Good evening, everyone. Welcome to NANS Educational Committee webinar session. Today we have a very exciting topic with STEAM faculty and experts in virtual reality. Our topic for today's webinar is exploring the virtual reality frontier in neuromodulation. Before I start, you will see the disclosures for our panelists. We're here to explore how virtual reality is not only revolutionizing the treatment of chronic pain, but enhancing the quality of care, improving patient access, and promoting care equity, which is another novel part of this advanced technology to take the treatments that we have in the hospitals and clinics to their patient's home, in their comfort, if they're in rural areas, and make it accessible to all the patients. It's an immersive interactive capabilities we all know that it has a lot of potentials in different aspects of medicine, but now we are exploring its potentials in chronic pain, and today we're going to talk about its role in neuromodulation. But luckily, we have three experts to help us to discuss this novel topic. We have Dr. Brent Spiegel, he is the author of the famous book VRX, and I recommend everybody to read that. He's the director of health services research at Cedars-Sinai Medical Center, and he's a leading figure in digital health with numerous trials, publications, and education nationwide and internationally regarding virtual reality and digital health. So we're all excited to hear his talk today. After that, we're going to have Dr. Maggott Gerges. Dr. Gerges is a renowned pain management specialist. He's a service line system chair at Ochsner Health System, where we work together, and I've had a pleasure to work with him for several years, and the last six years as colleagues, as a program director of fellowship, and him as a service line chair. And he has several publications, and he's been a leading pain physician in the societies and forefront of conducting research in pain management. And the both of us had a pleasure to work with Dr. Spiegel on NIH-funded grant on virtual reality and about rural areas access, which is the topic that is close to our hearts. And lastly, we're going to have Dr. Christine Hans, wonderful friend of mine, and it's always a pleasure to see her and learn from her. She's a distinguished professor of pain medicine at Mayo Clinic Florida. She's one of the leaders and innovators and researchers in pain management, and we always hear wonderful talks and innovative ideas from her in all the meetings. And he is a wonderful educator and spends a lot of time to educate the future pain physicians. So time to start. First we're going to start with Dr. Brandon Spiegel, and he's going to talk about the virtual reality in his, I would say, baby project. And he's a GI specialist, but interestingly, he's the wonderful expert other than being a GI specialist in virtual reality. Dr. Spiegel, podium is yours. Thank you very much for that kind introduction and for the opportunity to speak here today with this wonderful panel on this emerging and interesting topic of what I'll call spatial computing for chronic pain. Spatial computing is the newest term, although it's been around for a while, it's about using the three-dimensional space around you to help affect the human mind in a way that ideally can countervail noxious experiences like chronic pain. So this is a picture of a patient who is experiencing chronic pain. She's allowed us to show her image and she's about to try a VR headset. And she's one of over 3,000 patients that we have treated with virtual reality here at Cedars-Sinai in Los Angeles. When most people think of VR, they think of headsets like these. They might think about, you know, kids playing first person shooter games, things like that. You might think of this as a platform mainly for gaming and entertainment. But actually this has been around for a long time, since the mid 1900s, actually. We had early use of virtual reality, particularly by the Department of Defense for simulation and training. And then psychology labs around the world started to recognize that there was a value of these, not just for games and entertainment, but for affecting the psychology of people That could be used for negative purposes, even dystopian purposes, or for very positive uses, as we'll see today. The most recent version of all this is this device here. And this is an incredible device with 23 million pixels in it. And it's the next phase of using these technologies for patient care. I'm not going to mention any brand names here or companies, although these are not health care companies. But nonetheless, you may have seen this particular headset in the news recently. Now if you think this is an unusual topic, or maybe a niche field, think again, because this is a field that has been rapidly expanding. If you look at PubMed, and just look at the number of papers that have been published on use of virtual reality in general, we're going to talk about pain today, you can see an exponential rise. And that's consistent with the same thing you'd see if you did a search for artificial intelligence, you'd see an exponential rise. And there are now over 30,000 papers, not 30, not 300, 30,000 papers that are looking at the use of VR in health care. So this is now a field of medicine. And in fact, the FDA has a name for it. It's called MXR, or medical extended reality, which is now an FDA recognized field of medicine. On the left panel, you can see a website from the FDA on their MXR program. On the right is an infographic from the very first public workshop that they held back in March of 2020, just before the pandemic, where they brought a number of companies and hospitals together to explore the opportunities in health care of using VR. And since then, the field has only expanded. Now we have a journal, the Journal of Medical Extended Reality, JMedXR. I happen to be the founding editor. It is the official journal of the American Medical Extended Reality Association, the AMXRA. So if you're interested in this field, it's only $100 to join AMXRA. And it's a great not for profit society, association that is promoting the use of VR, including in pain medicine and other fields. If you're interested in more on this, we wrote the first AMXRA guideline recently, it's online. What is medical extended reality, a taxonomy that you can follow for those in the field. And then there's even the International Virtual Reality Healthcare Association. So this is an expanding field. Now let's talk about the uses of VR for pain. This is a patient who I saw many years ago. You can tell because this is an old headset. That's a Galaxy S7 smartphone, which doesn't exist anymore, snapped into a Samsung Gear VR headset. This patient has sickle cell anemia, recurrent severe pain. As you know, these patients can suffer significantly. Moments before we took this picture, he was doubled over in pain in his long bones and his chest. But at this moment, he's flying over fjords in Iceland in virtual reality, and you can see the emotional response on his face. And I'll tell you that afterwards, he said he didn't have pain. We'll talk more about how that is and why that is and how long that works and so on. But just look at the emotional response. You can see it. So this is my first of three key points here that will set up the use case of VR for pain. The first is that emotion matters. What do I mean by that? If you think about the most powerful memories of your life, both the positive and the negative memories, they're all tied to some strong emotional experience. It's emotions that drive memories and that drive learning. For example, if I gave you this lecture with a bunch of bullet points and didn't tell you