Cedars-Sinai expert Dr. Brennan Spiegel answered some questions about using VR in healthcare on FacebookLive. Check out his answers to some of the most commonly asked questions.
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Hi all. I'm Brennan Spiegel, I'm a director of health services research here at Cedars Sinai Medical Center and thanks for joining me on this livestream discussion about virtual reality or VR in healthcare. Now. Many of you may know that, you know, virtual reality has been around for a while when people think of VR, they usually think of these headsets that you put on your face. I should probably have one here to show you. But I think, you know what they look like. Um and you know, it's mainly to play games. So kids will play first person shooter games or all sorts of different, you know, fantastical worlds that they go into for entertainment purposes. We're hearing hearing more and more about how VR is being used in entertainment. But what we've come to learn here at cedars and all around the world, other hospitals is that VR has this powerful ability to influence the human mind and it could be used, you know, for entertainment, but it can also be used for healthcare purposes to actually improve how people are feeling. So we've been using VR to help manage pain and we can talk about that today. VR is being used to help battle anxiety, depression, phobias. Um it's being used in people with dementia uh with cognitive impairment. It's being used for eating disorders. It's being used for physical rehabilitation. There's so many applications now for VR that it's becoming its own field. So the FDA, the Food and Drug Administration is now put a name to this whole field. It's called M. X. R. Or Medical extended reality And the F. D. A. Is gonna have its first public forum to discuss. Mx are this upcoming March. And they'll be speakers from all around the country unfortunate to be one of them to represent Cedars Sinai in the work we've been doing here and all this is just an indication that people are starting to really pay attention to what VR can do and really how it works. So one of the most common uses of VR that we might want to talk about is it's used for pain management and you know people wonder well how does VR really work for pain? Is it just sort of like a distraction? And that's one way that it works. So we've been using virtual reality at cedars Sinai now for the past about five years And we've kind of lost track of exactly how many people have gotten it. But it's somewhere around 3000 patients here at Cedar Sinai have received virtual reality for a wide variety of different painful conditions. We've used it for everything from um spinal injuries and and bone fractures to women undergoing labor and delivery. So melissa Wong who is an obstetrician here has just recently finished a study using using VR for labor and delivery. We've been using it for gastrointestinal pain for irritable bowel syndrome for fibromyalgia. And part of it is what works just through distraction. But it seems to do more than that. Uh It seems to also allow the mind to, in a way take control over the body and how that works is pretty fascinating. It turns out that we can only pay attention to so much at once. Like right now I'm sitting here talking to you, I'm trying to pay attention to what I'm saying, I'm trying to look into the camera, but I'm not thinking about the pressure of the chair pushing up underneath my bottom. Like that's like something I don't have time to think about right now. I'm not thinking about how many times my eyes have blinked in the last minute, right? That's just not relevant. So what that shows is that I can only focus on so much at once and so can you, our brains are only designed to focus on so much at once. So if we're focusing on pain and then all of a sudden we find ourselves in a fantastical environment floating in outer space, sitting on a beach, the brain all of a sudden has trouble focusing on the pain. But what's interesting is when the headset comes off, it's not like people go right back to having pain. Sometimes they do. But sometimes it's as if the pain in the brain has been temporarily inoculated for some period of time to not feel as much pain and people come to realize that, oh my God, I didn't realize I had this power. It's almost like a superpower. This ability to block pain signals and it turns out that the brain can fight back. It's not like the brain just sits there and soaks soaks up all these pain signals that the brain can send signals right back down the spinal cord and block pain from coming up. And if we put the brain under the right circumstances into a peaceful state of mind for example the brain is in a better position to fight back. And then we can add on to that cognitive behavioral therapy where people can learn how to breathe. We can use the microphone in the headset to detect people's breathing patterns and through breathing. They can literally see a metaphorical narrative. Like they can blow life into a tree literally in virtual reality as they're breathing in real reality and learn how they can control their mind. Even using e. G. Devices to measure brain waves and use that. There's one there's one company that allows people to teleport up the side of a waterfall just by using their brain waves and you can literally will yourself up and over a waterfall and fly through the sky just on the power of your brain waves through this virtual world. So I'm just touching the surface here of some of the different ways that VR is being used now um to manage pain in particular and a wide variety of of other conditions. So I can talk for a while. But I'll try to stop there for a second and I got it here, so off of the camera, looking to see if we've got any questions coming in and anyone have any questions so far. Okay, let's start with, has VR been used in any kind of physical therapy treatment? Yeah, so the question is about VR for physical therapy and there's a wide variety of studies now using VR for a number of different physical therapeutic applications. Um So one example that comes to mind is for people who have chronic lower back pain, so lower back pain is one of the most common causes of chronic pain that really humans experience. And one of the issues with lower back pain is there's people can