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Ep. 165 - LiveWell Talk On...Therapeutic Virtual Realilty (Dr. Benjamin Tallman)

episode 165

Ep. 165 - LiveWell Talk On...Therapeutic Virtual Reality

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guests: Dr. Benjamin Tallmanpsychologist, St. Luke's Physical Medicine and Rehab

Dr. Arnold:
This is LiveWell Talk On...Therapeutic Virtual Reality. I'm Dr. Dustin Arnold, chief medical officer at St. Luke's Hospital. Returning to the podcast day is Dr. Benjamin Tallman, psychologist at St. Luke's Physical Medicine and Rehabilitation, to discuss therapeutic virtual reality and how it can be used as an innovative approach to chronic pain management. Dr. Tallman, welcome back.

Dr. Tallman:
Thank you very much for having me, delighted to be here.

Dr. Arnold:
This is interesting. You know, this this topic, virtual reality, artificial intelligence. You know, I think we're just, we're in the infancy of the potential for this. So start off, what is therapeutic virtual reality?

Dr. Tallman:
Yeah. First of all, again, I appreciate the opportunity to chat today. VR is an immersive experience where patients are in a multi-sensory experience. So you have a virtual reality headset on and you're using all of your senses, your sense of smell, your sense of sight, tactile response. In some cases, even olfactory. Whether you're actually skydiving or swimming with the dolphins or walking on the beach, your body's physiological response is the same. So when people have a VR headset on for the first time, and I think a lot of us have seen some of those folks or YouTube videos, or maybe we've tried it ourselves. So when people have that virtually reality headset on for the first time, there's an excitement and sometimes even a surprise of, wow, it's like I'm in this particular virtual environment. So we use therapeutic virtual reality at St. Luke's as a way to help people address symptoms and specifically symptoms of anxiety and symptoms of pain management.

Dr. Arnold:
So I've never done it. So, you know, I don't have a personal reference here. But what does it look like? Is it a beach scene, is it...?

Dr. Tallman:
Well first of all, we're going to have to get a headset on you, Dr. Arnold. We can get you we can get you in a virtual world. One of the things that we've done at St. Luke's is use virtual reality for kind of two primary purposes. One is for anxiety management, the other's for pain management. And we have a number of different applications. So to go back to your question, Dustin, about what are the different types of environments, the range is really endless. If you think about all of the various apps in the apps store, all the apps on your phone and all the different environments that we have, there's essentially an app for every different type of virtual environment. So on the headsets that we have at St. Luke's, which they're called the Oculus Go headset and they're untethered, which means they're not connected to a computer or anything else. They're charged up, we can take them to the patient's room. We can give it to the patient, we train them, we put it on them, they're able to use it. And then they're able to select any number of apps that would be helpful for them. And we know from the literature, that when somebody has choice and they can choose which experience is best for them, they tend to have a little bit better response.

Now, the different apps, I think, fall into two categories. One of those categories is what probably people think of more as kind of relaxation: being on the beach, doing guided meditations, guided yoga, being relaxing, and really triggering that relaxation response. Or, you know, within our stress response, calming down the autonomic nervous system. So part of those apps calm and are really relaxing. So that's kind of one campus. So if a patient wants to relax and feel calm, we give them a calm place that will force serenity. So one of those might be the example of they're walking in a forest, they see a waterfall on the left hand side, they have different birds chirping in the background. There might be animals that are walking through. It's very peaceful, it's very serene. And as I mentioned, the mind and the body don't differentiate. Physiologically, our body is responding the same way if we were actually walking in the forest, or if we're in the virtual environment.

The second type of apps are those that are much more immersive. And these are more, what I kind of call when working with patients is, the ultimate distraction. So if somebody is really glued into, or really focused into, being on a roller coaster, and they're actually feeling the visceral response of going up and down. Or they're doing some target practice, or they're fishing, or they're kayaking in the ocean or in a mountain lake. Or one of my favorites is, there's an app where you're shooting these geometric figures and balls are coming at you, and you're circling around. I can tell you that when you're in these very immersive experiences or these immersive apps, you don't have any idea what's going on around you. You're really focused and present. And again, the thought is that the more present, the more that somebody is engaging all of their senses, the more that it could disrupt pain pathways. And that's really how it kind of works for pain management.

Dr. Arnold:
I was just sitting here recalling growing up out north of town, we used to ride our bikes to—it was a 7-Eleven, now it's like a quick shop on 42nd and Center Point road—to play dragons layer. It was a video game, you know the old, but it was like the first one that ever had like three dimensional sort of things. And it was, I don't know, I rode a bike a long way for a 50 cent game. It might have even been a quarter. But, I imagine there are patients that are good candidates to do virtual reality, and there are others that you'd want to avoid. Can you take us through that?

Dr. Tallman:
Yeah, absolutely. You know, when we look at the literature and, you know, who's a potentially a good candidate, who's not a good candidate. There aren't really any major rule outs. There's some research to suggest that people who have symptoms of motion sickness, that we really need to be careful about the types of apps we use with them. Because they might have a higher possibility of experiencing motion sickness during the virtual reality. So if they have a history of motion sickness, we ask all our patients about that, we want to proceed with caution. We typically don't start those patients on the roller coaster. You know, we would probably start them more on something like being on the beach or in a scene that's not going be as immersive as some of those others. And then, you know, some of the other, again, there's not really any hard and fast contraindications. But so for example, if somebody has any issues with their eyes or if they've had something, you know, any sutures or things on their heads, they have to be able to wear the headset.