stories, you would probably be bored and check in your emails by now. You might be bored anyway. I don't know. But if I show you a picture and tell you a story, there's an emotional component and you remember, you learn better. That's because 50% of our brain is dedicated to visual processing. Virtual reality hacks into that like no other audio visual medium ever invented. And that's the power is it taps into those emotion centers, which allows us to rethink ourselves, to rethink our own minds and bodies in a way that's powerful and therapeutic. The second concept I want to leave you with today is this idea of escape and the idea that escape matters. When patients experience pain, we all know, you know, this is not just a physical experience. This is a biopsychosocial illness experience. We can try to stop the pain at its source. We can try to treat the pain in the tissue. But the brain has this ability to keep generating pain long after the tissue has recovered. And so the idea then is how do we get people to escape the four walls, not of just the room they're in, but of the biopsychosocial illness experience that they're having, the four walls of their own mind. And here we have these cables in the foreground that almost make it look like she's in almost like a jail. And here we are with Dr. Amira Liron, who's a psychiatrist, and we're monitoring her heart rate, her heart rate variability, her pupil diameter, and her eye tracking through that particular headset, which has sensors built into it. And using an API, we're able to see her cognitive load moment to moment. And this is allowing us to create metaphorical narratives visually in the headset to try and countervail what she's experiencing. The third concept I want to describe here is this notion of awe. This is Harmon Clark. He's a patient of ours who has recurrent significant pain. He has allowed us to show his picture, tell a story. And when he comes into the hospital, the first thing he asks for is the VR headset. We have a VR consult service here at Cedars-Sinai, and he likes to go into outer space. He likes to go into space and look back upon the planet, upon the earth. He says it gives him a sense of awe. And by that, he means he feels as if he's part of something greater than himself. It gives him perspective about himself and about the world in which he inhabits. And through doing this, he actually feels less pain. He has used virtual reality to help titrate off of opioids and has given a separate talk about how he did that, augmenting traditional tapering approaches with virtual reality. He says it gives him goosebumps. And goosebumps is a neurophysiologic response to awe. You can actually see this experimentally. This is a study from Simon Fraser University in British Columbia. Are you awed yet? How VR gives us awe and goosebumps. What they did here is they took research participants, they put them in VR, and they had them fly up and over their city, which was Vancouver, and look down upon it. Then they flew up over the Canadian Rockies, and then they blasted them up into space, just like our patient likes to do, and look back upon the earth. And as they're doing that, they have an experimental setup where they have a camera that's monitoring goosebumps. It's called the GooseCam, looking on the forearm, and they can see this immediate rise in the goosebumps as soon as you get into outer space, which is something that astronauts report on the International Space Station, too. And so the idea is, how can we parlay all of this to help manage pain, these strong emotional responses that people are having? So these are the three concepts, emotion and escape and awe. I want to now show you the three concepts coming together with a patient. In this room, you can't see, there's a patient. The patient has severe recurrent abdominal pain, irritable bowel syndrome. So I'm a gastroenterologist, as you heard, and as a result, I'm sort of a pain doctor, too, because we see a lot of abdominal pain, visceral pain. And this patient has had all sorts of treatments. She's been on all sorts of antibiotics and all sorts of centrally acting neuromodulators, and she's been on all sorts of different therapeutics. About six months before we took this video, her son tragically died in a car accident, which only made her more anxious and depressed and upset and in pain. Nothing seemed to work. At this moment, she's in virtual reality, and you see two computers. On the left is a computer that's showing us her bio data moment to moment, which I mentioned earlier includes the heart rate, heart rate variability, pupil diameter, and it's all integrated into a single metric called the cognitive load. On the right, you can see what she's seeing. It's only in two dimensions here, though. She's actually on a beach looking at a mandala that expands and contracts, and she's breathing in and breathing out. She can see her breath coming in and out of her body. And when she first came in, she was in a whole bunch of pain. You can see physiologically, like her autonomic nervous system up here. This is a unitless measure called cognitive load. As soon as we started the virtual reality, it's like she had this autonomic collapse, almost as if she were hypnotized. We thought she was asleep, but we could see her eyes were open on the cameras. Right about here, she said she was in heaven with her son, and she was crying. And right about here, she said she was with God. Pretty profound. When we took her out, she said she had no more pain. She said, I don't have any pain at all. I haven't felt this way for as long as I can remember. She said, I feel as if I've been lifted up. I feel as if my nervous system has released its grip upon me. Like I can float now. Like I can finally break the chains of Earth's tug of gravity itself, pulling her down. That's a powerful thing to say. And when people say that, I will show them this picture. This is the glass brain by Adam Gazaley at UC San Francisco. And the glass brain is a powerful visualization of the networks within the brain. And what it shows is the brain is a dynamic, living, shape-shifting organ, like any other organ in our body. And I say the brain is not like a block of Play-Doh in your head rattling around. It changes. And even when we are in physical distress, even when we can't always fix the problem or put a needle into the problem or stop the inflammation or fix something surgically, you can still modify how your brain perceives your body. That's a profound realization for some people. And although the pain may come back by the time you leave this office or tomorrow morning, you have to figure out what is happening in your brain right now, because we did not inject you with anything. You did this yourself. Supernatural. And I literally mean that. Super means above, as in they found a level of consciousness above their normal level of consciousness. It's natural. Did it themselves. Their own internal endogenous opioid systems. So that's what we try to do and do it over a course of eight to 12 weeks of daily therapy. Now, we do know from functional MRI scans of the brain, this is studies going back to 2007 in the University of Washington, that VR can tamp down pain, not only in the sensory cortex, where you can see here, the sensory cortex is lighting up in this patient with a pain experience and also in the limbic system. The both physical experience of pain and the emotional and cognitive experience of pain are both tamped down, and that's been shown for a long time. This is research going back to the early 2000s with what now looks like an ancient game, but it still worked, called Snow World from Hunter Hoffman, University of Washington, where he had people