develop a fear of moving. Uh so just because they're worried about triggering the pain, they end up restricting the range of motion. Now, there's a recent study that uses virtual reality and people with chronic lower back pain and they put on the headset and they find themselves in a dodgeball arena and the balls come flying at, you sort of in virtual space at exact very specific levels and slowly start realizing that you have to bend over more and more to grab or bounce these balls off so that you don't get disqualified from the game. And what they've been able to show consistently now is that people in the dodgeball world are able to extend their back far more than they could when they're not playing that dodge ball game. And part of it is literally using Gamification to overcome the fear of moving your back. And people realized during the game that they're not feeling that pain and discomfort that they would have otherwise felt if they had just been asked to bend over. So, that's one example. There are many more uses of VR for physical therapy. You know, you can think about, for example, somebody who's recovering from a heart attack and needs to do um cardiovascular training. Um so cardiac rehabilitation and we have to be very careful after somebody has had a heart attack to restore function slowly and deliberately. So in this case, you can use virtual reality with biofeedback. We can measure blood pressure, measure heart rate, for example, and stay within certain physiologic parameters so that the activity that the persons within maybe they're playing uh doing tai chi maybe something more aggressive like um doing some boxing or actually some fitness is is kept within certain boundaries based upon the feedback that biosensors are providing. So, these are just a couple examples of physical therapy applications of VR. Are there certain demographics that benefit more from VR? Yeah. So who really benefits the most from VR. There's certain demographics, certain patient characteristics. So that's the question. Really good question. So, uh we have a few answers to this now. So, in our own research here at cedar Sinai where we've been using virtual reality for pain management. We found a few things. So firstly, uh regarding age, we have found that older individuals are generally a little more reluctant to use the virtual reality, but once they do, they have a larger benefit, a larger reduction in pain compared to younger individuals. Not that it doesn't work in younger people, but it does seem to be more effective in older people. That's kind of curious. I'm not totally sure why that is, it may have to do partly with expectations around technology and there's something called this digital divide that in general, people that did not grow up with the internet and with digital devices have a different relationship with digital technologies than people who did grow up with the internet and with digital technologies and that that variation can affect how people are, how willing people are to engage and what their reactions are. Um, so it may in fact be kind of paradoxical that older people have a larger benefit, even though they're less willing to use it in our in our own hands so far. Um, other things we've looked at by the way, in terms of patient level predictors are how bad is the pain, This is another kind of paradox. It turns out that the worst, the pain is, the better the VR works. And that was surprising to us at first when we measure pain on a typical scale from 0 to 10, when people score 89 or 10 out of 10, those people have the largest drop in pain with VR compared to people with lower levels of pain. That's also kind of curious. I don't know why that is for sure. But buddha said many years ago that pain has two arrows. And what he meant by that was the first arrow of pain is when the art share, pulls the bow and you get hit by it and it hurts. But the second arrow buddha said is the self inflicted wound where you look at the first arrow and you think oh my God, what does this mean? You get anxious about your worried, am I going to die? It's the emotional experience of pain and it turns out both types of pain are equally important. And it looks like virtual reality can tamp down both the physical and the emotional components of pain when functional M. R. I. Scans are done and we look at the brains of people using VR. Both parts of pain seem to reduce and it could be that people with scores that are 89 or 10 not only a very high physical pain but also very high emotional pain. And it may be that VR can help with that as opposed to an opioid which can help but the physical pain but may not help as much or at all with the emotional components of pain. Where do you visualize virtual reality to be in five years? Yeah. So what's the future of er where are we heading with all this? Well I've got a bunch to say about this. So first of all just yesterday um I was in Washington D. C. Visiting the american Medical Association the A. M. A. Where I was invited to come and talk about virtual reality. And the reason I was invited is because the A. M. A. Helps with cPT codes. So these are current procedural terminology codes which are basically numerical codes that doctors can use to help build for their time and services. So right now virtual reality doesn't really have a code but the A. M. A. Is starting to recognize that we have enough evidence now that VR really works that it's time to start putting codes to it So doctors can start to really do this and get reimbursed for their time in effort not just in administering the headset but really interacting with the patient, understanding their bio psychosocial illness experiences and understanding how the VR can really help them as a novel type of therapeutic. So that's one small data point in a larger discussion about what's the future of er what I think is going to begin happening as we start to see VR becoming more and more evidence based is there may be a new type of clinician called a virtual ist. The virtual Ist will be somebody who is an expert in administering immersive therapeutics I've been talking about. We are today but there's also a r there's something called M. R. X. R. But all together we call these immersive therapeutics. And the Virtual ist will interact with all sorts of different clinicians. So VR is used for