Virtual reality: The next generation of chronic pain treatment

More than one in five adult American (20.6%) experience chronic pain, according to data provided by the U.S. Centers for Disease Control and Prevention (CDC).¹ For 6.9% of the population, their pain is not only long-term but also considered high-impact, meaning it causes them to substantially restrict their regular life or work activities on most days.  

While the National Center for Complementary and Integrative Health reports² spinal manipulation can aid in the management of certain pain-based conditions — along with other complementary approaches, such as acupuncture, massage therapy and yoga — research suggests virtual reality may have a positive effect as well.  

What is virtual reality?

Virtual reality (VR) is a computer-simulated 3D environment in which a person can interact with the virtual environment in a seemingly real way. Often, it involves wearing a headset, goggles or other device that creates virtual images. Some systems also require the use of other equipment to receive user input, such as fitted gloves or handheld devices with sensors. 

The Academy of Animated Art reports 64 million Americans use VR. One-third use this technology monthly, with 43% owning a headset.³ 

Research supports VR for pain

On May 23, 2023, the journal Pain Medicine published the results of a randomized controlled trial involving VR for chronic low-back pain.⁴ It piggybacked a previous in-home, self-administered, skills-based VR study in which half the subjects engaged in 56 VR experiences over eight weeks. These experiences incorporated cognitive behavioral therapy (CBT) skills, as well as mindfulness and pain neuroscience education. The other half of the subjects engaged in sham VR sessions (two-dimensional nature content delivered via a VR headset). 

At the end of this initial study, the intervention group’s results were superior to those of the sham group. The goal of this secondary study was to learn more about the length of the clinically meaningful reduction in pain, defined as a 30% or more reduction. Subjects completed a survey 24 months after the first VR study concluded; 65% reported they had retained the positive effects in terms of reduced pain intensity and less interference in their lives. 

Several other larger pieces of research also support the use of VR for chronic pain conditions. One was a systematic review and meta-analysis published in JMIR Serious Games in 2022.5 After looking at 41 individual studies, researchers concluded there was evidence to support the use of VR as a pain intervention. Based on the data, this technology can positively impact a person’s ability to function, their psychological and neurological outcomes and their overall quality of life. 

How VR works

The manner in which VR can help ease chronic pain is not completely clear. One theory is VR serves as a distraction from the pain being experienced. This is similar to how you might have a headache but not notice the throbbing in your temples when a good friend calls and you’re engaged in conversation over the phone. 

Another theory is that VR creates a focus shift. Instead of concentrating on their pain levels, the person’s focus transitions to a more pleasant, albeit virtual world. By shifting their focus, they’re less likely to feel the sensation of pain. 

Some VR programs, such as the one in the previously-mentioned Pain Medicine study, help reduce pain and/or act as pain interference by using CBT, a set of methodologies designed to help people change their patterns of thinking and behavior to better cope with psychological issues. The goal of a CBT-based VR session is to teach users skills they can use to reduce their pain levels. CBT strategies employed through VR include visualization, deep relaxation, interoceptive awareness, acceptance and immersive enjoyment. 

VR benefits

While more studies are needed to fully understand the short- and long-term effectiveness of VR for pain relief and which conditions it may be most useful in treating, researchers in another 2023 study⁶ noted this treatment option has several benefits, such as: 

• Providing patients a chronic pain treatment they can use independently at home, outside a doctor’s office. 
• Offering a highly customizable environment that can easily be adapted to individual patients’ needs. 
• Not having the side effects common with many pharmacological pain treatments, including drowsiness, headaches and the risk of drug-related addiction and dependence. 

What about VR addiction?

Although VR may help reduce the risk of addiction to pain-relieving drugs, some experts are concerned about the risk of patients becoming addicted to VR. According to research published in Frontiers in Virtual Reality, between 2% and 20% of frequent VR users meet the criteria for compulsive use.⁷ This is roughly the same prevalence rate as users engaged in non-VR games and social media activities, suggesting VR is not more addictive than other technologies. 

FDA-authorized VR devices

The U.S. Food and Drug Administration (FDA) has authorized the marketing of some VR systems for the treatment of certain chronic pain conditions. For example, on Nov. 16, 2021, the FDA issued a press announcement⁸ stating it had authorized the marketing of a prescription-only VR system that uses CBT and other behavioral approaches to reduce chronic low-back pain in adults. It consists of a headset and controller and walks the user through 56 sessions, each of which ranges from two to 16 minutes in length. The course of treatment is intended to be eight weeks and consists of daily sessions. 