who had severe burn injuries. This was more of an acute pain model. I'll get to chronic pain in a second, who were distracted by this experience. It was just a pure distraction, not even cognitive behavioral therapy. Just distraction was enough to change the spotlight of attention away from the pain and towards a more pleasant experience. This has consistently been shown to reduce not just the physical experience of pain, which is in the sensory cortex, but the emotional experience of pain, the time spent thinking about the pain, the unpleasantness of the pain, and they had more fun too while they were going through these bandage dressing changes. Also, he's been able to demonstrate combinations of VR with and without an opioid. This again goes back to 2007. There's a lot of data here, but in short, when the two are combined, at least in an acute pain model, there is a greater benefit than either alone and pretty equivalent for acute pain using virtual reality as distraction compared to an opioid, in this case, hydromorphone. We also have looked at this in the hospital. This is a randomized controlled trial that we performed several years ago of 140 inpatients with pain. It could be pain from any cause. They had to have scores of three or greater on the numeric rating scale, and we randomized them between having a VR headset at their bedside throughout their hospital stay, or they would use a two-dimensional screen, which was a form of a sham, which did have health and wellness experiences, but it wasn't immersive. When we combined them, when we compared them, the VR had a lower overall mean pain reduction over the course of the hospital stay compared to the TV, and when we focused on those with the most severe pain, scores of eight, nine, or 10 out of 10, that's where we really saw the largest absolute and relative difference in favor of virtual reality. Now, as I mentioned, I'm a gastroenterologist, so I'm always interested in other use cases, and here there's several studies now using it during colonoscopy, a study here demonstrating that when randomized to VR, not only does it lower pain scores, but it reduces skin conductance as well, demonstrating a change in arousal and autonomic response during what can be a very stressful experience for people. Now let's turn our attention to chronic pain. This is a study that is an important study in the field, a study for an eight-week self-administered at-home intervention. This is an FDA-cleared intervention, and this was a study comparing an active VR program versus sham VR, and the sham VR, you have a VR headset, but you're not immersed. You're just looking at a two-dimensional image, in this case, of various nature scenes, and when the team looked at the average pain intensity over the course of 56 days, they saw separation in pain scores in favor of those receiving this VR intervention. The VR intervention includes psychoeducation, it includes breathing exercises with biofeedback, and it includes, you know, distractive games as well, and a variety of other modules. Now we've been interested in this as well, including working with the Mayo Clinic Florida. Our colleague here comes from there, so Dr. Brian Lacey, Dr. David Kanjemi, and I have been working together looking at how do we use this for chronic abdominal pain, and we've been looking at chronic functional dyspepsia, a very common condition that we see in gastroenterology where there are no FDA-cleared therapies, and we recently conducted a virtual reality randomized controlled trial, sham controlled, and found benefits for recurrent functional abdominal pain. This is a study that we're doing with our colleagues here, with Maged and Yashar, and at Ochsner. This is a study, a randomized controlled trial in rural America, looking at two head-to-head interventions, both digital home-based interventions, where on the left, we send them this therapy called Pain Trainer. This was actually a not-for-profit company that was developed out of NIH-funded research versus this three-dimensional VR program, which is a branded program, so I won't mention any names there. But this is a head-to-head study of two different interventions, 2D versus 3D. We don't have the results quite yet, but I will say we will very soon have the results because we've just completed this study, and we're digging into it now, so stay tuned for that. I'm going to end, I'm just about done here, with another example of how we're using VR for chronic pain. This is an AI-enabled system where a patient can use a VR headset and then talk to a robot, specifically a robot, not a human. It's a robot that here looks a little goofy, but is a psychotherapist. We worked with our psychotherapists to train it over the course of about six to eight months. At first, it was a terrible psychotherapist. After about three months, the AI got smarter than I ever could have imagined it would and started causing people to cry with positive tears, having emotional breakthroughs, coming to the hospital and asking for this robot. It even can write a note and send it to the doctor and put it in the chart. This is an example of what the note looks like after a patient engages with this robot in virtual reality using cognitive behavioral therapy. And the whole idea of using VR, this is what it looks like, is to be able to use the AI to change the environment. This is what it looks like at home. Patient in the hospital, for example, could be talking about how anxious they are, and the robot will pick up on that and put them in a forest. And maybe they're experiencing severe pain, so they're going to provide some cooling tones like the blue light on the chest there. Or if that scene isn't working and the AI detects that, it might make it a bioluminescent forest. And it will continuously change while doing cognitive behavioral therapy for pain while in this environment. So this is an example of using these advanced techniques with AI and spatial computing combined. We wrote a paper about this recently, which you can see there. I will say I have a conflict of interest, although this is not a regulated product, it's not a medical product, but this is something developed at Cedars-Sinai that is available separately. Okay, so I'm done. If you're interested in these topics, we have a website. This is our website called virtualmedicine.org, and you can check it out to learn more about what we do. We put on a conference every year in March, which is always very exciting. And you heard earlier that I wrote a book about this stuff, so you can check that out if you're interested. And since I'm sitting here in Hollywood, I'm going to end with a scroll to thank all the different people that participate in our research here. So thanks so much, guys, for the invite. I hope that was a helpful quick overview. And I'm going to end there and pass it along to our next speaker. Thanks again. Thank you so much, Dr. Spiegel. It's amazing that every time you hear from Dr. Spiegel, he is able to surprise you and amazes you with the new advances in virtual reality. And now we're hearing about integrating AI, and I'm sure we're going to hear more about these two amazing technologies as a solo treatment or even adjunct treatment. But next step is going to be talking about neuromodulation. We are talking from NAND society, and we want to see if this advanced treatment, how it can be beneficial, and what are the potential benefits and challenges of integrating virtual reality in a neuromodulation practice. And we have Dr. Maggott-Gerges over here as an expert in neuromodulation and virtual reality to talk to us about this topic. Thank you, Azhar, for that kind introduction. And it's actually very hard to follow up with