Melanie Cole, MS (Host): Welcome to Back To Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back To Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And today, we have a really exciting show for you on virtual reality advances in pain management, how virtual reality is changing how we treat pain. We have a panel for you today with Dr. John Rubin and Dr. Rubin Jotwani. They're both Assistant Professors of Clinical Anesthesiology at Weill Cornell Medical College Cornell University.

Doctors, thank you so much. This is really a great topic. And Dr. Rubin, I'd like to start with you. Since pain is somewhat subjective, can you just tell the audience a little bit about how you, as an anesthesiologist, how you measure pain at all?

Dr John Rubin: Sure. Well, first of all, thank you so much for having me, Dr. Jotwani and I are really honored to be here and to be able to share our message with the viewers that are out there. You know, when we think about pain, there are many different types of pain. And so, my specialty is with what we call acute pain, and Rubin deals with chronic pain. We'll talk a little bit more about what that entails in a little bit.

But generally speaking, we think about three different buckets of pain, and one is called nociceptive pain. Say, you cut your hand, that's the initial stimulus from that type of pain. And then, there's neuropathic pain. It's literally like an electrical sensation that you have in your body. Some people who have sciatica might have neuropathic pain from sciatic problems. And then, there's a third symptom, which is called nociplastic pain. And that condition is where you have a sensation of pain in your body, but there's no specific inciting trauma. And so, those are three different types of pain that we deal with on a regular basis. And each one of those, we have to assess it in a different way. But from my perspective, when I'm taking care of a patient from the acute pain setting, I'm mainly dealing with nociceptive pain. So, the type of pain you have when you have a cut or you have a tissue injury or a broken bone. And so, there are many ways that we quantify that. But one way is with a pain scale, a numerical pain scale. And there are other ways that we do that, by looking at the patient, like literally examining the patient and seeing what they look like. We ask them subjective piece of information. And we try to piece all the different puzzle pieces together to try and get a better global picture of the patient.

Dr Rohan Jotwani: I'll add one thing too. I think Dr. Rubin is super on point when he says we try and break down pain, which to most people is the same thing, right? People don't really come to us and tell us, "Well, you know, I have 10% nociplastic pain, 90% nociceptive pain." That's really our job as pain doctors, is to be able to think through, take a subjective experience and try and objectify it a little bit, so that way we know how best to treat it.

One other thing that we often see is what do we mean when we say the word pain? I think for most people, pain is a sensory experience. But as pain doctors, we also know that there's just more than the sensation itself, right? So, oftentimes when I'm meeting a patient for the first time, I'm trying to figure out how much of this is a biological or physiological situation and how much of this is truly suffering. And we do tend to find that patients who live in pain also begin to suffer a fair bit. And how do we tell the difference between those two things? So, we are doctors who try and create objectivity out of something that is truly subjective.

Melanie Cole, MS: Well, Dr. Jotwani, explain just a little bit about your role as chronic pain because Dr. Rubin mentioned that he's dealing with post surgical pain or things of that nature, acute pain, but yours is chronic. So, tell us what that entails. What are people suffering from when we hear the term chronic pain?

Dr Rohan Jotwani: I think it's something that a lot of patients really struggle with, because they hear that some anesthesiologists deal with pain right after surgery. An area of specialization that I have is I deal with pain, which technically speaking, lasts longer than the acute period.

So there's the acute period, which is right after surgery, usually around the three-month mark is when we start to see patients transition to something called chronic pain. And chronic pain is what Dr. Rubin was mentioning before, the initial injury may have gone away, but the signal of pain has not stopped. So, the body is under no acute trauma, but that signal of ongoing uncomfortableness continues. And that could be because of things like aging. So, we do see a fair bit of pain that comes from things like arthritis. It could be because of signaling issues. Like for example, a nerve that was damaged, which has now recovered from that damage, has not stopped emitting its signal, like it's continuing to be damaged or it could be because of issues with pain processing, where things that should not be painful, like say, wearing clothing, become very painful for patients. Because it's almost like I describe it to a lot of patients as there's a song being sung and that volume button is being turned all the way up.

