Doctors often prescribe opioids for the treatment of acute and chronic pain. However, opioids have a high potential for misuse, and long-term opioid use can lead to dependence.
Consequently, in recent years, there has been a growing emphasis on finding safer pharmacological and nonpharmacological approaches to alleviating pain.
Several studies have shown that mindful breathing has analgesic, or pain-relieving, effects. Thus, mindful breathing could be a safer alternative to pharmacological methods for relieving pain.
Mindful breathing requires individuals to focus their attention on their own internal experience, specifically the sensation of inhaling and exhaling.
Mindful breathing can be particularly difficult for beginners, as it involves focusing on an internal sensation for longer periods. VR-guided breathing has the potential to address this challenge.
How VR might help
VR allows individuals to interact with a computer-generated, three-dimensional, immersive environment.
Studies show that engaging with the external stimulus in the form of the immersive, or realistic, sensory environment that a VR system presents can help reduce pain.
However, scientists do not fully understand the mechanism by which VR modulates brain activity to reduce pain perception.
Experts believe that the amount of attention directed at the painful experience modulates the perception of pain. Engaging with VR requires visual and auditory attention, and this distraction reduces the attention directed toward pain. This in turn lowers the perceived levels of pain.
Moreover, recent developments suggest that exposure to VR may reduce pain even when individuals are not actively engaging with it.
In other words, VR may help alleviate pain by a mechanism other than the distraction of attention.
A recent study that appears in the Journal of Medical Internet Research used brain imaging to investigate the mechanisms underlying the analgesic effects of VR.
The researchers compared the brain activation patterns in healthy individuals practicing traditional mindful breathing with the patterns in those who used VR-aided mindful breathing.
The study reports that individuals using either of the techniques had a higher threshold for pain after practicing mindful breathing for 1 week.
Significantly, the two breathing practices produced different brain activation patterns during the breathing exercise and when the participant was subjected to a painful stimulus immediately after the breathing exercise.
The study’s lead author, Dr. Alexandre DaSilva, professor at the University of Michigan (U-M), told Medical News Today,
“We found that both meditative breathing methods decreased pain sensitivity, but our study showed two distinct analgesic mechanisms in the brain, like yin and yang.”
“In the traditional mindful breathing practice,” he continued, “more frontal regions of the participants’ brains modulated pain sensitivity by prioritizing their attention on the internal sensations (interception).”
“In the VR breathing group, more sensory-related regions in the brains modulated pain sensitivity by prioritizing the processing of the external VR […] immersive experience (exteroception).”
In short, standard breathing techniques reduced pain by focusing the mind on internal sensations, and VR-guided breathing reduced pain by focusing the user’s attention on external sensations.
The present study involved 40 healthy adults who practiced either traditional or VR-aided mindful breathing for 7 days.
The traditional mindful breathing group and the VR mindful breathing group performed their respective breathing technique in the lab on the 1st and 7th day. They also practiced these breathing routines at home during the remaining 5 days.
In the VR breathing technique, the headset displayed a 3D image of virtual lungs that moved in synchrony with the participants’ breathing patterns. The participants wore headphones that played breathing sounds that were also synchronized with their own breaths.
Since the participants in the VR group did not have access to the VR headset at home, the researchers asked them to recreate the VR experience by imagining and visualizing their lungs as they practiced the breathing routine.
After the completion of the breathing activity in the lab on the 1st and 7th day, the researchers administered a test to measure the participants’ pain thresholds.
They recorded the brain activity of the participants during the breathing exercise and the pain threshold test. They tracked changes in brain activity levels using an imaging technique called functional near-infrared spectroscopy (fNIRS).
fNIRS uses low levels of harmless nonionizing light to continuously track blood flow changes in brain regions. This technique uses the principle that when a brain region is activated during a task, there is an increase in blood flow.
Differences in brain activity
The researchers found that both traditional and VR-aided mindful breathing increased the participants’ pain thresholds after 1 week of practice.
They then looked at the differences in brain activation patterns between the traditional and VR mindful breathing groups during the pain test.