Dr. Spiegel. I mean, he's one of the founders like for medical VR, and I work with Brennan for a while now. I recall our first meeting, I had the wow effect or the awe effect when I heard his lecture the first time. And still every single lecture that Dr. Spiegel gives, give me that effect, who I am very grateful to hear his lectures all around multiple society. I'm going to talk a little bit different on that, and I'm going to, you know, go two steps backward just to differentiate some old terms, either old terms, and, you know, if you talk to Dr. Spiegel, he'll tell you like, okay, mixed reality is now most probably the term that we use. But just to have an idea, if anybody doesn't have had experience a lot with virtual reality, there is virtual reality, there is like mixed reality, and there's augmented reality, and some people use immersive reality. And I think the future is going to be more towards mixed and immersive reality. And immersive would include a lot of things. And I want to tell you like mixed reality is really compared to a newer technology that have hit the market recently, without talking to brand names, but it would take whatever you're seeing, whatever you're doing and mix that with a virtual reality or computer generated image. So I want you to keep that in mind whenever we talk about this mixed reality. More of immersive reality to come, and I think, as Dr. Spiegel said, the military had way years in advance in creating that, and particularly now they are more focused in immersive reality. I think that would help us a lot, especially in mental health and cognitive therapy, and these would include some sensation. And I'm going to come to talk about the challenges of virtual reality that we got right now. And some of the challenges is that, you know, a surgeon would say like, it's never going to imitate the real surgery, or I wouldn't feel the same feeling. And a lot of people would say like, there's a lot of things that goes into learning, for example, in, you know, multiple sensation, and you're only, you know, expressing some virtual reality through a visual field. How about the sense of touch, the sense of smell, the sense of hearing things differently. And all of this is coming up. I'm going to tell you that I was in a conference talking about virtual reality, and I meet this hedge fund person that really helps a lot of startups, and she said, well, I work in virtual reality, and I used to work in gaming, and she mentioned a famous game that makes billions of dollars up till now. And I was like, is that, and she was like, I was supposedly designing the virtual reality for it. But now, even the founder of this gaming system is like investing in creating more senses to the game. And I was like, what do you mean by more senses? She was like, imagine a headset that can mix certain chemicals to get you a smell of a burn or a fire, or a smell of, of dust or a collapsing building from, of a gunpowder. I was like, what are you talking about? And she was like, imagine that a headset can do that for you by mixing certain chemicals at a certain time or from a movie or a game. And that was mind blowing. And I think that's going to be the future of, of actually immersive reality. So application of virtual reality is numerous, and you can think about starting the gaming industry. Now it follows up everywhere in, in particularly medical or health. boomed up about $19 billion net worth of investing virtual reality in healthcare right now around the world. I can tell you, it depends on where you read about the net worth of virtual reality. But from multiple sources, it's somewhere between 45 and 55 billion in the year of 2024 of all virtual reality, including gaming was expectation to increase by 26% in 2029. And by 2032, there's a huge expectation that it would reach $300 billion. I just want to make you understand that neural modulation up till now didn't get fraction of those numbers. And that's one pacemaker. Other things in healthcare have not reached those numbers with a lot of investments that people think about even, even automated cars and, and AI, even up till now, don't hit those big numbers that virtual reality will be hitting in the year of 2030. So I think it will invade not only the gaming entertainment industry, it will be everywhere. And I can tell you, there's a big look of safety, there is a lot come from army research that would trinkle down to like firefighter, police, architecture, design, and other things by imitating scenarios in virtual reality and asking people to react for it. And making sure that the people have good reaction and, you know, teaching, like looking a little bit further in the psychology of this in doing it over and over and over. And I go, I'm going to talk a little bit about it in medical education. So application is in education is numerous, numerous, I took some articles over here, you can go ahead and see those articles for the sake of time, I'm going to like really pass through articles really fast. But these are specific for medical education. You can see a lot of application of chronic pain, Dr. Spiegel, you know, particularly mentioned some in, and you can see also, I think the next speaker, Dr. Hunt's gonna mention some of those, but it is really invading the world of chronic pain. And it's either invading in acute or chronic pain, and even post-surgical pain, there's a lot of application to virtual reality. And as we have seen in the previous lecture, it is even used for perioperative surgical pain. And there's multiple actual studies are coming out about people doing multiple procedure while wearing a head of virtual reality and comparing that to receiving analgesia or sometimes anesthesia by itself. So it's coming and it's coming like particularly to chronic pain and even osteoarthritis is going to be a placement for having virtual reality. Now, application in neuromodulation, I'm going to just show you multiple articles. The first article, I'm going to leave to Dr. Hunt to dive on in detail, but it just discuss a specific study that done by multiple scientists and researcher and included a famous figure of neuromodulation. That's Dr. Rezai. He's a famous neuromodulator neurosurgeon, and I had the pleasure of working with Dr. Rezai when he was in Cleveland Clinic, and he's such a great researcher. And they just talk about in this study, particularly how can we utilize virtual reality to map certain areas of the body that we have prosthesis of neuromodulation versus not doing that versus actually not having virtual reality at all. And they figured out as they map and make the person immersed in a virtual reality scenario and figure out where the stimulation is, they have better analgesia. I think recently it really hit where in another study looks at education, and this is another study that comes from Seoul, Korea that actually used a certain program to develop education for trialing and implanting a spinal cord stimulation, utilizing virtual reality and showed great success and actual better learning pattern from actually using those on cadaver as a learning modality for it. And I will show a small video at the end that show you how some of those are designed. Now, there's multiple studies that went a little bit about discussing the role of virtual reality in spinal stimulation, spinal cord stimulation, the feasibility of it, what are the challenges, and some of them even went a little bit further to discuss it in neurorehabilitation using neuromodulation. Some went in again to even discuss the utilization of virtual reality with vagal nerve stimulation and even with randomized controlled trial to look at that in actually combining it sometimes with DBS or deep brain