Melanie Cole, MS: This is so interesting as so many people in this country suffer really debilitating pain. It affects just so much of our quality of life. Dr. Rubin, can you please describe the role of virtual reality in pain management? How does that differ from what we think of as traditional approaches? While you're talking about this, tell us potential advantages of using virtual reality as a non-pharmacological pain management tool compared to some of those other methods because we think of opioid use, which we know has become a real issue and there's now stewardship and we're looking toward this multimodal way. Tell us, Dr. Rubin, how all this fits in together for that approach so that we're kind of moving away from just strict opioid use.

Dr John Rubin: Well, that's a great question, but let's just take a step back for a second and break it down. So, first of all, for your listeners, I think the first question they may have is, what is virtual reality? So, virtual reality is part of a larger spectrum of things which we call extended reality. So within the extended reality spectrum, there's virtual reality, there's augmented reality, and then there's mixed reality, and they all have different definitions. But broadly speaking, within that context of virtual reality, this is where you're wearing a headset, so the front of the headset is opaque, you can't see through it, and you have a 360 degree space in which you interact with digital holograms. So, that's what the virtual world is like.

So, why would we use virtual reality in the context of pain management? Well, there are really two reasons. The first is we can use it as a distraction technique. So, say, somebody is coming to the operating room for a colonoscopy. You know, in my job, I do a lot of anesthesia for orthopedic surgery, and we do a procedure called a nerve block. So, we insert a small needle in between two different muscle layers. And we inject some local anesthetic medication and it numbs up your arm or any part of your body where you're having the procedure. When we do those procedures on a patient, the patient's typically awake, and we typically give some sedation for that. It's not a particularly painful procedure, but it's not very pleasant. Nobody likes having a needle placed in them. One area where we can use that distraction technique is for those types of procedures. So instead of receiving sedation for the procedure, you would wear a virtual reality headset. You engage in a virtual space, and then the procedure be done, and you're kind of distracted. So, that's one area where we use virtual reality.

And the second area is for actual treatment of pain. And typically, when we use it for treatment, we use it in the setting of chronic pain. So, Dr. Jotwani can talk about this more. But essentially, when he interacts with patients with pain, a lot of times the wires have been crossed, and the pain pathways in the body have gone awry. And so, there's certain types of virtual reality treatment, where you can actually go into this virtual world, And by being in a certain virtual space, as surprising as it sounds, it can actually help to reduce the sensations that people have. And so, those are all different ways that we can use virtual reality within the context of pain management.

Melanie Cole, MS: Dr. Jotwani, from your experience, tell us a little bit more, expand a little bit more as you specialize in chronic pain. And this is something, as I said, can affect the quality of life. Back pain, all of these things are huge, whether it's orthopedic in nature or something else. How do patients typically respond? Tell us a little more about how this actually works.

Dr Rohan Jotwani: I think that's a great question. And it really centers on what you had mentioned before, which is this idea of multimodal pain management. So when it comes to treating patients and their chronic pain, I often walk into a room and tell patients that often there's no one silver bullet that's going to fix everything.

And if it were, usually the patient never makes it to me. Somebody else usually figures it out in the earlier stages, right? If there was one magic medicine that could fix all of pain, I don't think John and I would really have jobs in pain medicine. But unfortunately, there isn't. And so, the way that we structure our practice in pain medicine is around the notion that various things done in certain proportions ultimately allow patients to achieve their quality of life again. And so when I meet a patient for the first time, something I might be thinking about is, how do I integrate non-pharmacological approaches into their care? And by that, I may want them to do things like learn things, like integrative medicine type therapies, mindfulness, meditation, physical therapy. All of those various approaches that we have tons of evidence for help reduce chronic pain.