Perception of pain activates brain regions involved in processing sensory information and emotional responses. Processing pain also involves brain regions that are associated with higher-level cognitive functions, such as the prefrontal cortex.
Previous studies have shown that mindful meditation lowers activity in the anterior prefrontal cortex. Importantly, scientists associated lower activity in this brain region with a higher pain threshold.
Both groups in the present study showed a reduction in the anterior prefrontal cortex activation after 7 days of mindful breathing practice.
The VR breathing group also showed greater activation of the dorsolateral prefrontal cortex than the mindful breathing group.
Scientists associate activation of the dorsolateral region of the prefrontal cortex with reduced unpleasantness and intensity of pain. They also associate activation of this region with reduced activity in brain regions that process sensory and emotional components of pain.
Additionally, the VR breathing group showed increased activity in brain regions involved in processing sensory information, including visual and auditory stimuli, compared with the mindful breathing group.
The present study thus shows that VR breathing can modulate pain even after completion of the VR breathing exercise. Also, an increase in pain threshold occurred alongside activation of specific brain regions.
These results show that VR can produce analgesic effects through an alternative mechanism, not just through the distraction of attention due to active engagement with VR.
The researchers assessed differences in functional connectivity associated with the performance of the two breathing exercises. Functional connectivity refers to the coordinated or correlated activity of brain regions during the performance of a task.
The researchers observed that coordination of activity among brain regions involved in processing sensory information was greater during traditional mindful breathing than during VR-aided mindful breathing.
They then investigated whether the degree of coordination between two brain regions during the breathing exercise was correlated with pain thresholds during the subsequent pain test.
The brain regions whose coordinated activity predicted pain threshold differed between the traditional and VR mindful breathing groups.
These results show that traditional mindful breathing and VR-aided mindful breathing modulate the activity between different brain regions in a distinct manner to increase the pain threshold.
MNT spoke with Dr. Jeffrey I. Gold, founder and director emeritus of the Pediatric Pain Medicine Clinic at Children’s Hospital Los Angeles (CHLA) and investigator at The Saban Research Institute of CHLA.
Dr. Gold, who was not involved in the study, said:
“It’s a very well-constructed study, looking at traditional breathing methods for pain management and the use of VR in this augmented way, which is really fascinating. And they integrate wonderful technology with fNIRS, which is a method of measuring brain activation, which I think is great.”
“It looked like both were effective at reducing pain or increasing thresholds for pain,” he explained. “But clearly, it appeared that the VR aspect of it was able to interrupt that sensory experience, such that they were able to tolerate even more stimulus and create a higher pain threshold.”
“I think it really does demonstrate the brain’s capacity through either conditional mindful breathing and VR-augmented breathing to have an impact on pain,” Dr. Gold concluded.
Strengths and limitations
“The first strength of the study was the development of the VR breathing technology that synchronized 3D lungs, like an avatar, with the patients’ own breathing in real time,” said Dr. DaSilva.
“This captivating experience facilitated their attention to the practice, decreasing distractions common in the traditional mindful breathing method.”
Dr. DaSilva further noted: “The second strength was the use of fNIRS as a neuroimaging technique to examine our participants’ brains. fNIRS is quiet, relatively portable, and perfect for providing a more natural environment for our meditative breathing protocol, instead of the usual noisy and confined MRI scanners from other previous studies.”
The authors acknowledge that there were a few limitations to their study. Dr. DaSilva observed:
“Between the immersive day 1 and [day 7] lab visits, participants were asked to mimic the virtual experience for at-home practices […], which might have dampened its effect. We are working on a mobile VR device solution via smartphone for our future studies to address this issue.”
The authors also note that they did not have a control group to compare the brain activity levels and pain thresholds observed in the traditional mindful breathing group and the VR mindful breathing group.
“To make our [VR] breathing technology more portable in the future, we are about to start a clinical trial at [U-M] with chronic pain patients. Now that we better understand the analgesic mechanism of [VR] in the brain, we intend to extend and adapt the technology to various pain disorders, including migraine, one of the focuses of our laboratory,” said Dr. DaSilva.