usability," Josh Sackman said. "Our vision kind of came from translating concepts and design principles that have been proven in academic labs and translating them into real world applications."
After launching, the three got to work on their first product, SootheVR. It's already on the market, used by hospitals as a general wellness tool to help patients relax and be distracted from their pain. AppliedVR is expecting FDA approval for another version of SootheVR by the end of the year.
AppliedVR plans on using the Series A funding to further develop EaseVRx, the first virtual reality prescription treatment granted a "breakthrough device designation" by the FDA. This designation provides it closer access to the FDA, and could also mean it is covered by Medicare.
EaseVRx is a daily program that targets chronic low back pain. Patients put on the VR set and participate in an eight-week program that teaches different positive habits and coping skills to approach their pain management. The company will also double their team in the next year across all teams, including engineering and product marketing, said Josh Sackman.
The round includes investors F-Prime Capital, JAZZ Venture Partners, Sway Ventures, GSR Ventures, Magnetic Ventures and Cedars-Sinai. Many of these funds have other investments in the health care field, and it brings a diverse perspective to AppliedVR's decisions, Josh Sackman said.
"People very rarely think of the board, or their investor base, as part of their team," Josh Sackman said. "We try to, and really think through the same criteria of who we would hire, would bring into the business."