stimulation. You can see also multiple trials coming up discussing virtual reality and treating patients with fibromyalgia or doing pilot studies with application of virtual reality, people with Parkinson's and utilizing deep brain stimulation. I would say I'll focus more of like what's the benefit of this as a neuromodulator. So I think of it as a neuromodulator and I look at it in the big portion of it. I think there's a lot of studies that would come in combining that with the treatment of spinal cord stimulation and augmenting that treatment for us, making the analgesia of the spinal cord stimulator better, the adherence, the compliance. I'm thinking a lot of studies that would come and combine AI with virtual reality while evaluating patient to give us also some form of realization of how they are doing with neuromodulation. So not only instead of like collecting their data through a smartphone or a digital app, we will be able actually to collect those data through virtual reality and understanding better the functionality of the patient. So I wanted to imagine, we always ask our patient after putting a spinal cord stimulator, how many steps can you do? How about your function? Actually, when they are wearing a headset and doing things, specifically exercises through virtual reality, we can have a better idea about how the treatment is helping them. But I'm going to take a little bit step back and talk about what is available right now. And what's available right now is helping us actually educate in surgery. And when I think about surgery, I think about spinal cord stimulator trialing and spinal cord stimulator implant, similar with DBS and peripheral nerve stimulation. So you can see that multiple things have developed in, and I want to have an idea about like there's a lot of like development right now in surgical gloves, digital surgical gloves that's connected to virtual reality set and looking at the sensitivity of those gloves to touch, to pressure, to even suturing and understanding different types of suture. So there's newer gloves that's being created every day. And one of my colleagues surgeon tells me there is this simulator of suturing that even if he closes his eyes and from his experience, put his hands in those gloves, he would tell once he suture if that's a silk suture, bicryl, monocryl, and that's how accurate those gloves are giving those sensation in right now, combine that with virtual reality. I think you can give a great experience to a learner, especially in the surgical field. Multiple studies have showed the benefit of augmented reality, especially in surgery. And now more studies are showing up even the help of augmented reality of multiple surgeon being in different location of the world and utilizing virtual headsets to help each other in one of the surgeries that happened in England, actually showing the implantation of a spinal co-stimulator. And you can see there's a lot of things. You can augment that reality with some stereotactic imaging and other images that can help. Recently, one of those augmented reality systems have been helpful in a spine surgery done in England where actual nursing and assistant in the surgery was able to look at the manual of certain instrument and discuss with the surgeon while giving them this new interest, this new instrument, what they think these instruments are doing or how this instrument would be helpful for the surgeon in lifetime better than other instrument. So only by looking at the instrument, they kind of like get data about that instrument and a video about utilization of assembling an instrument for the surgeon. And I wanted to imagine how much time we actually waste in trying to explain to a surgical assistant how he can, you know, get everything ready for the surgeon that can be done in real time while wearing some of those augmented glasses. So you see a lot of benefits that can help us in neuromodulation, either in the stages of trialing surgery implant, or even after putting the spinal co-stimulator and augmenting the analgesia that we get from that therapy. Now, let's talk about challenging. Challenging would come in enormously like challenge of VR. What's the challenge of VR? We got challenges everywhere, and COAST would be one of them. We have challenges specific for education, and I'm going to be specific to education, move to neuromodulation. So for education, and if you're thinking about educating some younger neuromodulator, you have to understand the virtual reality, there's a reduced face-to-face time. Whether I'm telling you those surgical gloves and virtual reality is coming to be as realistic as possible, it is still not imitating the same touch. So you got this lack of face-to-face time, you know, you got this high COAST, you have the user attitude, because sometimes you only have a user avatar. You can't read facial expression of the trainees, you can't understand what the student is thinking about, and this is something that's very important for surgical training, because a lot of the time the surgeon teach the residents and their fellows a lot about managing anxiety during a critical surgery or something like that, or how to manage complication. You can see like specific challenges, and also specific challenges of designing. When we design virtual reality for like helping surgery and neuromodulation, it cannot be like a gaming system. It has to be interesting, it has to be attractive, but at the same time, it has to be realistic to whatever they're going to see in the OR, which means that we have to depend on expensive design and the design has to be, it's going to be a little bit challenging. Also, facilitating the incorporation of that design while you're wearing a headset and actually in an actual surgery or actual virtual reality world to imitate that particular surgery. So you have also some side effects of virtual reality. A lot of people like myself have to fight a little bit with the headache or the nausea whenever they're in virtual reality, and some people can't even use it because of that. You have some challenges that I think are specific for neuromodulation. It was not utilized in the neuromodulation world that much to say that these are the challenges that are specific, but you have cost of equipment, developing a software, like I mentioned. These are really expensive. Technical limitation of wearing all those headsets and trying to manage doing a spine surgery or implanting a spinal cord seminator and doing stitches while wearing all those devices. You get some side effects, like I mentioned, and then you get the clinical organization issue. And, you know, we have enough issues with implementing just EMR. How about implementing virtual reality going into the EMR? That's going to be accepted as easy. Is there going to be like a safety committee to talk about how wearing a virtual reality is going to be might endanger our patient in certain situation or certain surgery? You got lack of knowledge. You have to teach a lot of people about virtual reality, including your patient. You don't have that much research, unfortunately. Neither are the neuromodulation nor in the challenges that would affect virtual reality in medicine because of while it's now starting to be used, it's not as a normal based, you know, something that we use or do every day. You're going to have a lot of regulation. I'm glad to see that Dr. Spiegel published the guidelines. I think there's going to be a lot of issues about guidelines. And, you know, I fight with my peers every day for something new. And I think that might be a fight. And I don't I don't I don't see right now insurance would say, oh, I would pay more for that surgery because