Brian Lacy, MD, and Brennan Spiegel, MD, on Using Virtual Reality to Treat GI Disorders

In this podcast, Drs Brian Lacy and Brennan Spiegel discuss how the use of virtual reality is showing benefits in treating gastric disorders such as functional dyspepsia and irritable bowel syndrome.

Brian Lacy, MD, is a professor of medicine at Mayo Clinic-Jacksonville in Jacksonville, Florida. Brennan Spiegel, MD, is director of Health Services Research for Cedars-Sinai and professor of Medicine and Public Health at the University of California-Los Angeles.

TRANSCRIPT:

Dr Brian Lacy:
Welcome to this Gastroenterology Learning Network podcast. My name is Brian Lacy. I'm a professor of medicine at the Mayo Clinic in Jacksonville, Florida. I am absolutely delighted to be speaking today with Dr. Brennan Spiegel, professor of medicine at Cedar Sinai in Los Angeles, California. Our topic today is one that is generating a lot of interest and excitement in the field of gastroenterology, and that is the use of virtual reality to treat gastrointestinal disorders. Dr. Spiegel, welcome. Virtual reality. This is really innovative technology. To make sure that we all speak the same language, and to dispel some misconceptions about what virtual reality really is, could you briefly explain this technology to our listeners?

Dr. Brennan Spiegel:
Yeah. Thanks, Brian. Thanks for having me on the podcast. So it's a good place to start. Most people when they think about VR, or virtual reality, they think about kids playing games in headsets. First person shooter games, these kinds of things, that aren't necessarily all that healthy, doesn't necessarily make us think of health care or medical treatment, but it turns out VR's been around a lot longer than most people realize. Longer than Facebook or Oculus have been around. Even going back to the mid-1950s, virtual reality technology was available in being used by the Department of Defense to help train fighter pilots and helicopter pilots, for example. And then over the course of the second half of last century, psychology laboratories around the world started to evaluate virtual reality in terms of its impact on the human mind and for even psychological benefits.

And it was only recently that the headsets became more widely available and inexpensive, portable, and high quality that we're now all starting to hear a lot more about it. But in the end, what VR really is wearing a headset, and being immersed, and feeling like you're in these three dimensional environments that are typically digitally created and that you can interact with. So that's sort of a technical definition of VR,

Dr Lacy:
Brennan, that's great. And you actually kind of beat me to the punch on a few questions I was thinking about because there have been these significant changes in virtual reality. And you've already mentioned how I think a lot of people believe it's just kind of wearing a headset, like for a video game, but it's really much more than that. And this concept of kind of immersion is so critical, isn't it?

Dr Spiegel:
Yeah, that's right. And that's something that, unless you've used VR, and especially good VR, it is a little hard to describe what it's like to be inside of these worlds. And it turns out our brain never evolved to have to live in 2 realities at once. We pretty much accept what we are given. And so when we feel as if we're in another world, even if intellectually you know that you're not really in that world, the brain sort of accepts it. And so do the emotion centers in the brain, the limbic system, and the insular cortex, and these parts of the brain that really drive emotions. And when we think about the things that are most memorable in our lives, when you think about it yourself, right now, the strongest, positive and negative memories, they're almost always tied to some strong emotion. That's how we burn in memories. And so what VR can do, for good or for bad by the way, is can create environments that are emotionally powerful, and allow people to learn things faster and more deeply than they might otherwise.

Dr Lacy:
I really like that analogy with emotions. And I'm sure everybody who's listening in today will think about some powerful experience with some emotion, whether it's a happy experience or a sad one. So thinking about that in a little bit of a different way, there are a lot of theories about why VR may improve symptoms, and before we discuss specific disease states, why do you think VR works?

