CHI 2011 • Interactivity 2 Open May 7–12, 2011 • Vancouver, BC, Canada Immersive VR: A Non-pharmacological Analgesic for Chronic Pain? Diane Gromala, Ph.D Steven J. Barnes, Ph.D Abstract Simon Fraser University Surrey University of British Columbia This paper describes the research work being carried out 250 -13450 102 Avenue 2136 West Mall by the Transforming Pain Research Group – the only group Surrey, BC V3T 0A3 CANADA Vancouver, BC V6T 1Z4 CANADA whose work is exclusively focused on the use of immersive dgromala@sfu.ca sjb@nervouscreation.com VR for chronic pain management. Unlike VR research for Meehae Song Mark Nazemi this research posits a new paradigm for the use of VR. In Simon Fraser University Surrey Simon Fraser University Surrey addition to providing an overview of our work, the present 250 -13450 102 Avenue 250 -13450 102 Avenue paper also describes one of our current works in detail: the Surrey, BC V3T 0A3 CANADA Surrey, BC V3T 0A3 CANADA Virtual Meditative Walk. meehaes@sfu.ca mna31@sfu.ca Ji-Dong Yim Chris Shaw, Ph.D Simon Fraser University Surrey Simon Fraser University Surrey 250 -13450 102 Avenue 250 -13450 102 Avenue Surrey, BC V3T 0A3 CANADA Surrey, BC V3T 0A3 CANADA jdyim@sfu.ca shaw@sfu.ca Tyler Fox Dr. Pam Squire, MD, CCFP Simon Fraser University Surrey University of British Columbia 250 -13450 102 Avenue 317 - 2194 Health Sciences Mall Surrey, BC V3T 0A3 CANADA Vancouver, BC V6T 1Z3 CANADA tfox@sfu.ca ps@pamsquire.com acute or short-term pain, which relies on pain "distraction," Keywords Immersive Virtual Reality, Virtual Environments, Mindfulness Meditation, Meditation, Biofeedback, Chronic Pain, Non-pharmacological Analgesia, Self-modulation ACM Classification Keywords H.5.1 Multimedia Information Systems: Artificial, augmented, and virtual realities. General Terms Design, Experimentation Copyright is held by the author/owner(s). CHI 2011, May 7–12, 2011, Vancouver, BC, Canada. ACM 978-1-4503-0268-5/11/05. 1171 CHI 2011 • Interactivity 2 Open May 7–12, 2011 • Vancouver, BC, Canada Acute vs. Chronic Pain pain. There were two largely unexpected outcomes of Pain is considered to be one of two types: acute pain or Hoffman et al.’s ground breaking research: (1) In patients chronic pain. Acute pain can usually be traced to some experiencing acute pain, the magnitude of VR-induced observable damage to a specific body part. Acute pain will analgesia was shown to be comparable to that of opioids usually resolve itself relatively quickly: when we cut our [4], and (2) there was no development of tolerance to the finger with a knife, we experience acute pain; but that pain analgesic effects of VR on acute pain [5].Tolerance is a big will usually subside within minutes to hours. problem in opioid-based therapies. Acute pain has not been the only medical application of VR. Indeed, VR has been In contrast, chronic pain lasts much longer than acute used effectively for a variety of medical applications pain, and need not be associated with any observable ranging from post-stroke rehabilitation (e.g., [7]) to the bodily damage. Chronic pain persists well beyond the treatment of phobias [2] and post traumatic stress normal healing period might even persist for a lifetime. [8] disorder [3]. Chronic pain might result from any one of many antecedents, including even a brief exposure to acute pain. Virtual Reality for Chronic Pain? However, a clear antecedent injury isn’t necessarily a Given the demonstrated ability of VR to serve as a requirement for chronic pain, as neuropathic pain powerful treatment for acute pain, can similar therapeutic illustrates. In neuropathic pain, one common type of benefits of VR be derived for individuals suffering from chronic pain, there is no evidence of nociceptor activation chronic pain? And, if so, would the approach to VR have to in association with the experience of pain [12]. Chronic be fundamentally different from what has been used in VR- pain is the pathological side of pain: it is pain without any based therapies for acute pain? Although VR does work for clear protective purpose. the treatment of acute pain, there is no guarantee that it would also do so for its pathological counterpart, chronic An estimated 15%-29% of the North American population pain. Chronic pain is a medical condition with a complex currently suffers from chronic pain [1]. Decreases in etiology and idiosyncratic presentation that require a mobility and social interaction are both common sequelae fundamentally different approach to VR development. [11]. For example, we recently interviewed 20 senior citizens about how chronic pain impacted their lives, and Dr. Diane Gromala recently formed a