The problem is, oftentimes, it's really hard to create a system by which we can reliably ensure that patients can get these kinds of integrative services in a way consistent with maybe some of the issues that they're facing. So an often thing that I hear from people is, "I would love to learn how to meditate. But to be honest, I don't have three to five months to go to the Himalayan mountains and learn how to meditate in a monastery." Well, it turns out, we can actually give patients a pretty close experience to that through virtual reality. I've done versions of it myself and I have to say it feels real. At some point, your mind can't tell that you're no longer in your house, but you may wear the headset and, you know, there's software that can take you to places like the Himalayan mountains, and you have 360 sounds so that you can hear and see exactly what those spaces feel like. And it's hard to describe some of this stuff, it's almost like trying to explain to somebody who's never seen moving 2D pictures, I guess back when they had radio, but we're really dealing with an entirely new kind of media, which is immersive content. That gives you kind of complete immersion into these digital spaces.

So in these digital spaces, you can look down and you will see a different body than the body that you have in the physical world. Objects that are kind of fantastical in nature can appear in front of you. And so, we can take advantage of those type of holograms to be able to give patients experiences like lessons on how to engage in mindfulness. We can even do physical therapy. So using remote controllers, we can have patients engage in activities that measure kind of range of motion. And this has been shown to help with things. Like a very specific concept is kinesiophobia. So when patients live in chronic pain, a lot of times they self-regulate. They don't want to turn their neck a certain way. They don't want to move their arm a certain way because they associate with a great deal of pain. Well, it turns out that in the virtual world with a virtual body, people can engage in basically immersive video games that allow them to achieve that range of motion, which might scare them with their physical body. And to think that we can offer patients these kinds of solutions from their home, it's kind of incredible.

Melanie Cole, MS: It's not kind of incredible. It's amazing. And as an exercise physiologist myself, You've just got my mind reeling of the things. And I like that kinesophobia because I see it every single day in my practice. "Oh no, I can't lift that arm because..." And so, I see that. That's awesome, Dr. Rubin. For patients who might be hesitant to try this as a pain management method, what would you say to address their concerns, whatever those concerns may be, and encourage them to give it a chance?

Dr John Rubin: Yeah. And I think that's exactly what it comes down to is giving it a chance. I think whenever Dr. Jotwani or I or anybody really in healthcare, when we interact with patients who are hesitant about a certain thing, whether it's using a certain medication or they're concerned about what their pain management is going to look like or what is the outcome of a surgery, it's always helpful to clarify specifically what are they concerned about.

And I think with virtual reality, there are a couple things that we commonly see that can make people hesitant. So, the first is that, you know, this is an emerging technology. And so as a result, you have people who may not be comfortable with the technology. They may not know where to buy a headset, do they need to buy a headset? And if they have a headset, how do they access the software? How do they do all these different things? And so, that's one area where Dr. Jotwani and I are really able to assist is that, you know, actually, they make special headsets, that are very straightforward and simple. Literally, you just have to press the on button, and it comes preloaded with a certain software. And these things can be sent directly to you and give you an opportunity to use it for pain management.

And then, there's the other component of this, which is that it's a virtual space. And so, like I said before, we're interacting with digital holograms. I don't know if any of your listeners have suffered from this element, but personally, I have a lot of problems with motion sickness. When I'm in a car or I'm not even on an airplane, sometimes I get motion sick. And so, sometimes when you put on that headset, people are concerned that they're going to have that type of motion sickness as well. And the truth is, at least for me, I haven't experienced it to a great extent, and I think that a lot of the technology, the software is, especially for these pain management modalities, it's really geared towards having a nice, smooth transition and being able to place someone in a calm environment. And so, it's not like somebody's playing a first person shooter game where things are Moving all around, in rapid fire. These are very smooth streams, so it makes it a lot simpler. So, those are the most common things that we see. And I think beyond that, like I said, why not give something a shot? Dr. Jotwani and myself, we've had a lot of success with patients who've utilized this therapy. So, it might be something that people should consider.