Dr Spiegel:
It's kind of an interesting question because it's a little bit like how does medicine work? And of course the next question would be, "Well, what do you mean? Which medicine?" Because they all have a different mechanism of action. And although it's a reasonable question, Brian, of course, it's still what we're learning is there are different ways that it works and that's kind of what the FDA is starting to care more and more about, is what's the right treatment for the right patient at the right time. And what is the MOA, or mechanism of action, that we're trying to leverage. And so we can spend the next hour talking about that, but the big picture is virtual reality puts our mind into a different state of mind. And so if we can do that purposefully and thoughtfully and carefully, we can put people in a state of mind that helps to countervail or counteract the sort of pathologic processes that are occurring in their mind.

And sometimes it's just a very short, simple thing, like distracting somebody during a painful procedure, like let's say a colonoscopy. There's evidence that virtual reality can reduce propofol use and improve satisfaction with colonoscopy. But for long-term pain, for people with let's say chronic irritable bowel syndrome or chronic lower back pain, one time in VR is not going to necessarily do that much. There what we're doing is trying to deliver cognitive behavioral therapy. A good old fashioned CBT, but doing it in a way that is maybe more engaging and more impactful than a traditional way of delivering those kinds of psychotherapies.

Dr Lacy:
Wonderful. And it's amazing how this field is so rapidly progressing where it's not just does it work and how does it work, but which patient? And so speaking to that issue, do you think that with all the research you've done, do you think we're getting close to maybe where we could identify maybe a group of patients where they maybe respond better than another group? Is it younger patients, older patients, men, women?

Dr Spiegel:
Yeah. Great question. We definitely have been looking at that. And right now we have 3 ongoing NIH-funded studies, in part to help answer those questions. So I don't yet have all the answers, but we will have a lot more in the next couple years, let's say. But there are a few things we're seeing. For starters, age— this has been interesting. It turns out that older individuals are generally a little more hesitant to try VR, but when they do, they have a larger clinical benefit, for something like, let's say, pain. And there are other conditions that we manage, but just for pain, for example, and that may have to do with the digital divide. That people who grew up with the internet with digital technologies have a different relationship with and expectation of those technologies compared to people who are older.

But there's also something else very interesting. It's called immersive tendencies. And what this is, is that everyone knows somebody who gets really into books or really into movies. Like my son, he loves reading books. And if I yell his name out, he can hardly hear his name because he's just immersed in the book. And so it turns out this is a natural human spectrum that can be measured on a scale called the immersive tendencies questionnaire. And people who tend to be high on the immersive tendencies, who do get pulled in the narratives, pulled into environments, movies, books, sports, games, tend to do better in VR. They tend to have more goosebumps, more physiologic responses to the virtual reality. Whereas other people might get into VR and think, "Well, that was fun, but I can't say it did a lot for me." And they almost can't even understand how it might. Whereas other people have religious experiences or spiritual experiences. They're crying. They're seeing God. They have goosebumps. Their blood pressure is changing. And so the question is what distinguishes those people? And that's something we're trying to sort out.

Dr Lacy:
Fascinating stuff. So looking forward to hearing that over the next few years. And you mentioned some of these other disease states, and before we start talking about gastrointestinal disorders and how they might respond to VR, there is some of that earlier data, as you mentioned, about patients with back pain or burn or anxiety or depression, and that's a wealth of data, but could you just briefly summarize what kind of your view on how VR may or may not help?

Dr Spiegel:
Yeah. And in fact, I summarize a lot of this in a book I wrote called VRx. So this is a wide release book that came out in 2020, How Virtual Therapeutics Will Revolutionize Medicine. And as an aside, you could find that wherever books are sold, et cetera. But in that book, I sort of traced the history of VR in medicine. And I describe what is it teaching us about our own consciousness, about the way the mind and the body interconnect. And I talk about all these different disease states that it's being used for. And so it's amazing, if you really look at the literature, and there's over 10,000 studies now, I mean, this is not a new science. In fact, the FDA has a name for this science. Now it's called MXR, or medical extended reality. That's how mature the field has become at this stage.

