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the breath-fed tree as a way for visual elements
to ‘‘refl ect back to the user the changes that are
occurring in their own physiology.’’ She adds, ‘‘It’s
a powerful way to teach principles and concepts
that extend well beyond what we do in traditional
didactic cognitive behavioral therapy.’’ The sort
of biometric data that Spiegel and Liran captured
with their graphs are here distilled into an aes-
thetically appealing format that delivers imme-
diate, actionable feedback without interrupting
a patient’s immersion in virtual reality.
Because Jester left his headset at the facility
where he did physical therapy, he was unable
to use it for more than a year during the pan-
demic. But he discovered that he had retained
the lessons he learned in V.R. This is the kind
of lasting, real-world eff ect that V.R. experts see
as their ultimate goal. After all, as Hoff man, the
University of Washington professor, points out,
‘‘We can defi nitely reduce your pain while you’re
in the helmet, but you can’t stay in there all day.’’
RelieVRx also has modules that prompt patients
to redirect their attention through game play or by
allowing scenes — waves washing onto a sunny
coast, say — to soothe their nervous systems. The
average session lasts seven minutes, and patients
are directed to do just one a day for eight weeks.
Unlike the sort of V.R. that’s popular in gaming,
RelieVRx tracks only patients’ head movements,
meaning Jester can’t go up to the tree and grab
a branch (or chase cows away). The product is
designed to be easier to use than an iPhone — you
just strap on the headset and press the power but-
ton. Todd Maddox, a cognitive neuro scientist
and Applied VR’s vice president for research and
development, explains how RelieVRx works with
an example: ‘‘I am rewarding you with a tree that
fl ourishes for generating an appropriate breathing
pattern. I didn’t tell you to read a PDF or count in
your head.’’ But by using V.R. to engage the brain
in experiential learning, he says, ‘‘I have just set
you on a path for behavioral change.’’
To date, Applied VR has raised more than $70
million. Much of this money has been directed
toward product development and clinical trials. A
recently published study by researchers affi liated
with the company, for which they recruited sub-
jects during the pandemic through Facebook ads
and pain organizations, reported an average drop
in chronic back pain by nearly 43 percent for the
RelieVRx group compared with 25 percent forthe control group. For those who used RelieVRx,
pain also interfered less with their activity and
sleep. Three months after the last V.R. session,
these gains were mostly found to endure (and
sometimes they persisted for six months). If these
numbers hold up, they would indicate that users
had retained the coping skills they learned inside
the virtual world, as Jester did. Maddox hypothe-
sizes that the program ‘‘alters structure and func-
tion of the brain.’’ While acknowledging that he
does not have concrete evidence, he says, ‘‘You
don’t get changes in patient- reported outcomes
without changes in the brain.’’In mid- November, the F.D.A. gave Applied VR
authorization to market what is now RelieVRx
for chronic lower- back pain — a regulatory fi rst
that may pave the way for the agency to OK
similar V.R. products — in large part because the
side eff ects are minimal compared with those
of pharmaceuticals. ‘‘Medical- device regulation
is not drug regulation,’’ a senior offi cial at the
F.D.A. told me. ‘‘For V.R., some of those tech-
nologies and some of the uses we need to see
before they can be marketed. But we can also
envision and imagine there are some where
that’s not necessary.’’
Applied VR was founded by two entrepre-
neurs with expertise in business and market-
ing, not health care veterans. Sackman claimstheir backgrounds give them an advantage. The
fi rst questions he says he asked when he learned
about V.R. were: ‘‘If this stuff is so powerful, why
is it sitting in an academic lab? Why don’t more
people know about it? Why aren’t people using
this in clinical practice?’’ He answered the ques-
tions himself: ‘‘It’s because there aren’t people
productizing it. There’s not a business model.’’
Liran, at Cedars- Sinai, concedes the point.
‘‘We aren’t businessmen,’’ he told me. He and
Spiegel intend to keep their own V.R. products in
house. ‘‘The way we make money here is grants
— that’s our currency,’’ Spiegel says. ‘‘I don’t want
this to be suddenly sold and licensed commer-
cially, and now I can’t get an N.I.H. grant.’’ Apart
from a small one-time payment in 2016, Spiegel‘You’re tricking your brain,
using the visual system to move more, so that we have
bottom-up, top-down synergistic eff ects
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