utilize virtual reality for it. And then you have a lot about cybersecurity issues. We all know what is happening right now in the medicine world where the cyber attacks is really is real is a real threat. So you have to also remember that there's a lot of patient information and medical knowledge utilized through those like virtual reality headset that would have controlled cybersecurity. I would leave you with one thing, and this is the video that I got from permission from Dr. Gould, who is an orthopedic surgeon that actually is the CEO of that company that helped train in virtual reality. And this is like their first dibs on thinking about how can we utilize virtual reality in chronic pain management? And you can see it's a transforaminal procedure where you can have a lot of access to the spine. Think about it. Look at the X-ray. Take a picture. See in three dimensional image where your needle is and move it and understand it better and then put it back and continue doing the procedure. So I'm hopeful that that's going to be our future learning for our trainees and our fellows, especially in the field of neuromodulation. So in my conclusion, I think despite all the challenges, definitely there is more good than bad in virtual reality for neuromodulation. But a lot has to be done in the future to make this modality better for our training. And with this, I will leave you. Thank you, everybody. All right. Thank you so much, Dr. Gerges. Wonderful talk, as always. It's interesting to see that the more virtual reality opens this space in medicine, neuromodulation, chronic pain, the challenges with that, with the cybersecurity, HIPAA and cost access. these are all issues that we will start and we have to continue to look at those and probably regulate those challenges for the future purposes. So our next panelist, Dr. Christy Hunt, she's gonna talk about and educate us and the future directions and research opportunities in VR-enhanced neuromodulation. And we're gonna talk about the hurdles and the future of this treatment in neuromodulation. Dr. Hunt. Thank you, Dr. Ashaghi. Thank you so much. Thank you for the very kind introduction, especially at the beginning as well. It's an honor to be here and excited to talk about this topic. Although again, hard to follow up with both of those earlier speakers who are really doing, is at the very cutting edge of this new therapy. So I think when we think about virtual reality and we think about future directions, it feels like the future, it feels like we're already doing futuristic things, right? Everything that Dr. Spiegel and Dr. Gerges spoke with you all about are things that are really being used at the very cutting edge and are not widely adopted clinically. So to a degree, talking about the future of virtual reality is actually talking about what's being done right now because it's just not here yet. We talked about some of the barriers to those things, but there's a lot of exciting promise. So we're gonna try to look a little bit at the neuromodulation research that incorporates virtual reality and try to make some guesses or predictions regarding the role of virtual reality applications and neuromodulation. So what are we gonna try to do? We're gonna try to predict the future a little bit. So we think about applications of virtual reality and pain management. This is really important because virtual reality is a tool that means so many different things and almost an endless array of applications. So it's tricky, I think, to think about what do we mean by applications of virtual reality? It's incredibly wide. So let's look a little bit about what's being researched. There are currently 105 studies listed on clinicaltrials.gov investigating chronic pain with the incorporation of virtual reality, 46 of which are complete. So what do these incorporate? So a lot focused on hypnosis and distraction. So post-surgical applications with pain management and controlling anxiety, procedural distraction, which we use at Mayo Clinic in Florida in very select cases. We sort of have one headset that we can use. And then in the inpatient setting, and Dr. Spiegel described actually some really neat applications of that. Virtual reality is also being studied in things like mindfulness, meditation, behavioral therapy, biofeedback, a lot of this kind of psychiatric literature and psychiatric applications. They were sort of one of the earliest adopters of this. And then as a physiatrist, I think a lot about rehab augmentation. My first encounter with virtual reality was actually in the rehab setting. And I remember the very first one I ever saw, this was years ago, back at University of Washington. They were, for occupational therapy, they were having patients sort of practice taking fruit off of a fruit stand in virtual reality. And the goal was to just practice that grabbing and reaching kind of motion. So, it was very simplistic, right? And nothing like it's already come light years ahead. But very early on, this has been used very widely adopted in the inpatient rehab setting. And that has really been something that's been going on for years. So, but when we think about rehab augmentation ambulatory setting as well, we think about, and the clinical trials are studying low back pain, mirror therapy, studies in motor recovery and also telemedicine applications, of course. And then of course we have neuromodulation, which we've talked about a lot this evening. So, virtual reality is really unique in that it's a modality with an incredibly broad range of applications. So, we can sort of cherry pick a little bit interesting things to talk about, but it's just very wide and diverse. And so, I wanted to highlight that a little bit here. So, this study was really interesting. I think this is one of the most well, this is the most well done study that's been published to date, in terms of study design and how to look at therapies like this. So, this was an eight week cognitive behavioral therapy based self-administered program. They took individuals with reported chronic low back pain of at least six months with an average pain intensity greater than four. So, these are patients in moderate to severe pain that have been chronic. And they were recruited nationally through various chronic pain organizations, healthcare organizations and online advertisements. And they took a standardized 56 day program that's proprietary and they delivered virtual reality content through a prescribed sequence of daily immersive experiences. And they ranged in time from two minutes to 16 minutes. And they, again, what was very important, this was a self-administered program that patients administered to themselves at home. So, they called this the proprietary skills based VR for chronic pain therapy, as an, again, an eight week sequential multimodal self-administered immersive therapeutic program for in-home use. And they combined sort of self regulatory skills that are widely used in cognitive behavioral therapy, things like diaphragmatic breathing, biofeedback, cognition, emotional regulation, some mindfulness principles and pain education. Those sort of like a pain rehab in your own home, but really augmented with this virtual reality. And they had 188 patients. So, when they looked at their results, again, and again, I think this was also, was a really well-defined study. When they looked at their results, they saw that at 18 months after the conclusion of treatments, they had to give the headsets back after eight weeks, the average pain reduction for skills based VR for chronic low back pain was significantly larger than that for the sham group. And that was statistically significant, as well as in pain related stress and