But boy, we could spend 2 days...and in fact, we have a 2-day conference every year, in March in LA, talking about everything from schizophrenia and how it is managed with virtual reality, through something called trial log therapy, to obesity management, anorexia, stroke rehabilitation. And it goes on and on. Autism. And so in each case, the use of VR is a little bit different. The programs are different and the mechanism of action is thought to be different. So I've been talking so long, I almost forgot what your question was, but I think it was one of those questions that it's a big one. Cause there's a lot underneath the surface of this discussion.

Dr Lacy:
And some very interesting data about those diseases in terms of VR helping burns and back pain. And for listeners who are as excited about this topic as I am, the book Brennan mentioned is fascinating. It's called VRx, capital V-R, and then the x like a prescription sign. So definitely worth reading. So in terms of reading too, you published an article recently in the American Journal of Gastroenterology, looking at VR for the treatment of IBS, irritable bowel syndrome. Could you kind briefly explain that study and why you think IBS might be responsive to VR?

Dr Spiegel:
Yeah, absolutely. So we know, first of all, IBS is one of the most common conditions of humankind. It affects 10% of the world's population. So it's something we need to sort out. It's also a condition that we clearly know now is a disorder of gut-brain interaction. As you and I both know well, it's something we both study in our own careers, and there's been a lot of very interesting research over the years linking the brain and the gut to one another. And I often think of them as really one thing, without getting too far a field for a moment, because the topic is VR. We know that the brain, and the gut, and the rest of the body are so tightly connected that I actually think of the gut and even the muscles, bones, tendons, immune system, endocrine system. I think of all of that as just part of the brain.

It's just the part of the brain that's not in the skull. It's the extracranial extension of our brain and it's all one system. So when we think about it that way, we think, wow, if we can modify the way the brain is experiencing the rest of the body, then maybe even if you inherited a body that's betrayed you, a body that is not working the way you want it to—we tried to fix it with surgery, with medications—even if you've inherited a body that's not working, you still can modify the way you experience that body. And that's powerful.

And that's sort of the basis of cognitive behavioral therapy and also the basis of many therapies for IBS. Therapies like CBT and hypnotherapy and central neuromodulation. These are all effective therapies. And so what VR is doing is really amplifying that effect. And what we did is create a program called IBS VR. And in that paper we basically described the initial validation. It turns out there's several stages for developing these programs and this was the first stage. And basically we showed that the patients enjoyed it and that's kind of the whole goal of the first step. Now we have to demonstrate, in proper randomized trials, whether it's helpful.

Dr Lacy:
Brennan, I'm going to come back in just a second, because there was some really interesting data about how patients responded. And it's a little tricky to do this on a podcast. And I've seen your programs using VR, which are just absolutely amazing for our listeners, but could you just try to briefly explain how somebody enters this virtual reality and what they may or may not see?

Dr Spiegel:
Yeah. So I often say that rather than always having to bring patients to the clinic, what if we could bring the clinic to the patient, and that's sort of what we can do in part with virtual reality. Because in this program, IBS VR, we've created almost a literal clinic. And I say almost, it is a literal clinic. There are hallways and rooms and people explore and move through this space over the course of an 8-week period, except it's all at home. And rather than brick and mortar, this clinic is made of bits and bytes. It's just made of different metaphysical material, but it's still a genuine experience that has effects on the body. So we allow people to move through different rooms. We have, for example, a gut directed hypnotherapy room. A very involved cognitive behavioral therapy room where people can practice over and over again, stressful experiences.

Like, for example, giving a talk in a meeting and IBS symptoms strike, what are you going to do? Are you going to excuse yourself, and get up and leave, or sit there and struggle through it. These are things that you can practice ahead of time. And it turns out by practicing over and over in a safe place at home, in your own room, on your own time, it can help in real life. And that's the real goal of VR. We don't want people living in VR forever, like Ready Player One. We want them to learn something about their mind and body that they can then bring with them to real reality, or RR, to live a better richer life. And that's what we're trying to do with IBS. And there are many other rooms, if there were more time, I'd go through, but that's sort of an overview of how it works.

