AGA Tech Summit

Virtual reality emerges as a therapeutic tool in gastroenterology



SAN FRANCISCO – The body of evidence to support virtual reality (VR) as a therapeutic modality will increasingly involve the GI tract, according to evidence summarized at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology. Evolving from its early use in acute or chronic pain, where its function was to simply divert attention from symptoms, VR computer-generated environments are now being applied to alter patient perceptions and behavior that may involve changes in brain function, according to Brennan Spiegel, MD, AGAF, director of Health Services Research for Cedars-Sinai Medical Center, Los Angeles.

“The field of gastroenterology is a particularly promising area for treatment based on VR because of the well-established brain-gut interaction,” Dr. Spiegel explained. He said this tool has now been shown repeatedly to change how patients experience their symptoms in a variety of clinical contexts.

The field is not entirely new. Already by 2017, 11 randomized controlled trials of VR for therapeutic purposes were identified in a systematic review (Innov Clin Neurosci 2017;14:14-21). These trials, dating back to 2010, have explored this technology in depression, cognitive and motor rehabilitation, and eating disorders. Most showed significant benefit. In eating disorders, for example, response at one year was 44% in those receiving VR as an adjunct to cognitive behavioral therapy versus 10% in the controls.

“VR may not just alter perception. In studies being conducted with functional MRI imaging, changes in brain function similar to those observed in patients taking opioids have been observed,” said Dr. Spiegel, outlining objective evidence that VR has physiological effects.

VR already has an established role as a training tool for physicians in GI and other areas of medicine, but Dr. Spiegel focused on the evidence of its applications in treatment. Earlier this year, an expert panel in which he participated published a methodology for VR clinical trials to help move the field forward by defining how to establish evidence of benefit (JMIR Mental Health 2019;6:e11973). With a growing body of data suggesting VR has measurable clinical benefits, the field is poised to grow quickly.

In gastroenterology specifically, Dr. Spiegel envisions applications in functional diseases, such as irritable bowel syndrome (IBS), in which there is already strong evidence of a mind-gut component to symptom flares. He said, “VR can help patients to engage with their body differently, changing how they react to symptoms and leading to better coping mechanisms.”

In one example, Dr. Spiegel displayed a video depicting a woman with severe pain due to liver ascites testifying to substantial pain relief after a VR experience that included images that took her far from the hospital room in which she was sitting at the time. He reported that gastrointestinal pain relief is so consistent with VR that failure to respond prompts him to reevaluate patients for missed organic pathology.

Implementation of VR as a therapeutic tool is not without obstacles. For example, patients susceptible to motion sickness can react poorly to the three-dimensional environment created by VR, according to Dr. Spiegel. Many patients have expressed reluctance to try VR for any one of a number of reasons, including skepticism. However, there are many potential advantages. In the management of pain, for example, VR circumvents a long list of adverse events related to opioids or other analgesics.

This technology is only being used in a few centers, but there is enough evidence of clinical benefit that Dr. Siegel expects it to be more broadly adopted as indications expand. With more controlled trials being performed to measure and establish benefits, he envisions an evidence-based VR pharmacy that will allow clinicians to prescribe specific VR software suitable not only for the target condition but matched to patient preferences for VR environments.

“We have good evidence that VR is a powerful tool to manage mood disorders and pain perception. Although there is so far a fairly limited about of research specific to GI conditions, this is coming,” Dr. Spiegel said.

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