Melanie Cole, MS: Well, I certainly agree. And sticking with you for just a minute, Dr. Rubin, as you treat inpatient pain, tell us a little bit about what that's like, because then I'm going to ask Dr. Jotwani about how he uses that outpatient pain clinic and that multimodal approach, but you're dealing with post-surgical pain, sometimes pretty intense. How do you determine when discharge can happen based on the pain levels? How do you two work together to transfer someone from Dr. Rubin to Dr. Jotwani?

Dr John Rubin: Well, first of all, I hope that I never have to transfer a patient from myself to Dr. Jotwani. But you're right, sometimes it happens. I think the first thing that I want your listeners to appreciate is that to a certain extent, healing is normal. When somebody has a tissue injury, there's an inflammatory process that occurs. And then from that inflammatory process, you have the initiation of wound healing. And so, pain is actually a normal mandatory part of that inflammatory process. And in fact, there's no healing without pain. But we want to try to minimize it as best as we can from a symptomatology standpoint. And then, hopefully we get people over the hump, over the worst part of that inflammation, usually in the first day or two, and then patients begin to improve quite rapidly after that process.

So from the inpatient standpoint, the way that we typically think about this is actually we start with the end goal in mind. And then, we say, "Well, what is our optimal outcome here?" And then, we try to reverse engineer the process day by day by day to say, "Okay. On the first day, when you enter the hospital, when you have surgery, or when you had your initial injury, is there something that we can do that's going to help to mitigate pain as best we can, and then set you up for success in each additional day down the road?"

So, in general, hopefully by the time the patient is leaving the hospital, we're hopefully at a situation where they may not need any opioid pain medication. But if they do, it's minimized and it's really an as needed therapy, as Rubin described earlier, to help people achieve higher quality of life to be able to engage in certain movements and things like that.

And hopefully, again, as that healing process continues and people engage in physical therapy, the amount of pain that they have is better. And if it's not getting better, then after a few weeks, we begin to think about maybe they need to go to Dr. Jotwani.

Melanie Cole, MS: Well, I agree that hopefully they don't have to, because it doesn't become chronic. And I hear what you're saying there. Now, Dr. Jotwani, dealing with chronic pain, which as we said earlier, it could be knees, it could be backs, it could be shoulders, any of these things. Tell us about your outpatient pain clinics, your multidisciplinary approach, your multimodal approach. How does this work for people that are suffering from chronic pain and how does it incorporate that really cool virtual reality into it all?

Dr Rohan Jotwani: It's probably the highlight of my career and my job that I get to take care of patients when they have chronic pain and they come to see me and we begin to think about how to, like Dr. Rubin was talking about, reverse engineer them feeling better. And I think it all starts with listening to patients and listening to their stories. I see patients who are three months out of surgery. I see patients who are 30 years out of surgery, all of whom may be experiencing chronic pain. And you start by really trying to understand, "Well, what is this person living through? How does their pain manifest? Is it worse at night? Is it worse in the day? Are they unable to go back to work because of it? Are they unable to do certain tasks at work because of it?" Really, in order to understand how to make somebody feel better with chronic pain, you have to understand that person and what being better means to them. I have patients who told me, "It's not really about getting me off of a particular kind of medication. It's not really about this goal, like getting my pain score to be from, I don't know, say a nine to a one. It's about getting me back to gardening again." And so then, my entire treatment plan multimodally focuses on that factor. But we always have to let the patients decide what those factors are, and we have to meet them there.

And so, once we kind of understand what this patient might be living through and what their end goals are, the next step is then to employ, as you mentioned, a multimodal treatment plan, which includes things like medication, physical therapy, interventions, maybe sometimes advanced pain interventions that we do here at Weill Cornell, which focus on therapies like neuromodulation or injections, all the way to things like integrative medicine. So, I often tell patients that when it comes to making them feel better, I'm agnostic. I will look through whatever and work through whatever sort of modalities they'd like to try. So some patients say, "I really want to try acupuncture." Some patients say, "I really want to try vitamins and natural therapies before I start things like medications that have maybe a different kind of side effect profile." And the answer from my side is usually, "Great. Let's give it a shot."