Dr Lacy:
And I know you are still looking at that data, and you've got other projects in place, and without divulging too much, if you think about that study and many of the other things you're doing, are there maybe some symptoms that respond a little bit better to VR then to another?

Dr Spiegel:
Yeah, well for starters, pain is very well managed or responsive to VR, and pain of all sorts. Both visceral pain, the kind we tend to think about, abdominal pain. But also somatic pain. The one caveat I'd say is neuropathic pain, I have noticed is a little bit tougher to manage with VR. Don't know why exactly. Maybe just the nature of that pain, the nerves themselves are affected. And that's the actual transmission wires are causing the pain as opposed to the peripheral tissues. And I don't know why that makes a difference, but I've noticed that. That's just an observation. But in general, pain is experienced in the brain and there's two parts to pain. There's the physical component, the ouch part. And then there's the mental cognitive component.

That's what Buddha called the two arrows of pain. He said, the first arrow is when the archer strikes your body and it hurts. You look, and there's an arrow sticking out of your shoulder. But then the second arrow, Buddha said, was when you look at that arrow and you think to yourself, "I'm going to die. I'm dying here." That's the self-inflicted wound. And so sometimes that's a more painful wound than the original wound. And so VR, when we look at brain imaging, which is fascinating, seems to tamp down both the physical parts of the pain, the sensory aspects and the sensory cortex, and the emotional cognitive components in the limbic system itself. And that's what makes VR so interesting.

Dr Lacy:
Amazing that in a podcast on virtual reality, you were so nicely able to weave in Buddha. I hadn't thought about that. That's great. So for many of our listeners, they recognize that there's a big overlap for patients with irritable bowel syndrome, IBS, and kind of a disorder of hypersensitivity in the upper GI tract, thing called functional dyspepsia. And I know you've been involved in a pilot study looking at the efficacy and safety of VR for the treatment of functional dyspepsia, some data presented an abstract form. Can you just briefly talk about those results and again, why it might work for functional dyspepsia?

Dr Spiegel:
Right. Right. Well, really this is to give you credit, you and David at Mayo, your initiative. And I appreciate being a part of it. And really what you guys have been doing, as I said, I've been happy to be a part of it, is looking at these patients with functional dyspepsia. And as you pointed out before, a lot of people may realize they have IBS or have been given that diagnosis, but they don't always know that they have functional dyspepsia. It's sort of just, people might call it gastritis or some random terms. But for our listeners, if you don't already know this is recurrent upper abdominal pain or discomfort where we can't find a clear organic reason. There isn't an ulcer in there for example, but there's still definitely pain. And very much like IBS, it is a disorder of gut brain interaction. What we've been showing together is when we use virtual reality and follow these patients over time, looking at the PAGI-SYM, which is this very well-validated widely used endpoint, that looks at multiple components of dyspepsia and not just the pain, but the effects of that on people's lives.

That's where we start to see reductions across many of the PAGI-SYM scales. As I recall, I don't think it was all of them, but in the initial trial that was published maybe a year ago in, I think it was a DDW, you can correct me if I'm wrong, found reductions in many or most of the PAGI-SYM scores. That to me is impactful. We still need the randomized control trials, which is going to be presented soon, we think. It's under review.

The good news is that we continue to see benefits. And what I often say is even if it isn't huge impact to any one person, just giving people the opportunity to try different things out, unto itself, I think, says something about the doctor, that they're willing to try things that are maybe a little bit different. And I find patients really appreciate that. Now it has to be better than a placebo. That's why we do controlled trials. But still just thinking a little bit differently about how we manage people, not as a replacement for traditional medications, but to augment our usual approaches. I think that's been one of the lessons I've taken away from the dyspepsia work as well.