Offering VR pain management services

DCs can enhance their service offerings by giving patients with chronic pain access to VR treatments. These treatments may even be covered by insurance soon. On March 21, 2023, a VR company announced one of its programs,⁹ developed for people with chronic low-back pain, had received a unique HCPCS Level II code from the Centers for Medicare and Medicaid Services (CMS) under the category of durable medical equipment. This enabled the two entities to begin talks on an established payment rate. 

Deciding what to charge for a VR session, which can be provided in-office as an adjunct to spinal manipulation, will require you to take into consideration several factors. First, choosing a system and programs can be a challenge, and there may be an ongoing subscription fee required for the software you select. Also keep in mind VR use will likely require staff involvement for troubleshooting technical issues or offering patient guidance, especially with patients experiencing VR for the first time. If the system utilized requires the patient to move around the room, space in your office will be a consideration as well. All these variables will factor in as you determine your VR session rate. The skills these VR programs teach can also be valuable between treatment sessions by helping patients learn how to better manage their pain anytime and anywhere. VR could be a potential offering as part of a total wellness package or as a treatment add-on.  

Final thoughts

If you’ve never experienced VR, you must try before you buy; testing out a VR device firsthand can help you as a DC decide the best approach for adding this treatment to your practice. It can also reveal any changes you may need to make or guidelines you need to implement in your office to keep patients safe and comfortable while they engage in VR-based treatments. 

CHRISTINA DEBUSK is a writer for Chiropractic Economics. 

References 

1. Rikard SM, et al. Chronic Pain Among Adults — United States, 2019–2021. Weekly. 2023;72(15):379–385. CDC website. https://www.cdc.gov/mmwr/volumes/72/wr/mm7215a1.htm. Accessed Jan. 25, 2024. 
2. Chronic Pain: What You Need To Know. Updated Jan. 2023. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/chronic-pain-what-you-need-to-know. Accessed Jan. 25, 2024. 
3. Katatikarn J. Virtual Reality Statistics: The Ultimate List in 2024. Last updated Jan. 11, 2024. Academy of Animated Art. https://academyofanimatedart.com/virtual-reality-statistics. Accessed Jan. 25, 2024. 
4. Maddox T, et al. Durable chronic low back pain reductions up to 24 months after treatment for an accessible, 8-week, in-home behavioral skills–based virtual reality program: a randomized controlled trial. Pain Medicine. 2023;24(10):1200–1203. Oxford Academic. https://academic.oup.com/painmedicine/article/24/10/1200/7176373?login=false.  
5. Goudman L, et al. Virtual Reality Applications in Chronic Pain Management: Systematic Review and Meta-analysis. JMIR Serious Games. 2022;10(2):e34402. JMIR Publications. https://games.jmir.org/2022/2/e34402. Accessed Jan. 25, 2024.  
6. DeVries FS, et al. Pain education and pain management skills in virtual reality in the treatment of chronic low back pain: A multiple baseline single-case experimental design. Behaviour Research and Therapy. 2023;162:104257. Elsevier. https://www.sciencedirect.com/science/article/abs/pii/S0005796723000062. Accessed Jan. 25, 2024. 
7. Barreda-Angeles M, Hartmann T. Hooked on the metaverse? Exploring the prevalence of addiction to virtual reality applications. [Brief Research Report.] Front. Virtual Real. 2022;3. Frontiers. https://www.frontiersin.org/articles/10.3389/frvir.2022.1031697/full. Accessed Jan. 25, 2024.  
8. FDA Authorizes Marketing of Virtual Reality System for Chronic Pain Reduction. [FDA News Release.] Nov. 16, 2021. FDA website. https://www.fda.gov/news-events/press-announcements/fda-authorizes-marketing-virtual-reality-system-chronic-pain-reduction. Accessed Jan. 25, 2024.  
9. Applied VR Becomes First Virtual Reality Provider to Receive HCPCS Level II Code from Centers for Medicare and Medicaid Services as Durable Medical Equipment. [News.] Mar. 21, 2023. PR Newswire. https://www.prnewswire.com/news-releases/appliedvr-becomes-first-virtual-reality-provider-to-receive-hcpcs-level-ii-code-from-centers-for-medicare-and-medicaid-services-as-durable-medical-equipment-301773521.html. Accessed Jan. 25, 2024.