multidisciplinary found that their pain had the most serious impact on research group composed of a medical practitioner, a scheduled social activities. These impacts occurred most neuroscientist, psychologists, computer scientists, an strongly when analgesic methods failed. We hope that the engineer and artists. As the Transforming Pain Research approach proposed here can add alternative analgesic Group, we are involved in several large projects that avenues where others fail. collectively seek to help individuals living with chronic pain deal with the various aspects of their illness. Virtual Reality for Acute Pain Hoffman et al. [4] have convincingly shown that immersive One of our major areas of concern has been to address the virtual reality (VR) is effective for the treatment of acute question of whether VR can be developed as a therapeutic 1172 CHI 2011 • Interactivity 2 Open May 7–12, 2011 • Vancouver, BC, Canada application for chronic pain. To that end, a major focus of because we wanted to directly address the decreases in our group has been on the development of VR treatments mobility that are known to accompany chronic pain, while that build on and integrate what we already know can be simultaneously using our VE to augment meditative effective for the management of chronic pain. One line of training and encourage the adoption of a long-term research is the investigation of the utility of VR-based mindfulness meditative practice. biofeedback and meditative practices, since these interventions have consistently been shown effective for This new work-in-progress, the Virtual Meditative Walk, improving major aspects of functioning in sufferers of incorporates a unidirectional treadmill. The speed of the chronic pain (e.g., [6]). In their Meditation Chamber, users’ ambulation on that treadmill is recorded and serves Shaw, Gromala, and colleagues [9,10] demonstrated that as the primary input that drives the navigation of the biofeedback and VR can be effectively combined to user’s avatar through the VE. In short, ambulation on the accelerate the adoption of a meditative practice. More treadmill leads to a forward motion through the VE. In specifically, they showed that VR can enhance a user’s addition, the physiological data that are recorded from the ability to enter a meditative state and to effectively use participant and fed into the system affect various visual biofeedback. Based on that foundational work, we are now and sonic aspects of the virtual landscape. That is, as the creating a VR-based therapy for chronic pain that meditator becomes increasingly relaxed and begins to incorporates a unique virtual environment (VE) with display physiological characteristics indicative of a biofeedback and meditation. meditative state, they are given feedback about their successes via visual and sonic changes within the VE. Figure 2 illustrates the general overview of the VR system for the Virtual Meditative Walk. To experience the VE, a participant must first be attached to one or more biofeedback devices, be positioned on a treadmill and don the head-mounted display (HMD). The system is also capable of providing output to observers (e.g., researchers, physicians) about the individual’s performance in terms of their biofeedback variables, ambulation speed, etc. figure 1. Immesant Meditating in the Meditation Chamber Virtual Meditative Walk The VE that we are building engages the participant in a walking mediation. We chose a walking form of meditation 1173 CHI 2011 • Interactivity 2 Open May 7–12, 2011 • Vancouver, BC, Canada 3DVIA’s Virtools where they affect the translation of the camera within the VE. This causes the user’s avatar to either move forwards or backwards at various speeds as a function of the immersant’s direction and velocity of ambulation. figure 2. Overall Structure of the System for the Virtual Meditative Walk Figure 3 provides a more detailed illustration of the Virtual Meditative Walk system architecture. Biofeedback signals recorded by Thought Technology’s ProComp+ device are sent through a client to Thought Technology’s Connection Instrument (i.e., a specialized socket server). These data are subsequently passed into 3DVIA’s Virtools application where those data have a real-time effect on the VE content that is currently being rendered by Virtools. figure 3. Detailed System Architecture of the Virtual Meditative Walk We have arranged to conduct user studies on our Virtual Meditative Walk in the Fall of 2011. Participants with chronic pain have been recruited from a pain clinic in Vancouver, Canada and testing will occur in a quiet room in that clinic. Velocity data are collected from the