Dr Lacy:
Yeah, that's a great statement. And I think patients appreciate that willingness to explore other options, which is great. So Brennan, you've got so many studies going on. Impressive. You have 3 NIH funded studies looking at VR. Can you kind of tell us a little bit where you think maybe the field is headed and what we should be looking for in the next 5 to 10 years?

Dr Spiegel:
Right. Well, you can tell I'm a little long winded on my answers when we talk about VR. So I'll try to keep this one as tight as I can, because this is such a great question. And it's really a question on many people's minds, developers, patients, investors. We do know that the metaverse is coming. This is a buzzword these days, and it's a real thing. We're going to see the metaverse. Facebook, now Meta, is building its own version of the metaverse and whether you like it or not, whether you think it's some horrible dystopian future or not, and it could be. It's coming. So one of the things we need to think about, in this field, is how do we protect some corner of this metaverse, which is going to be a new version of the internet, where we live part of our lives in these VR worlds.

How do we protect a little part of that to support human health and well-being? Not for just purely gaming entertainment or money making, but really to support humans and their health. That's one big area, and the FDA cares about that. Which is why the FDA has named this branch of medicine MXR, is now regulating these therapies. And so the big issue now is how do we scale it and who pays for it? And so insurance companies are looking at this, but from a clinical standpoint, what we are starting to see is we have a VR consult service here now at Cedar Sinai. We call ourselves The Virtualists. It's run through a psychiatrist, Omar Liran, on our team, who will, with some of our assistants, go and administer the VR, often in the hospital. And we actually measure outcomes.

In the headset, we can actually measure their pain and anxiety scores. And we're even starting to automate this a little bit, looking into ways that the headset itself can automatically write a note in the EHR. There's a lot of interesting approaches to implement this in everyday practice. But I think where we're headed is a new field called MXR. It might take a few more years to get there, where there will be a specialist who manages the equipment and then works with the experts across different fields. But we'll see how it plays out.

Dr Lacy:
That's just fascinating to hear that Cedar Sinai has a virtual reality consult. I mean, that is just absolutely amazing. So Brennan, this has been an amazing conversation. Before I ask you about any last thoughts for our listeners, for our listeners, if you have access to the New York Times, there was a great article about a patient's experience with VR at Cedar Sinai. And was that in June, Brennan?

Dr Spiegel:
Yeah. Right. May or June, I'm forgetting. I think it was June.

Dr Lacy:
Okay. So I think for listeners, if you want to do a little bit more reading other than the book, go to the New York Times and look up Dr. Spiegel and it's just a fascinating article. So last thought for our listeners, you've opened my mind as always. You've probably intrigued a lot of people and got people excited, because I'm super excited about this. Last thoughts for our listeners.

Dr Spiegel:
If you want to learn more, you can go to our website, it's called virtualmedicine.org. And this is an independent website that we run through our lab. On it we have a lot of information. For example, we have a list of some of our favorite VR programs. We don't take money from them to go on that site. So you can decide if or not, if they're useful. Some of those programs, patients of yours can download right now. So if you are interested, and your patients have an Oculus headset, for example, there's an app store. They can download certain programs and we have a list of those there.

We have a whole library of lectures. And we put on an annual conference. And if you are interested, that's a great place, it's a 2-day conference in March. It's called Virtual Medicine. Actually it's been sold out. Amazingly, one year we had somebody scalping tickets outside of an academic conference, which I took a photo of it, because it's almost hard to believe. So check that out and come and join us if you want to learn more. The world's top experts come from around the world to LA each March for this really fun conference. And you can also demo the equipment, and see what it's like, and learn firsthand tips and tricks for how to use this in clinical practice.

Dr Lacy:
All right. Wow, wonderful. This has been super interesting, incredibly informative as always. And I'm sure that a lot of people are going to be just as excited as I am. Brennan, thank you so much for carving time out of your very busy day. Thank you for leading the field in this. And we're all looking forward to hearing lots of exciting things in the next few years.

Dr Spiegel:
It's been a pleasure as always. Thanks for having me, Brian.