pain interference with activity. Interestingly, mood didn't seem to have an impact. So, it didn't seem to be the case that this was all mediated through improvement in mood or improvement in depression somehow. It definitely seemed that the overall pain scores and pain based interference were not necessarily directly related to mood. So, the VR group definitely did better. And these results were sustained at 18 months after treatment. So, again, when you sort of, you know, kind of bottom line it here, more than 50% of the patients maintained a clinically meaningful reduction in their pain interference at 18 months. So, that's a pretty good number. So, when you look at sort of what are our standard responder rates, 30% to 50% in terms of responder rates, we saw that substantial, the majority of patients did maintain some significant pain relief at that 18 month mark, which is pretty impressive for this type of cohort of patient. So, moving forward to our next study here. So, this was a study that looked at virtual reality enhanced spinal cord stimulation. And then Dr. Durgas referred to the study. They took patients with chronic leg pain that had a spinal cord stimulator implanted for at least three months. And they wanted to do some sort of paresthesia based testing. So, what did they do here? It's kind of an interesting study design. So, they took patients and they positioned them such that they would, when the patient was looking at themselves, they would be able to, you know, perceive, okay, this is my right leg, this is my left leg. They called that the SCS congruent group. And then they're the portion of the group. They rotated their body 90 degrees counterclockwise to induce a misalignment between visual feedback that they experienced with the VR headset and SCS induced paresthesia. So, everybody's wearing headsets. And then for some of them, they're able to look at their legs and what they're seeing in the virtual reality in terms of the laterality of the leg is the same. It's congruent. And then they took another group and they flip-flopped that so that it was incongruent. And then they applied paresthesias and they used the VR headset to basically augment that paresthesia sensation. And they did it for about seven and a half minutes in each subject. And they took their pain rating at every 90 seconds. So, you can see here, this is sort of, they're trying to kind of show you, you know, where the patients would be able to visualize, okay, where's my paresthesia. And when they looked at the group that had just virtual reality alone, no sort of SCS stimulation, they didn't change. They pretty much stayed the same. But when you took the patients with the incongruent SCS virtual reality group, they actually got a little bit better. But the group that had the congruent spinal cord stimulation with the virtual reality headset, those got significantly better with statistical significance. Now, this is a very small study, only 15 patients, obviously just a pilot study. But again, an interesting way to think about virtual reality actually enhancing that sensation of stimulation and more importantly, the analgesic benefit that patients are getting out of that stimulation sensation. So, this was just really a case report study here, but again, as a physiatrist rehab doc, I thought this was pretty interesting and really kind of shows how in a rehab setting, these applications that have been widely used can really be ramped up. So, they took a patient who was a T9 and based on their description, she seemed to be in Asian impairment scale level B, although they didn't really say that, but this was following a TAA dissection. So, she had a significant spinal cord injury. And if anybody on here is a physiatrist, you know that rehab docs and physical therapists have been using functional electrical stimulation, FES for years. So, they're very familiar with neuromodulation, right? So, these are kind of externally applied electrodes and this was a little bit different, but they took this patient who was an AISB. So, she has some sensation, but she doesn't have functional use of the limbs. And over about a six month period, she was kept in rehab for a much longer than we're able to keep patients in rehab here. They applied these external electrodes and they were able to sort of try to induce some muscle activation. They induced contraction of the quadriceps, hamstrings, triceps, tibialis anterior, and they wrapped it kind of around her waist thigh and then her distal lower limbs. And this was performed as self-training. So, the patient kind of engaged in self-training separately from our physical therapy, five times a week for 20 minutes at a time. And it was just enough so that the muscle contraction appeared and was there, but could be tolerated. And they noticed that she started to develop slight development of contraction herself several weeks after starting the protocol. Then they incorporated some virtual reality here. So, in order to try to increase some truncal control, they sort of had this little game where the subject put this headset on and she was sort of had this little tool here to try to kind of catch this ball. And they would be able to sort of influence how far away the ball was to try to help with feedback for that control of the trunk, which is very important for our wheelchair, for our users who mobilize from a wheelchair base. So, if any of you guys have been in a rehab gym, you'll kind of see the physical therapist might kind of toss one of those sort of floaty balls kind of around and try to help the patient practice some of these truncal control movements. But this could be a lot more specific and tailored to the patient's individual needs. And then again, they realized that after six months, the patient did main significant gains in urinary function, as well as some motor strength. She was able to increase her walking distance from 120 meters to 600 meters with AFOs and lost strand crutches. Again, we know that these patients are gonna gradually get better over time, but typically we think about two levels over the course of six months to a year, not necessarily as much function as she regained. But so, just one case study, but just interesting examples of some use there. So, what about our future applications in neuromodulation? I wanna make sure we have time for questions and we're coming up at the end of the hour. So, you guys have heard a lot this evening. I wanted to wrap up several things. Patient education, trainee education, of course, but patient education is a big one. CBT enhancement of neuromodulation therapies is really promising. Enhancement of analgesic benefit of therapies in general, but particularly as neuromodulators, we think about neuromodulation and also providing some enzyalysis during treatment. From a research standpoint, it's really interesting to think about VR augmentation of SCS applications, particularly in our spinal cord injury patients, as well as our pain patients. And then also thinking about some programming assistance and also ongoing monitoring, potentially remote monitoring, some exciting applications there. So, with that, I'll make sure we have some time for questions, just to wrap things up. Applications are growing. They're not widely used yet, although we use them a lot in rehab applications and opportunities for patient education haven't really been well-studied yet. So that's probably an interesting, promising future target. Thank you so much, Dr. Hunt, a wonderful talk. And as always, a very interesting topic. I have a few questions, but we don't have a lot of time. I'm gonna start with one question for all of our panelists, because the topic is the applications of virtual