The Multiple Realities of Pain

PAIN IS COMPLEX. When we talk about pain, we can’t help but draw from our own experience. Think about a time you might have been in pain. For me, it’s a recurrent low back pain which emerges every so often to remind me that being tall isn’t always a great thing. For you, it might be something different.Whilst you may not be able to summon up the actual sensation again, I’m sure you can recall the fear and anxiety,  the worry about the implications to your personal and social life. Pain might fade over time, but the emotional and social impact often remains.
As a result, when you try and treat pain, you neglect the whole person at your peril. While drugs can ease the physical suffering, the effect of that pain on the person’s life, relationships, and their standing in the world may go neglected.
This complex interrelationship was strikingly laid bare at ‘Ugly Lies the Bone’, which I saw at the National Theatre last week.
This is the second revival of the Lindsey Ferrentino‘s play, set in the heart of Florida’s Space Coast in 2011 at the time of NASA’s last shuttle flight. It focuses on the return of Jess, a veteran of the conflict in Afghansitan, horribly injured in an IED explosion. As part of her treatment she takes part in revolutionary new Virtual Reality therapy that helps her to escape her pain. As the play progresses, just what form that pain takes becomes clearer – the physical pain of her scars, the emotional and social pain of her return to her home and the effect this has on her friends and family, and how Post Traumatic Stress Disorder never lets her fully escape
It’s not really my role to act as a critic of the play, so I’ll keep that bit short – it’s brilliant, go and see it before it closes on the 6th of June. 
Olivia Darnley (Kacie) in Ugly Lies The Bone at the National Theatre (Photo: Mark Douet
Olivia Darnley (Kacie) in Ugly Lies The Bone at the National Theatre (Photo: Mark Douet
One of the characters in the play is simply listed as ‘Voice’ – the verbal presence of the therapist during Jess’ sessions in VR. Being a therapist myself I was particularly affected by her role, and it served to reflect the rather shallow focus that I’ve been guilty of in the past. Concentrating on the numerical rating of the pain, and the short-term goals of the treatment, the disembodied clinician seems to drift away from the other components of her patient’s pain, leaving her stranded once  the game is complete.

VIRTUAL REALITY HOLDS REAL PROMISE FOR MANAGING PAIN. From distraction and manipulation of the senses, to the respite from reality, and the freedom from physical limitation, we’re seeing examples every day of how this new technology can help people.
Two days after the trip to the National Theatre, I was able to explore this in much more detail in a meeting held at Digital Health: London. There I met with Howard Rose, CEO of Deepstream VR, and leader in the field for over 20 years. In attendance we also had Nick Peres, creator of PatientVR.co.uk and champion of immersive VR. Richard Dolan, Innovation lead at NHS Dorset CCG.
(LtoR) Keith, Richard, Howard and Nick – Clinical VR Aficionados
 We spent two hours experiencing COOL! and GLOW!, both Firsthand VR products used for the management of acute and chronic pain, and anxiety. Cool! was of particular relevance, as it is the direct ‘descendent’ of SnowWorld – the VR experience that played a part in inspiring the story of ‘Ugly Lies the Bone’. As with all VR, it’s a little difficult to convey the experience without it sounding daft – after all, I was throwing iridescent trout and glowing orbs at otters playing on the riverbank – but it did work to reduce my back pain.
GLOW! was particularly beguiling. In this I found myself sitting next to a stone totem with my heart rate illuminated on the rock face. A Leap Motion controller, attached to the front of the headset, meant I could see glowing outlines of my hands, which would summon and dispel fireflies as I opened and closed my hands. The stars above, the cicadas, and the babbling water, all conveyed through stereoscopic images and binaural sound had a remarkable effect on my pulse, leaving me calm and comfortable for hours afterwards.
Glowing hands, fireflies, and a soothing biofeedback experience in the world of GLOW! c Firsthand Technology
We then moved on the PSIOUS VR, which was demo’d by Richard Dolan. Psious is a Gear VR/Laptop based mental health application used to help treat mental health problems, particularly phobias and anxiety. Linked to a stress measuring wearable, the therapist is able to tailor a variety of scenarios to expose the patient in a safe and graduated way to their fears. Accordingly, I sweated my way up a construction lift bolted to the outside of a skyscraper, whilst Nick was taken through a personal fear – preparing for take-off in a commercial jet. Whilst the graphics were more basic than those of COOL! and GLOW!, it was astonishing how they nevertheless generated that familiar discomfort. The level at which VR can deliver benefit – at which point the immersion is ‘good enough’, is a question for researchers and those evaluating VR in healthcare.
Richard works as Innovation Lead at Dorset Clinical Commissioning Group, and it was great to see such a passion for innovation, especially within the NHS. I meet many CCG staff in the Digital Health sphere, and it’s encouraging to find everyone reaching out to each other and beginning to develop networks to share learning and opportunities. Similarly, Nick Peres at Torbay NHS Trust is doing amazing work with 360 video in highlighting the important of human touch in healthcare – patientvr.co.uk. You can find out more about his story on my podcast, CURISTICA.
Being on the receiving end of healthcare can transform your perspective! (Pic Nick Peres, PatientVR.co.uk)

WE’RE ALL AFFECTED BY PAIN IN DIFFERENT WAYS. Some, like Jess, suffer the full spectrum of misery. Others have a thankfully more fleeting acquaintance. For each person, Virtual Reality has a potential role to play. What was made clear in the play, and at the meeting, was how this role could be across every facet of pain – the physical, emotional, cognitive and social.  Given that VR is also not the sole preserve of the clinician, it suddenly becomes a much more interesting proposition. Unlike prescribed drugs, the tools for relief and recovery are now in the hands of the patient.
We need to work carefully to understand what evidence there is for benefit in acute and chronic pain. Are there potential risks or harms? Will VR work only while the user is immersed, or does it persist afterwards? We already have published evidence supporting VR analgesia, but precious little about how it can be scaled, and provided equitably.
For now, I go back to my day job a little wiser and more optimistic than I was before. As a Doctor,I need to step back and always consider the wider implications that pain has on an patient’s life. Maybe I can bring new hope to some of my more troubled patients, for those that have found conventional medicine lacking or limited by side effects. Maybe next time my back seizes up, I’ll reach for the headset before the tablets.

 Links & Declarations

I’d like to thank Nick, Rebekah, and Yinka at Digital Health: London for their kind assistance in providing a room for the meeting. All of the participants are colleagues I’ve met through meetings and on my voyage of Digital Health discovery through Social Media. I have no financial interest in any of the companies mentioned, although I am an NHS GP and CCG governing body member (Eastbourne Hailsham and Seaford).

All costs for these events, including travel and tickets, were paid for personally. My back pain is sadly provided for free.

Howard Rose – firsthand.comLinkedIn @deepstreamVR
Richard Dolan – Dorset CCGLinkedIN @RichPDolan
National Theatre – Ugly Lies the Bone – Lindsey Ferrentino @LindsFerrentino

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