Dr. Arnold:
Okay, that makes sense.

Dr. Tallman:
Sometimes, you know, working with patients that have had, you know, a cranny or they've had some type of head trauma, we want to make sure that we can have the headset on them. And then very similar to some of the other techniques that I use, the person has to be able to have the cognitive ability to be able to manage and kind of navigate the virtual reality headset. And I tell people, if you can run a smartphone, which most of us can, you can run the virtual reality headset. There's a controller, it's got a number of different buttons on it. There's a back button, there's a home button and there's a trigger, which is essentially kind of like a mouse click. And then there's, when you have the headset on, there's a home screen. So it takes a little bit, there's a small learning curve for patients to be able to navigate and be able to work their way around the headset. It's kind of like, you know, if you're at home watching Netflix or Hulu or any other social media platform you might use. You have to learn your way around it. It's very similar to VR. So patients have to have the cognitive capacity to be able to use it.

Now, I will say with that said, I have had some patients that didn't have time to be able to learn to use the VR. I had one particular patient, this was a while back, who was having a procedure that was being done and was really, really anxious about having some dressing changes. I think in this case, it was some sutures removed. So I actually booted up the headset and held it held it to this particular individual's face while they pulled off the sutures and five minutes into the experience, they said when are you all going to start pulling them out? And we said, we've already finished. So they didn't even know that we had pulled out the sutures because we had already finished. But that was kind of a rare example of the patient not having to learn how to use it. Ideally, we give them a training session. Many of our nurses and techs train at St. Luke's to be able to administer the VR. We go into the patient's room, we talk about some of the contraindications which we've discussed. And then there are sometimes symptoms of cyber sickness that we want to assess for. Cyber sickness could be eye strain, nausea, dizziness. It happens in a small amount of patients. If the patients experience any of those things, they just take the headset off. If I have the headset on for about 30 minutes or more, I typically have a little eye strain. But we coach our providers and nurses to be able to use the headset for about 10 or 15 minutes, and then take a break and then to be able to use it again.

Dr. Arnold:
That's interesting, cyber sickness. The what's the DRG ICD-10 for that one, you know?

Dr. Tallman:
Oh, boy.

Dr. Arnold:
There probably is one.

Dr. Tallman:
I'm sure there is one, yeah.

Dr. Arnold:
We have injury by falling space debris in there, so I mean, why wouldn't cyber sickness be in there? How can listeners learn more about virtual reality? I'm sure it's just one of the many elements that you use in your program, that's obvious. But how can they learn more about it in other nonpharmacologic interventions?

Dr. Tallman:
Yeah, one of the best things that listers can do is, we have within our pain program at St. Luke's, we have our pain empowerment program. And that's really focused on the nonpharmacologic treatment of pain. We're not against medications, but we also know that there are many different evidence-based treatments that can be effective for pain: cognitive behavioral therapy, clinical hypnosis, therapeutic virtual reality. So the best way that patients can learn more about these different techniques is to contact our Physical Medicine and Rehabilitation Department. That number is 319-369-733. We can get patients scheduled in our orientation class. It's a 90 minute to two hour class, and we talk about all things pain psychology, how different types of biopsychosocial factors can impact and influence the experience of pain, thinking patterns, behavioral patterns, environmental stressors. And then we talk about a number of other different types of techniques to manage pain, again, like cognitive behavioral therapy and hypnosis.

VR is just one specific modality and intervention that we use. Quite honestly, we use it more on the inpatient side than the outpatient side. I introduce it to patients on the outpatient side, but we're really using it on the inpatient side. So if you're going to have a procedure or be hospitalized at St. Luke's, hopefully some of those things are planned if you are having to do anything. But many of our nurses and techs have been trained to be able to administer VR.

And a little bit of background, part of this VR program is part of a research program that I run in collaboration with some undergraduate students and colleagues from Coe College. Or as we like to call it, refer to it, the Harvard of the Midwest. And so we know that there's good research to support the use of therapeutic virtual reality. We good randomized controlled trials. What we don't know is how do you take a VR headset, put it in the hands of a nurse or a healthcare provider, and be able to integrate it into their already busy workflow. And that's one of the things that our research team is looking at, is how can you take this into and put it into a hands of a healthcare provider and be able to use it effectively, teach patients to use it, and be able to use it effectively. We don't want it to just be an extra thing that a provider or nurse has to do. We want it to be one more tool that they have to be able to help manage their patients pain. And so far, the reception has been very positive. We've been able to implement it at St. Luke's Birth Care. So if you're going to be having a baby anytime soon in near future, please ask them about using therapeutic virtual reality. There's some good research that suggest that it's helpful. And we've also implemented on several other of our units at St. Luke's, surgical units, as well as our rehabilitation unit. So if you're in the hospital, you can certainly be able to use VR. And then if you come to our outpatient program or that outpatient orientation class that I mentioned, you can learn more about it.

Dr. Arnold:
I've said before and I'll say it again, anytime that we can help a patient without a pill and without a scalpel, it's a victory.

Dr. Tallman:
I agree a hundred percent.

Dr. Arnold:
This has been really fun. Once again, this is Dr. Benjamin Tallman, psychologist at St. Luke's Physical Medicine and Rehabilitation. For more information, visit UnityPoint.org.

Dr. Tallman:
Thank you very much.

Dr. Arnold:
Thank you for listening LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcast. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.