everything from stroke rehabilitation to pain management and on and on anxiety, depression, mental health, the virtue this will work with all those different doctors and be an expert in the interactions with technology and patient care. So I think we're going to start seeing more and more new type of specialty emerge. And also the FDA is becoming much more engaged in this and the NIH is becoming more engaged in this. We just received a grant from the NIH to really study in more detail how VR is working. So all of these are just to say that I think more and more we're going to see VR becoming a more regular part of the everyday care of patients, not just in hospitals like Cedars Sinai but in the community as well. What else we got? Do I need anything special to use VR to help me with chronic pain or can I just use any VR equipment available in the store? Yeah. So this is a great question about, well, alright, do I need a specially designed treatment for pain or can I just you know use stuff that's free on the internet and so the answer is I don't actually know for sure the answer and that's partly what we're going to be studying very soon in our new NIH Grant is sort of some of these off the shelf available experiences, like just literally sitting on a beach and meditating um which is not specific to anything, it's just nice being in a forest. One experience we use a lot that people really love is uh is created by the dolphin swim club and they're not for profit organization out of europe, where you can literally just swim with dolphins in the lagoon and listen to them and float around with them. And it's very peaceful and really just like engages the whole mind and body, but it's not specific, it's not like this is an FDA approved treatment for pain. There are companies now more and more companies and I won't list them because there's just so many that are developing specific treatments for chronic pain. Um so there's one that we use that has 28 different modules where people can go through a variety of different specific CBT or cognitive behavioral therapy modules. There are breathing exercises, there's psycho education around pain, working with Beth Darnell. She is a pain psychologist, a very famous psychologist at stanford who has been doing research around pain for years and we're taking her research and and literally taking her and putting her into the virtual reality. So she will pop up and work with you, like having a therapist at home. That particular program was developed by a company called Applied VR uh here in Los Angeles and is available and we're testing that program and a head to head study versus some of these more generic off the shelf treatments. So I think in different people, different things work better than others and trial and error is part of it but we need to be more sophisticated and figuring out what's gonna work for each individual person. So often we have a library of different experiences and we let the patient sort of explore this VR pharmacy so to speak and figure out what what they really like and what works for them. What should I do if I'm interested in trying VR for my chronic pain. Yeah so what's the first step to get started? Um Well so you need a headset for starters um and I don't have any relationships with these headset companies just so you know we generally recommend right now the Oculus go. Um the Oculus go is $199 headset. Um Considering that it's a full computer, that's a pretty affordable computer. Not everyone has the resources to put down 100 $99 to buy a headset but there are cheaper ones, you can actually, if you already have a smartphone, certain smartphone phones like Androids will fit right into a $30 headsets like one developed by Samsung Samsung gear VR you can click that in but if you go to Oculus and look at what they have Oculus as a company that was actually purchased by facebook. So facebook owns Oculus and is Mark Zuckerberg really sees VR sort of the next computing platform. So they created this headset. The Oculus go there's a whole app store. When you buy it, you can get into this app store and buy whatever you want or have some free downloads. I happen to like nature trek a lot. Again, I have nothing to do with Nature track. I don't get any, you don't get paid to talk for them or anything like that. I just think they have some really great visualizations which are very engaging. You can go, you know, on safari, you can sit on a beach, you can do all sorts of really beautiful things with music. Um and that's often a good starting point is to try some of these higher end um really gorgeous visualizations that are available through the Oculus store if you're looking for specific treatments. Um There are more, as I said, companies coming out. I mentioned one applied VR um and I said I wasn't gonna mention companies but there's so many ex our health as another one. Karuna Labs is another one. Um you know, I'm afraid to even say them because I'm gonna miss some behavior or behavior is another one. Mind VR all of these companies, you can go on their websites and literally just order their their programs for a fee and I think they all have different different prices that they charge for their for their programs. So those are just a few suggestions to start thinking about it. Hopefully as we as doctors become more familiar with this and hopefully they start to get paid by insurance companies to administer these treatments. You can get sort of one on one guidance from individual practitioners about what really may work best for you as an individual, can you elaborate more about these studies about the effectiveness of VR that have been done so far? Yeah so a little more information on the studies that have been done um I was up for pain or for just for pain management. So we've published a few papers but there have been many, many more papers than the ones we did. The ones that we did were specific to the hospital environment here at cedar Sinai in particular. Uh So I can speak about those for starters. You know what we found is on average VR seems to reduce pain by about 25%. Uh sometimes up to 50%. Um and it usually works initially when people are in the headset but as I said after the headset is removed there's a we called an analgesia tail. So there's sort of a persistent benefit in many people. We