Virtual Meditative Walk

Dr.Diane Gromala, Dr.Chris Shaw, Xin Tong, Servet Ulas, Dr.Owen Williamson, Dr.Pam Squire

Pain experts don’t yet know what causes chronic pain, and so far, there is no cure.
Using VR as the better-known form of ‘pain distraction’ can be helpful for short-term “breakthrough” pain,
but it doesn’t last after you take the VR gear off.

We wonder: if people use VR to build new neural pathways, might those pathways escape the dysfunctional way chronic pain is processed?  While we explore that, we are updating our VR interventions for people who live with persistent pain. Our virtual environments are made to calm a usually overactive neurological system, to help patients become or maintain physical activity, and to confront the social stigma that they face. Currently, via a central dashboard, we’re updating the way we visualize self-reported pain data over time and alert users to what seems to be affecting their pain (potential causes and effects), how well users learn to calm their states, and identify what triggers their pain and to see if tracking one’s function & quality of life can matter.

 

Description
This VR system incorporates biofeedback sensors, stereoscopic sound, data visualization and an optional dashboard. It was designed and built to help chronic pain patients learn and practice Mindfulness-Based Stress Reduction (MSBR), a well-studied intervention known to help those who live with chronic pain better self-manage their pain and some of its effects. Unlike pain distraction, MBSR is a skill that can persist well beyond VR sessions if practiced.The Design. As patients learn to better understand their pain and to control their psychophysiological responses, the virtual environment (VE) changes in real-time: fog and clouds dissipate and the audio becomes livelier. Although VR is not necessary to learn MBSR, our studies suggest that our ambient biofeedback assures them that “something is really (physiologically) happening” as the result of their efforts. Rather than breaking their interoceptive (inward-focused) attention with a graph, the changing fog functions as ‘ambient feedback’ that users can simply glimpse or “sense.” The VR experience.
Fig.1   An image of the pond in the Virtual Meditative Walk
We hypothesize that VR functions as an enhanced perceptual and sensory frame that enhances patients’ learning and confidence. As patients glide down a path in a deciduous forest, they listen to soothing but upbeat background music and listen to a vocal coach. As they learn to reduce their ‘stress’ (arousal inferred from GSR/EDA data), the fog and clouds dissipate, and sounds become more lively and vivid. Visual and sonic assets can be personalized to a degree for long-term use. The tech. Conceived of as a system, the VMW includes VR gear and biofeedback sensors such as EDA. After the VR, data captured during the session is transformed into a printable visualization and displayed on a dashboard. Based on our research results, the visualized data is an important way that patients’ efforts “become concrete,” especially for first-time users. Data automatically captured from the sensors & HMD is integrated with self-reported pain to enable tracking beyond VR and longitudinal comparisons.
 Fig.2   Virtual Meditative Walk: This technical overlay depicts the path that users glide down and maps the carefully-designed milestones that appear at ~5 minute intervals: boulders, a pond, clumps of bushes and tall grasses that gently move in a virtual breeze.Numerous technical, usability and design studies (p.5) were conducted before clinical trials began in hospitals, pain clinics and homes. Our design and perception studies reveal that many patients have sensitivities to certain sound frequencies (including chimes often used for meditation), animations, interactions, and metals used in sensors and pressure from the gear (allodynia, CRPS).

 Results

Early, inferential analyses of our preliminary user studies aimed at assessing 

  • whether MBSR worked in VR, and 
  • if it had a significant short-term effect on chronic pain patients’ reported pain levels (NRS ratings). 

Results from the largest and most recent study show a significant difference in pain levels in the control group (M=0.16, SD=1.16) and the VR group (M=2.71, SD=1.88), t (10)=2.96, p < 0.05. 

It suggests that the VMW reduces patients’ self-reported pain levels during VR and shortly thereafter. 

A 9-week longitudinal study of 100 patients is in progress, as is a 2-year ethnographic study of patients using VMW at home.

Fig. 3 & 4: Virtual Meditative Walk’s biofeedback: As patients learn to reduce their ‘stress’ (rate of arousal inferred from sensor data) in real-time, the fog dissipates. The more patients ‘relax,’ the more the clouds also dissipate, and ambient sounds become spatialized and livelier. 

Length of VR Session: 22 minutes

Visuals: 3D assets: clouds, deciduous trees, distant mountains, nearby boulders, a pond, tall grasses, far-off insects   

Audio: background music (can be personalized)

Audio: Vocal Coach (English, Spanish, Farsi, Mandarin)

Audio: ambient sounds of birds, insects, water, leaves in a breeze

Biosensors: streaming GSR/EDA data affect the density of low-lying fog and eventually, clouds & ambient sounds

Visualizations: post-VR session: data from GSR/EDA appears as a graph for a patient’s analysis 

Research testing: The Virtual Meditative Walk builds on the Meditation Chamber created in 2001 at Georgia Tech 

by Dr. Diane Gromala, Dr. Larry Hodges, Dr. Chris Shaw and Fleming Seay, and Dr. Gromala’s Virtual Bodies (1991–1999).