reality neuromodulation. Other than distraction, CBT, other than educational benefits of virtual reality, I'm hearing that Dr. Spiegel mentioning that even virtual reality might have synergistic effects with opioids. What if it might have a synergistic effect with neuromodulation? Do we think that there's a role to salvage a failed or starting to fail neuromodulation to reprogram the patients? Is there any role that maybe even to give the experience of a trial, spinal cord stimulation trial for the patients before they actually go to the trial, so they will have a much better realistic understanding of what spinal cord stimulation is gonna give them? Would it improve the outcome? So, Dr. Spiegel. Yeah, well, I'm not a pain doctor, so I'll start with that caveat, but as you guys know well, pain starts on the periphery, you got nociceptive, neuropathic, and nociplastic. So the three forms of pain are going to coexist, and the longer the pain is, or the tissue is damaged, and the longer the transmission systems are being activated, and the longer the brain is being stimulated and having to integrate those signals, the more that circuit is going to burn itself in all the way from end to end. And so it only makes sense that we use multimodal therapy, and there may be synergy. It might be hard to know in any one individual exactly which of those three forms of pain are driving the experience of pain the most. So to use synergistic therapies, neuromodulation, spinal cord stimulation, along with centrally acting therapies to try and change the brain's perception of the pain itself, the sort of nociplastic component of this pain makes sense to me, and I think I'd love to see more research seeing if there's an incremental gain, not only for failed, but even for first-time neuromodulation to see if partnering that with VR could be effective over and above monotherapy. Wonderful. Dr. Gerges. I mean, I agree with Dr. Spiegel, and I think there's, if you think about pain differently, you can think about where VR has an effect to help that in specifically neuroplasticity, where there's a lot of sauce. There's a lot of actually research talks about phantom limb and utilization of VR. Problem with spinal cord stimulation or neuromodulation, I'm not going to talk about deep brain stimulation. I unfortunately don't have a great experience with those, but I'm going to talk more of spinal cord stimulation. It's like the understanding of mechanism of action is not clear in spinal cord stimulation, but definitely there's a lot of correlation of looking at functional brain imaging studies. I have to give it up to a couple of researchers, specifically in University of San Francisco, that looked at actually functional imaging. And I think that's where we can actually see VR help. So I think two things. I think practically right now, VR can help us in cognitive behavioral therapy of somebody who have an existing spinal cord stimulator. So a lot of our failed therapy might've been missing that part of spinal cord stimulator. And now there's a lot of technologies that are coming in Dr. Spiegel. So AI-induced virtual reality, you know, type of therapy is something that's going to be available to everybody. We dealing with a lot of chronic pain patient, they have a limitation of finding a psychologist or a psychiatrist to help us go in this behavioral therapy. So that's one. The second, I always feel like it can help us measure function because there's a lot of activities in gaming that can be done with virtual reality that actually while doing that game, measure a lot of things for us and give us a realistic functional improvement baseline versus when we put a spinal cord stimulator and neuromodulation. I think the third is where the technology in the future is coming. And I think there's going to be a multiple things that are going to be attached to this virtual reality that's going to give us idea about heart rate, tachycardia, breathing frequency, and maybe in the future, EEG monitoring that would give us a lot about spiking of pain, combine that with ECAP monitoring from spinal cord stimulator. I think we have a very futuristic spectrum to look at a spinal cord stimulator patient and realize exactly what's going on and when they peak for pain and when the therapy fails them, and we might dive deep and understand better how this therapy is working and how can we salvage that. Excellent. Dr. Hunt, great points from Dr. Spiegel and Dr. Gerges. What do you think? Is there any role in an expanding role? We know that this is potentially an expensive treatment, access might be an issue, but it can change the practice. It can improve the outcome. It might actually be very easily justifiable as financially cost-effective. Where the future stands? Yeah, that's actually what I was going to comment on. So I totally agree with what everyone's saying and it's very exciting to think about applications, but we are definitely at a point in healthcare, particularly in pain medicine, where we have to show benefit to payers and the bottom line, it's going to come down to, financially, is this something that is NOI neutral at least, if not even better, sort of provide some sort of cost savings. Now, what can that mean? That can mean substantially improved outcomes. What Dr. Gerges talked about with sort of surgery, maybe not necessarily in pain medicine, but if there are other surgeries where we can perhaps reduce length of surgical time, improve surgical outcomes substantially, reduce length of stay, reduce that 30-day readmission rate. Those are going to be things where this really matters. And I think we're going to have to show in those types of use cases before we can think about really expanding them widely to pain medicine, because just showing that they improve patient outcomes in terms of pain relief or analgesia, I don't know that that's going to be enough yet, at least not in the space that we're operating in. So what I think we're going to have to see is we're going to have to show that there's some substantial benefit in selective types of use cases. I really like what Dr. Spiegel, Dr. Gerges are both doing. So it's going to either be that sort of kind of, sort of the basic, you know, using the headset to provide some procedural angiolysis and some of those CBT applications, which are great. But when we're really thinking about that next generation, that really immersive, connected experience that we all, that Dr. Gerges and Dr. Spiegel both talked about, I think we're going to have to see some, there's going to have to be some real data showing some improvement in some of those bigger outcome data in terms of cost, big change in terms of safety. Like I said, reduced length of stay, reduced 30-day admission rate, that sort of thing. Excellent. Thank you so much, everyone. Wonderful talks, great opinions from the experts in the field. This is a technology that continues to evolve and grow and surprise us with its capabilities and future indications. We are, we're going to stand tuned about the future outcomes and applications of this treatment coming up. Thank you to the audience to listen and please, you can always go back to our NANDS website and listen to this webinar and use that as an educational tool. Our next webinar in August, stay tuned for artificial intelligence in neuromodulation and we will kind of have experts in that part of neuromodulation to talk. Thank you so much, everyone. Have a wonderful night and looking forward to see you all soon again. Thank you. Thank you. Good night.

virtual reality

neuromodulation

chronic pain

treatment

quality of care

patient access

care equity

medicine

spinal cord stimulation

cognitive behavioral therapy