generally recommend using it 10 minutes at a time. Not much more than That because people can get a little dizzy if they're in it for a long time three times a day and sort of as needed for breakthrough pain. And so we found 25-50% reductions. We've seen that not only after the first treatment, but after persistent treatments over the course of a hospital stay there's been so many other studies and even meta analyses. So, meta analysis is a study of studies. So we have um and in fact we now have a meta analysis of meta analyses. So there's studies of studies of studies summarizing all of the data for pain management. And on average, we are seeing a benefit of about this 25% range or so In some applications and some studies larger in some studies smaller. One of the most famous studies was done by Hunter Hoffman at the University of Washington all the way back in 2011 where he took people with burn injuries. This is one of the most severe painful experiences a human can endure not only with the burn injury, but undergoing bandage changes on those burn wounds and randomize them to virtual reality. Using a program he could cool world where in cool world you would be in the snowy cool environment to kind of counter program the searing heat of it burn compared to know VR. And he showed tremendous differences in pain. Also differences in which is a strange outcome. They looked at fun literally, How much fun did you have during your bandage changes, Which is not something anyone would ever think about, but literally he was able to show that people undergoing bandage changes in VR had more fun than those who didn't. This is an interesting side effect of er is it promotes joy and we don't measure joy usually in clinical trials, but joy is real joy is important. I think we should leverage that, like, crazy. So that's just one of many different studies and there's so many more. Are there any medical or legal regulations to consider if your health system wants to consider using VR? What barriers do you see to the scaling across the country? Yeah, So this is a question about a few things wrapped into one, which is one of the sort of how do we scale this? And are there going to be barriers to scaling it? Um, and are there some regulatory barriers to doing this? But I generally say about this is is that at this point, especially for pain management science, is not the barrier. So, I know what the barrier isn't the barrier isn't that we need 20 more studies to show that VR can be helpful for pain. We're going to keep learning about how to use it when to use it. But at this point we have enough data that it seems to work. The barriers are more mundane, like who's going to pay for this right now. Many hospitals over 200 hospitals around the US over 250 eyeball, we are using VR, they may not be getting paid by insurance companies, but it just seems like the right thing to do at cedars Sinai, we have a VR program. I'm not getting paid by insurance companies, but we do it because it helps our patients. And of course, we're research institutions so we can study this. But to scale it, payment is one training. We need to train more providers. And the question then is, do we need a certification program? So, we put on a conference every year here at cedars Sinai, it's called virtual medicine. It will be next March 25th and 26th. You can find out more in line. Just go to virtual medicine dot org or virtual medicine dot health. And we're now starting to offer workshops to really do more hands on training so people can understand how to use this. So, that's another barrier. And then there's barriers around just availability of the technology cleaning. How do we clean it? There's different techniques for how we do that to make sure we don't spread infection. How do we uh staff these services. So, we have looked at the health economics of this and it does look like it's cost effective to have a virtual reality console service in a hospital. But these are just touching on some of the issues from a regulatory standpoint, it's really a matter of just making sure that these devices are clean and that it passes through, you know, the hospital epidemiology requirements, but otherwise there aren't, there aren't really clear cut regulatory issues once we start getting FDA cleared um, programs which are starting to see more and more than they will need to be used within within the uh, you know, the accepted boundaries of that, of those regulators. So, I'm just touching on a little bit. But yeah, big question. What else? This is our last question. Do you think social VR can effectively battle loneliness among the elderly? Yeah, what a great question. It's our last question. And the question is about social VR. So what social VR is is people who are both are a group of people all using a VR headset can interact with one another in a shared environment. So we're starting to see more and more of this. In fact, there's a company called Thera VR that's starting to use a livestream um, social VR to help with anxiety and depression. Um, the idea of using it, whether it's for seniors or anyone who's lonely is really a powerful opportunity um, to engage people in a new and different way what VR does unlike television, unlike really any other audio visual medium ever created so far, is it in a way hijacks the brain and that could be used for evil, but it could also be used for good. It provides this sense of presence. That's what psychologists call it, where, you literally literally feel like you're in that place, wherever that place. It you may intellectually know that you're not in a forest, but your brain doesn't care. It says I'm in a forest. So if people who are lonely can be engaged with other people in what seems like a real environment, it can trigger the brain to secrete certain chemicals like dopamine the pleasure chemical, oxytocin, which has lots of effects on the body. But one of those effects is a sense of community, this sense of belonging that that can come from some of these changes in the brain that occur when people are in virtual reality. So, this is a very interesting area of research and we're going to see more and more on social VR for loneliness. So I think that does it. And I hope that was helpful. We covered a lot of topics. Thanks so much for tuning in and I hope to see you again sometime