Multidisciplinary collaboration Like indie movies or video games, creating bespoke VR content requires multiple forms of expertise: clinical, technical, and visual & sound design. We also collaborate with patient-partners.

Our co-design and iterative research with patient partners of:

  • the design of content (a VR ‘title’ or ‘app’) and its ability to meet clinical goals,
  • testing the continually changing technologies and their affordances,
  • testing patients’ and clinicians’ acceptance of technologies & interaction techniques, 
  • more deeply understanding specific contexts of use and 
  • understanding what patients specifically need (“know thy user”)

resulted in discoveries that would not likely be apparent in or a part of an RCT: 

– sensitivities that many chronic pain patients have to certain sounds, visuals, interactions & amount of time they can sit, stand or move; 

– their ability to tolerate devices that they wear (HMDs, sensors);

– connections between their body image and body schema; 

– cultural proclivities, preferences and barriers; and 

– how the content or devices may trigger anxiety or catastrophizing or increase pain. 

Our habit of documenting unforeseen needs during clinical implementation with clinical staff have also increased our attention to ease-of-use and the importance of framing VR sessions for patients and staff alike.

Fig.4 Multiple research studies. As researchers whose grad students go on to populate tech companies and start-ups, we have the luxury of investing time to continually conduct research across disciplines. Although design and technical research studies are comparatively small, over 20 studies of the VMW and resulting modifications mean that it has withstood the test of time, especially for longitudinal studies and commercialization.

Fig. 5  Printable, post-VR Session visualization of EDA data.

Design Lessons: 

  • Ease-of-use rules.

   More than any other factor, this one continues to draw the most (and vociferous) comments.

  • Perceived safety counts. Usability testing made it clear that ~85% of patients who identify as female were far more comfortable and “felt safe” in this fairly weedless forest because they could see beyond, vs.forests w/thick underbrush.
  • To learn MBSR requires users to manage their attention; distractions are contraindicated.

   – Visual distractions inhibited patients’ ability to keep their attention directed inward. Colorful, “bling-filled” VR meditation apps proved to be distracting. Although initially preferred (as 2D images on Steam), patients rejected them once they experienced them in VR and actually tried to meditate. According to one patient, “I want to play in them … but it’s too confusing.” 

  – Only certain bird calls were deemed distracting, and the characteristics of that sound asset is in keeping with results from our prior sonic sensitivity studies.

  – Physical (motor) interactions often proved distracting.

In structured interviews, chronic pain patients reported a desire for a dashboard akin to those used by FitBit or the Apple Watch. Based on this and anecdotal information from pain conferences, this seems to be growing in importance as patients report wanting to track their data longitudinally in order to better understand, affect and manage their pain.

Currently, we are conducting studies of patients who use the VMW at home, and the role that the biofeedback, post-VR-session data visualization and dashboard may play over time. 

 Publication

Gromala D., Ofoghi Z. (2020). How does the virtual meditative walk affect activity and connectivity of the pain-related brain regions in chronic pain patients? design of a clinical, longitudinal MRI study. In: IASP virtual series on pain & expo: innovation in research and education. 2020. https://www.eventscribe.com/2020/IASP-Virtual-Series-on-Pain/aaStatic.asp?SFP=S0RVVFZRQ0dANDg5MA#Neuropathic Pain.

Tong, X., Gromala, D., Choo, A., Amin, A., Shaw, C., (2015). “The Virtual Meditative Walk: an Immersive Virtual Environment for Pain Self-modulation through Mindfulness-based Stress Reduction Meditation,” peer-reviewed paper presented at the Virtual, Augmented and Mixed Reality section of HCI International. Peer-reviewed paper published in Proceedings of HCI International (HCII), Vol. 9179, 388-397.

Gromala, D., Tong, X., Choo, A., Shaw, C. (2015). “The Virtual Meditative Walk: Virtual Reality Therapy for Chronic Pain Management.” Peer-reviewed paper presented at the Association for Computing Machinery (ACM) CHI 2015, April 18-24, Seoul, Korea. CHI ’15. Peer-reviewed paper published in the ACM’s (Association for Computing Machinery) CHI ’15 Proceedings of the 33rd Annual ACM Conference on Human Factors in Computing Systems, pp.521–524. New York, NY: ACM Press. DOI: 10.1145/2702123.2702344.