Virtual-reality game seeks to defeat pain

A local effort is launched to create a high-tech way to ease the suffering of sick or injured children facing painful medical procedures.

By William Patalon III
Sun Staff
Originally published September 11, 2005

His head almost completely hidden by a virtual-reality helmet, 12-year-old Eli Modlin plunged his hand into a vat of painfully cold ice water as his mind slipped into another aquatic world.

Now a diver navigating the ocean floor, Eli watched sharks and giant sea turtles slowly circle above the swaying sea grass and colorful coral reefs just ahead. The only sounds he could hear were of his own breathing. The allure of buried treasure dominated his thoughts.

Only later did Eli realize what he hadn't felt for a long stretch - the pain from the icy cold water.

The virtual-reality game the Catonsville seventh-grader recently tested, called "Free Dive," is an experiment in a new kind of pain-control tool, one that a local firm and two partners are developing to help ease the suffering of sick or injured children who have to undergo painful medical procedures.

"They told us it might be used for times like when kids need chemotherapy, [which] made me feel like I was really helping," said Eli, one of a group of healthy child volunteers who put "Free Dive" through its paces at a University of Maryland, Baltimore County research lab one recent morning.

"Because it's under water, it's very relaxing," Eli said. "But it still gives you a challenge, since you have to locate the treasure chests" if you want to do more than sightsee and actually score points.

"Free Dive" is the latest attempt to use virtual-reality technology for a medical problem, although it's likely the first to target pediatric pain, leading researchers say.

Given the wide range of early successes that other VR researchers have logged - from helping people overcome fear of spiders to enabling burn victims to escape into a soothingly cold world while undergoing excruciating wound debridement - several experts say the game's concept is technologically sound. The commercial challenges, however, could be more difficult.

The VR game was created by Breakaway Ltd., a Hunt Valley-based computer game company, at the request of the Catonsville-based Believe in Tomorrow National Children's Foundation. UMBC pediatric pain expert Dr. Lynnda M. Dahlquist has been running the research program.

"It's potentially a very powerful tool to use," said Dr. Dennis Turk, a University of Washington clinical psychologist and president of the American Pain Society. Researchers "have made tremendous strides in a very short period. But, as an art form [in terms of] treating pain, we're actually still in the Stone Age," meaning the technology and treatments will continue to evolve.

While treatments for pain have existed since ancient times, it has only been in the past 25 years or so that pain treatment has emerged as a distinct medical discipline. The focus on pediatric pain came a bit later. Virtual-reality therapy has been a most recent development, said Dr. David R. Patterson, a University of Washington researcher who has been a pioneer in the medical uses of VR technology.

The scientific theory on which "Free Dive" and other VR treatments are based is known as pain distraction, said UMBC's Dahlquist, a clinical psychologist. While pain is a sensation - and an unpleasant one, at that - it's also a perception, or experience. Anything that can steal the brain's focus is likely to decrease the pain a patient feels, she said. "The idea is that, to perceive pain, part of the brain has to pay attention to it," Dahlquist said. "The brain can cut off pain or at least diminish it."

The idea of using a virtual aquatic environment, as opposed to another kind of distraction, stems from the role that stress - good or bad - plays in exacerbating pain. The upshot: A pain-distraction device will work best if it is soothing and relaxing.

With its calm pace and nonthreatening environment, the "Free Dive" game is a distraction in itself, said Brian R. Morrison, founder and chief executive officer of the Believe in Tomorrow foundation. Also, the VR helmet, by covering the player's eyes and ears and blocking the outside world, could help reduce the stress of anticipating a painful procedure, he said.

A privately held firm with about $12 million in revenue and slightly more than 100 employees, Breakaway is known for its additions to consumer game lines created by other companies, with titles including "Emperor: Rise of the Middle Kingdom" and "Waterloo: Napoleon's Last Battle." It also has developed "expansion packs," which broaden the possibilities of an existing game, and modeling and simulation software for corporations, think tanks and government agencies.

The company agreed to forgo an estimated $500,000 in potential development fees to make "Free Dive" possible, though its motives weren't completely altruistic. It is trading the short-term fees for such possible future payoffs as product sales, and for the know-how the company gained.

With any project - especially one being done pro bono - Breakaway leaders will "consider several things," said company President Deborah Tillet. "We ask ourselves: Does it promote our technology, and does it move our technology forward? ... We also want to know whether it will [lead to] long-term profitability."

Before that can happen, "Free Dive" must prove its worth, a task that first falls to UMBC's Dahlquist.

She launched her research last summer while "Free Dive" was in development. Participants such as Eli Modlin were asked to immerse one hand in ice water and to keep that hand submerged for as long as they could stand it - a generally accepted, if not necessarily precise, substitute for pain - although the test was limited to four minutes. And since "Free Dive" wasn't yet available in that initial test phase, Dahlquist substituted an underwater chase segment from the game "Finding Nemo."

Healthy children were used as the subjects to test the treatment's efficacy before allowing sick children to use it, and because the use of a single pain stimulus will generate more consistent results, Dahlquist said.

In the first set of tests, nothing was used to distract the youngsters' attention when they immersed their hands in the ice water. The average endurance was only 28 seconds, she said.

In the second test, the children immersed their hands in the ice water and then watched a video of someone else playing "Finding Nemo." The average endurance rose to 34 seconds, she said. For the third test, each participant immersed one hand in the ice water and used the other to play the game while wearing the VR helmet. The average endurance soared to 60 seconds; several kids endured the maximum of four minutes.

This summer, Eli and others tried out "Free Dive" in a series of tests designed to compare its effectiveness with the earlier results from the "Finding Nemo" chase scene. That study is not complete.

Dahlquist said she expects better results with "Free Dive" because it has a less frenetic tempo, more soothing sounds and more content to engage the player's attention. For instance, the sharks are nonthreatening. They have been programmed to swim slowly ahead of the player and to turn and swim away when the player gets too close, Breakaway's designers say.

While tests have shown that children are far more likely than adults to benefit from VR-induced pain distraction therapy, experts such as the University of Washington's Patterson question the effectiveness of the tests. A hand in ice water isn't a precise substitute for such procedures as repeated chemotherapy treatments, or a spinal tap to test for meningitis. The business model for commercializing VR products poses a challenge, too, as there's no easy method of computing the return on investment, Patterson said.

A turnkey package - the hardware, including several PCs, joysticks and VR helmets, and the training to enable the doctors, nurses and medical technicians to understand how it works - could sell for $20,000 to $40,000. The VR helmet alone costs $4,000, Dahlquist said.

Even so, outlays of that magnitude could make the VR gear a relative bargain when compared to the savings from decreased treatment periods, the time freed up to treat more patients, and the reduced need to treat the pain- and anxiety-induced side effects of medical treatments, said Eugene Fram, a marketing professor for the Rochester Institute of Technology College of Business.

"For a medical facility, an [outlay] of $30,000 is an insignificant investment," Fram said. "But before that can happen, the product's credibility must be established via objective, third-party testing."

The young "Free Dive" testers appear to be sold.

"I like taking pictures of the animals," said Kelly Culotta, an 8-year-old fourth-grader from Catonsville, adding with a short laugh: "But I'm [still] scared the shark's going to get me."



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