treadmill via an optical sensor positioned on the surface of the treadmill such that it can register any ambulation by the participant. Those treadmill data are also fed into 1174 CHI 2011 • Interactivity 2 Open May 7–12, 2011 • Vancouver, BC, Canada Although the exact mechanism of VR’s effectiveness for acute pain is unknown, current speculation has settled around the idea that it serves as a form of “distraction.” If true, this further underscores the strong need for a fundamentally different approach to the development of VR-based therapies for chronic pain. Why? Simply because you can only distract a person for so long, and we also can’t expect a person with chronic pain to wear a head mounted display for every waking hour of their life. Thus, our multidisciplinary approach aligns well with the unique etiology and phenomenology of chronic pain. Based on our consultation with several well-known Canadian pain experts, we have adopted an approach to the development of a VR-based therapy for chronic pain that builds on those behavioral manipulations that we already know to be effective for the management of chronic pain: biofeedback and mindfulness meditation. figure 4. The Virtual Meditative Walk Discussion For the past 15 years, research on VR for pain has focused almost exclusively on therapies for acute pain. Our group’s focus on VR for the management of chronic pain is both novel and necessary—developing therapies for such a complex disorder requires a fundamentally different approach to VR development. This fall we will be conducting user studies with chronic pain sufferers in a pain clinic. Based on the outcomes of those studies and other questionnaire-based studies, we plan to develop a relatively low-cost turnkey system. This will allow the Virtual Meditative Walk to be employed more widely than in just one complex pain clinic. Ideally, once such a turnkey system is built, our hope is to see it being widely used in pain clinics and hospitals—giving another tool to physicians and patients trying to deal with chronic pain. 1175 CHI 2011 • Interactivity 2 Open May 7–12, 2011 • Vancouver, BC, Canada based pain control with multiple treatments. Clinical Journal of Pain 17 (2001), 229-235. Acknowledgements The Transforming Pain Research Group is supported by the Canadian Research Chairs Program, National Centres for Excellence GRAND, Social Sciences and Humanities Research Council, the Michael G. DeGroote National Pain Centre, Thought Technologies and FirstHand Technology. References [1] Boulanger, A., Clark, A. J., Squire, P., Cui, E., & Horbay, G. L. A. Chronic pain in Canada: Have we improved our management of chronic noncancer pain? Pain Research and Management 12 (2007), 39-47. [2] Brinkman, W. van der Mast, C., & de Vliegher, D. (2008). Virtual reality exposure therapy for social phobia: A pilot study in evoking fear in a virtual world. In Proc. HCI 2008 Workshop (2008), 29-35 [3] Emmelkamp. P. Post-traumatic stress disorder: Assessment and follow-up. In M.J. Roy (Ed.) Novel approaches to the diagnosis and treatment of posttraumatic stress disorder, IOS Press (2006), 309-320. [4] Hoffman, H. G., Richards, T. L., Van Oostrom, T., Coda, B. A., Jensen, M. P., Blough, D. K., Sharar, S.R. The analgesic effects of opioids and immersive virtual reality distraction: evidence from subjective and functional brain imaging assessments. Anesthesia and Analgesia 105 (2007), 1776-1783. [5] Hoffman, H. G., Patterson, D. R., Carrougher, G. J., & Sharar, S. R. Effectiveness of virtual reality- [6] Morone, N. E., Greco, C. M., & Weiner, D. K. Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study. Pain 134 (2008), 310-319. [7] O’Dell, M. W., Lin, C-C. D., & Harrison, V. Stroke rehabilitation: Strategies to enhance motor recovery. Annual Review of Medicine 60 (2009), 55-68. [8] Russo, C. & Brose, W. Chronic pain. Annual Review of Medicine 49 (1998), 123-133. [9] Shaw, C., Gromala, D., & Fleming Seay, A. The Meditation Chamber: Enacting autonomic senses. In Proc. of ENACTIVE/07 (2007), 405-408. [10] Shaw, C., Gromala, D., & Song, M. (in press) The Meditation Chamber: Towards Self-modulation. G. Mura, (Ed.) in Metaplasticity in Virtual Worlds: Aesthetics and Semantics Concepts (2011), IGI Publishing. [11] Statistics Canada (2008). Study: Chronic pain in Canadian seniors http://www.statcan.gc.ca/dailyquotidien/080221/dq080221b-eng.htm. Retrieved July 15, 2010. [12] Treede, R-D., Jensen, T.S., Campbell, J.N., Cruccu, G., Dostrovsky, J.O., Griffin, J.W., Hansson, P., Hughes, R., Nurmikko, T., & Serra, J. Neuropathic pain: Redefinition and a grading system for clinical and research purposes. Neurology 70 (2008), 1630-1635. 1176