Virtual Reality: An Effective Pain Treatment

By Bryan D. Vargo | November 20, 2022

The environment of virtual reality — commonly known as VR — may be artificial but according to recent research, it’s efficacy for the treatment of pain is genuine. And research presented at the 2022 conference of the American College of Rheumatology (ACR) shows the body of evidence to support it is growing.

Nancy Baker, OT, MPH, ScD, associate professor and chair, Department of Occupational Therapy at Tufts University, discussed why virtual reality should be used to treat pain, what VR is, how it works and how VR can be applied as a treatment for pain. 

Why VRx for Pain

In a scoping review co-authored by Baker and recently published in The Clinical Journal of Pain, she and researchers examined the use of virtual reality in the treatment of acute and chronic pain. Reviewing studies of adults and children with pain published in peer-reviewed journals from 2010 to 2020 used 70 studies representing 4,105 people.

“What we found, in general, is that VR is effective in treating pain — both acute pain and chronic pain. We had significant results for 45% of the studies and inconclusive results for about 5% to 10% of the studies. Even in chronic pain we were seeing significant results,” said Baker.

Studies looked at the intensity and quality of the pain, whether people stopped thinking about the pain, proxy measures of pain and other aspects of pain.

“There is quite a bit of evidence that suggests VR is an effective method to treat pain, particularly acute pain,” said Baker. “But there is this evidence that’s growing for chronic pain.”

Baker has also conducted a series of smaller studies using VR for pain in clinic that show a decrease of as much as 2 points on a 1-to-10-point pain scale. Opioids have shown similar affects, said Baker.

“We need to better understand how to use VR as a rehab or therapeutic tool. It’s not just a one-shot deal. It’s something that we can use therapeutically and build on in order to create this ability to reduce and control pain,” said Baker.

So why use VR for pain? “It’s relaxing. It’s escapism. When you go into a VR system you are in a different world, you are in a different place. You can be a different person. It’s distracting, and we all know distracting is a great way to work on pain. VR is a very distracting medium. It’s fun. How may treatments do we do with clients who have chronic pain where they have fun and come out smiling and laugh inside the treatment? Not many.” According to Baker, patients also find it interesting, non-invasive and there’s a change in focus, from patient to participant.

VRx Primer — What is It?

Immersive VR is a three-dimensional, life-sized computer-generated environment interacted via a computer headset and hand controllers. The headset allows you to see the environment, while the hand controllers and relevant program allow you to manipulate the environment. 

There is a continuum of virtual reality that ranges from our real environment to augmented reality to a total virtual environment, said Baker.

Therapeutic uses of VR include preventative health measures like physical activity and stress management as well as chronic conditions like arthritis, dementia, schizophrenia, anxiety disorders/PTSD, eating disorders, neurorehabilitation, pain management and more.

VRx Mechanisms

Baker identified three key mechanisms: 

• Distraction — engage resources (attention and emotion) which otherwise would be used to attend to pain. 

“VR is extremely distracting,” said Baker. “But it’s also very emotional. You can elicit joy, you can elicit fear, you can elicit a lot of different emotions in virtual reality because of the power of that visual interaction with the environment. So this combination of attention and emotion is very powerful as a distraction tool.”

• Sense of embodiment (key use for chronic pain) — a subjective experience in which a person views a simulated body and properties of that simulated body are processed as if they were the properties of the person’s own biological body. 

“To create good embodiment, you have to have three things. You have to have a sense of self-location, sense of agency and a sense of body ownership,” said Baker. Self-location is simply recognizing that the part of you (e.g., your virtual hand) that you’re looking at, is where it should be. Sense of agency is recognizing that you can move that limb. Sense of body ownership is recognizing that the limb or body part is your own. “I tend to call this the ‘freaky-weird’ aspect of VR because it just seems odd that you can take on a virtual limb,” said Baker.

• Enhance existing treatment (e.g., pain reduction, exercise, etc.) — “When you have all three things, all of a sudden that limb becomes part of your body. And as a therapist, you can then manipulate that limb or body part to enhance reductions in pain.” 

When comparing actual exertion vs. perceived exertion during active virtual reality game exercise, a study showed participants perceived exertion was lower than their actual exertion. “So if you have somebody who feels they can’t do an activity and you put them in virtual reality, they are likely to be able to do more of it in the virtual reality than outside the virtual reality — enhancing the treatment,” explained Baker. 

In another study focused on the effectiveness of virtual reality meditation on reducing chronic pain for older adults with knee osteoarthritis, Baker found that there was significant reduction in pain during meditation in VR that lasted 24 hours afterward. Meditation can be hard at first, but VR makes it easier, enhancing the intervention, said Baker.

VRx in the Clinic

Things to consider:

• VR System ¬Considerations — immersion, presence, tethered vs. untethered, available VR experiences, usability of headset and controllers. A good VR system can be $200 to $300.
• VR Experiences — Passive is like watching a 3D movie, 360 videos without hand controllers; Interactive includes headset and hand controllers that enable games, puzzles, etc.
• Dosage — from 1 minute to 30-plus minutes. Comparing 10 to 20 minutes, no significant difference. Ten minutes has proven effective.

Adverse Events

• Vision occluded — fences can be created to help.
• Motion sickness — Caution should be used if a patient has compromised balance.
• Infection — VR is worn so there is direct contact. 

Best Clinical Practice

• Match the interface/system to the client’s goals, strengths and limitations.
• It should be customized, adapted and client-centered.
• It must be combined with other interventions for maximal effectiveness.
• It can/does cause adverse effects (dizziness, nausea, headache, motion sickness).
• Therapists should be trained to use VR systems/software and there should be research to support specific utility.
• Be aware of potential barriers: client acceptance, institutional support, payor allowance, need for documentation of skilled intervention, equipment limitations and implementation.

“VR can have a clinically important effect on pain — greater than 30% change in pain and greater than 1 point reduction on a numerical rating scale. It can be used in a comprehensive pain program,” said Baker. “But VR is very much in its infancy. It’s the wild west out their guys. Whatever we’re figuring out now is going to shape how VR is used in therapy over the next several years. So there’s a lot of stuff we don’t know; there’s a lot of stuff we’re still figuring out. But it has a lot of potential and there are a lot of ways that we can use VR’s innate capability that you can’t find with other equipment.”