The New York Times Magazine 57In chronic pain, the body part that hurts may
be undamaged and even seem healthy; what’s
altered is the area of the brain that corresponds to
its anatomical location. Karuna extends the idea
of mirror therapy so that patients not only see
their aff licted body part as healthy and pain-free
in virtual reality; they also get to move it in com-
plex ways. In one module, patients pick up lotus
fl owers with their healthy arm and toss them into
a serene infi nity pond surrounded by mountains;
the V.R. mirrors the action but shows the opposite
arm doing the motions. Seeing themselves per-
form this novel action, in an unfamiliar environ-
ment that has no associations with pain, seems
to create new neural connections that eventually
help repair the dysfunctional parts of their brains.
At times, Karuna’s V.R. program exaggerates
bodily movements, so patients see themselves
moving more extensively in the virtual world
than in actuality; this further disrupts their brains’
predictive coding — or what they expect to hap-
pen when they move. If the brain predicts that
an action will be painful, then ‘‘it’s going to send
that threat signal out ahead of time,’’ Nguyen says.
But if people experience themselves maneuvering
more easily and with greater range in V.R., then
their brains may begin to recognize that increased
movement as safe — and, Nguyen hopes, eventu-
ally pleasurable. To that end, patients also score
points, accompanied by lights and dings, as in
video games, in order to activate the reward
centers in their brains. ‘‘We’re not trying to turn
you into a zombie that doesn’t experience pain,’’
Nguyen says. ‘‘But at some point, the brain has
gotten so good at making this pain signal. It’s very
vigilant, constantly looking for danger signals.’’
‘‘There’s no point in developing a technology
just because it’s cool,’’ says Leonardo Angelone,
who heads a program at the National Institute on
Drug Abuse that oversees, among other things,
F.D.A.-r egulated medical devices. If V.R.- therapy
companies can’t get their products onto patients’
heads, it doesn’t matter what the machinery can
do. That means a lot of people — would-be indi-
vidual users as well as decision makers in the
broader health care industry — will need to have
confi dence in the technology.
When Carol Dhainin heard about V.R. as a
therapy for chronic pain, she thought she ‘‘would
laugh in the doctor’s face if they gave this B.S.’’
Dhainin has struggled with chronic pain for more
than 15 years, following a series of dislocations of
her kneecap. The pain spread, until eventually she
was diagnosed with fi bro myalgia. She is 50 and
has had 28 operations. She takes opioids around
the clock, as well as several other medications, to
dampen her symptoms. After she tried physical
therapy, she was so exhausted that she slept for
10 days, setting her alarm to wake her every few
hours to take her pills. ‘‘When you’re in a full
fl are and you’re rocking and crying into sleep
in bed and your pain meds don’t work, virtual
reality is not going to do squat,’’ Dhainin says. A
tech- driven solution like V.R. can seem insulting
to someone who feels that she has tried it all.
‘‘To see someone say, ‘Oh, we’ll give you V.R. and
teach you to regulate your breathing’ — I’m like,
‘Didn’t you think I tried that already?’ ’’
Other skeptical reactions include preferences
for the convenience of pills over the encumbrance
of headsets, or fears that the widespread prescrib-
ing of V.R. will mean losing access to pain killers.
Nicole Hemmen way, the chief executive of the U.S.
Pain Foundation, views V.R. favorably — the more
tools available, the better — but she recognizes that
chronic- pain patients, who may feel that they have
long been ignored by the medical community,
now also face stigma and restrictions in response
to the opioid epidemic. ‘‘There is always a fear
that something else might come in the way of the
treatment you’re currently on,’’ Hemmen way says.
Of course, this assumes that medical providers
will eventually embrace the technology. When I
visited Cedars- Sinai, Spiegel had not yet been able
to get the E.R. staff there to adopt virtual reality. I
wasn’t surprised. The E.R. can be crushingly busy,
and it’s a place where expensive medical equip-
ment often gets damaged or lost; any extra bedside
therapy feels like a signifi cant burden in a system
that is already overwhelmed. In this setting, V.R.
seems to be one more time- consuming fantasy.
Even in less intense circumstances, some doctors
worry, V.R. could exclude those who don’t speak
English or who are disadvantaged and unable to
get the latest technology. In Applied VR’s study of
lower- back pain, nearly all the participants were
white and had at least some college education.
If doctors do start prescribing V.R., there’s
another hurdle to clear: Who will pay for it?
Aff ordable access to V.R. is Hemmen way’s big-
gest worry about the future of the technology.
F.D.A. clearance is most likely necessary for
the widespread adoption of any V.R. product; a
spokesperson for one major insurer told me that
the company wouldn’t even consider reimburse-
ment without the F.D.A.’s authorization. Payers
also want to see clinical trials demonstrating effi -
cacy and economic analyses showing that V.R.
can save money by keeping patients out of the
hospital and cutting down on expensive tests and
treatments. This is one reason Applied VR says it
prioritizes conducting studies.
Though RelieVRx has been authorized by the
F.D.A., insurers still don’t have to cover its cost.
The company hopes that by packaging it as a
single product, one that combines software and
hardware, its resemblance to traditional medical
equipment will lead to its acceptance by the Cen-
ters for Medicare and Medicaid Services, which
currently does not cover V.R. services. That could
change soon: In February, the C.M.S. approved a
code for F.D.A.- cleared software for behavioraltherapy, and a code is usually needed before
reimbursement is considered; a month later, a
bill was introduced in Congress that would push
Medicare to cover prescription digital therapeu-
tics. Private insurers determine their own poli-
cies, but the C.M.S. tends to set the standards.
Applied VR decided early on that if its product
is going to be used like a drug or a device, it needs
to function within the current health- coverage
environment. ‘‘It needs to be prescribed by doc-
tors and paid for by insurance,’’ Sackman says, ‘‘or
else this will be on the fringes for people who can
aff ord cash pay or believe in alternative medicine.’’
Workers’ compensation insurers, which have
strong incentives to help patients return to their
jobs, already provide reimbursements to Karuna,
as does the Department of Veterans Aff airs. Wein-
berg, Karuna’s chief operating offi cer, is hoping
to persuade companies to include Karuna in their
benefi t packages soon. The health care system has
been slow to fully buy into V.R. because it’s so new,
Nguyen says. ‘‘But our way in is: ‘Just try it out. What
do you have to lose? You tried everything else.’ ’’
In January, as Covid cases soared again, a man
in his late 50s with chronic back pain came into
the E.R. where I work. His pain killers were no
longer providing relief. He was unsure if they
ever really helped, but everything seemed worse
now, he said. He had been unable to travel; he
was stuck in his apartment, in pain, his doctors’
appointments scrambled with each pandem-
ic surge. I told him all I could do was order a
diff erent formulation of one of his medicines, a
desperate and often useless step that doctors take
when trying to alleviate chronic pain. But he had
come with an idea of his own.
‘‘Have you heard of people using virtual reality
for pain?’’ he asked me eagerly. ‘‘How can I get
that?’’¢Seeing themselves perform
this novel action, in an
unfamiliar environment
that has no associations
with pain, seems to create
new neural connections.
Virtual Reality
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