And so, we refer patients for acupuncture, for massage, for physical therapy, really for any modality that they might have an interest with. And at some point, if they are a good candidate for it, I may suggest something like, "Hey, why not try this virtual reality therapy as well, as an adjunct to everything else we're trying?" And so, all those things together typically help form a patient's plan and help them kind of get back on track and on that journey towards being themselves again.

Melanie Cole, MS: I'd love to give you each a chance for a final thought here, because this is really such an interesting topic and one that I think a lot of the listeners really don't know about, but it is amazing. And I feel that it is the future. So Dr. Rubin, first last word to you. I want you to just speak about how this is integrated into a comprehensive pain management plan from your point of view, from the intense post-surgical point of pain management, how you're using it, what you want patients to take away from this episode.

Dr John Rubin: When I interact with patients in the hospital, I'm typically seeing them on one of the worst days of their life. And my goal is that I can turn that day into a non-event. And so typically, we try to throw the kitchen sink at them, and we try to do every single thing possible to minimize the type of trauma and painful experience that they may have. And virtual reality is just another component of that toolkit that we're able to use, and we're just starting to roll this out here at Weill Cornell. We've just started in the last year to do so. And things are starting to accelerate, we're starting to see our colleagues in other specialties and surgical specialties beginning to use it more frequently. But as we continue, we're hopeful that we're going to use it, we're going to help people, we're going to alleviate the anxiety, we're going to help to treat pain, and to turn down the volume of the radio, to use Dr. Jotwani's analogy, and really just hope people keep an open mind about the technology and its uses.

Melanie Cole, MS: Dr. Jotwani, last word to you. I'd like you to speak from your perspective of chronic pain. And again, we know what a huge problem this is in this country. So, speak from your point of view of what you want us to take away from this podcast about virtual reality and how it can help in pain management.

Dr Rohan Jotwani: I think it goes back to something Dr. Rubin mentioned in an earlier part of this episode. Healing and pain are part of people's journeys. There's no healing without some element of pain. And so, pain is a part of life. I tell all my patients, trying to be completely pain-free, 100% for the rest of your life, that's something that people advertise on billboards, and it's something that you see a lot of commercials about. But the reality is, as we age, our bodies are going to have arthritis. As we grow older and we need surgeries, pain is almost inevitable. But while that may be the case, suffering does not have to be inevitable.

And so, a lot of what I try and have discussions with my patients about is that when they come to see a doctor like me, we're working together. Neither I nor the patient can alone create the solution. But together, we can get there. And things like virtual reality, which are a tool, I think of as honestly a tool of empowerment for patients to engage with things like pain psychology, with things like integrative medicine, with things like physical medicine and rehabilitation. It's a tool in the toolbox, but it represents a form of empowerment so that patients can begin to learn things and try things that help themselves feel better over time. And I think that's an important part of the conversation that sometimes gets missed. If it's up to sort of our system at large, we're always going to say, "Hey, try this pill. Try this procedure, try this thing that will take the pain away, and there's going to be very little buy-in from the patient's side. But virtual reality is one of those things that almost necessitates patient empowerment. And so, I'm really hopeful that it's going to be a bigger part of patient's journey, especially as we've all talked about in this episode, millions of Americans are living with chronic pain. And there is no silver bullet. We wish there was, but there is no current silver bullet in our arsenal. And so as these new therapies kind of come into fold, we're all hopeful that they're going to help people end suffering.

Melanie Cole, MS: The more tools we have in our toolbox, that was beautifully said by both of you doctors. Thank you so much for telling us all about virtual reality and pain management. This is a fascinating episode and a fascinating field of study and field of medicine. So, thank you again.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back To Health. We'd like to invite our audience to download, subscribe, and rate and review Back To Health on Apple Podcasts, Spotify and Google Podcasts. And for more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast, a lot of great podcasts there as well. I'm Melanie Cole. Thanks so much for joining us today.

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