Karuna Labs, Quest, and VR for Chronic Pain: An Interview with Karuna Labs’ COO, Jon Weinberg
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Karuna Labs offers a suite of Virtual Embodiment Training™ tools that provide chronic pain patients with education, Graded Motor Imagery and activities that combat fear of movement.
by Kristi Hansen Onkka
Personal experience has sparked many ideas in immersive healthcare. The father of Lincoln Nguyen (Karuna Labs’ CEO), was a PoW during the Vietnam War. As a result of his trauma, he suffered several strokes at a relatively young age. Lincoln became the “man of the house” in his teenage years caring for his father, his mom and his sister. Even though he couldn’t legally be a primary caregiver, he was the one driving his father to all his appointments and administering physical therapy at home because he was strong enough to carry him. The strokes left Lincoln’s father with a lot of stroke-related pain. One way to relieve this type of pain was something called mirror box therapy. Research on mirror box therapy was originally conducted on phantom limb pain people with amputations. But the same concept applies to stroke victims suffering from pain. Patients can mirror the non-painful side over to the painful side. This brain trick can sometimes fix sensory motor incongruences which cause a lot of the chronic pain.
Given his experience with his father, Lincoln saw that virtual reality could mimic the mirror box therapy capability after conducting research with Dr. Kim Bullock, a Stanford Neuropsychiatrist. While working a full-time job as a VR software engineer, Lincoln started Karuna Labs as an interest project. Soon he had added more therapeutic ideas into the project and as well as adding other folks to the team including his co-founder, Dr. Sharon Niv, a cognitive neuroscientist. The two soon realized they needed a business partner to help productize their ideas, so they brought Jon Weinberg onboard as the Chief Operating Officer and third co-founder.
Early this month I had the pleasure of sitting down with Jon to discuss Karuna Labs’ differentiated approach to using virtual reality for chronic pain therapy.
Karuna Labs has come a long way from its early days as just an interest project and now offers clinicians and patients a comprehensive suite of VR-enabled Virtual Embodiment Training™ programs for chronic pain and rehabilitation.
How is Karuna Labs’ approach for chronic pain different from other virtual reality experiences for acute pain?
Great question. In a nutshell, Karuna Labs focuses on durable pain management beyond distraction therapy.
The Karuna Labs Virtual Embodiment Training™ is a suite of therapeutic virtual reality experiences geared toward durable change in the brain. What we are really after is rewiring neural circuits associated with pain semi-permanently or perhaps permanently so that patients experience less pain in their day-to-day lives—or, at the very least, they have coping tools to deal with the pain that they do have. Karuna Labs is not a replacement for pharmaceuticals, physical therapy or occupational therapy. We are used as an adjunctive therapy.
As you know, Dr. Brennan Spiegel has done a lot of research on virtual reality for adjunctive pain management using VR as distraction therapy with acute pain patients at Cedars-Sinai. And even though we don’t focus specifically on acute pain, we do have a similar interest in relieving pain temporarily to get folks to do the corrective exercises and neuroscience-based activities that we’ve created.
Our virtual reality exercises have been developed using principles of cognitive neuroscience. The hope is that through our clinically informed visual tricks and corrective exercises, we can help patients make these neurological changes, or changing neural circuitry, so that they’re not slipping into kind of the same behaviors that reproduce pain.
Karuna Labs uses virtual reality to re-train the brain using neuroplasticity techniques.
Tell me a little bit more about the research involved in creating your suite of experiences.
Evidence-based research is extremely important to us. Karuna uses evidence-based techniques from physical therapy, pain psychology, cognitive neuroscience, and functional restoration programs. In the beginning, we had our hypothesis on certain pieces of our application, but we wanted to make sure that we weren’t just distracting patients with virtual reality. Our VP of Clinical Affairs is a PhD neuroscientist and runs our research. We also have two other resources who are running research concurrently. Most of our research so far has been feasibility and mechanistic studies and we’re gearing up this summer for several randomized control trials.
What are the virtual reality chronic pain management experiences you offer?
The parts of the body that we treat right now center on the torso and above: pain in the upper extremities, lower back, and cervical spine.
All of the experiences are segmented by indication. Somebody who has, say, fibromyalgia that’s giving them a lot of upper-extremity pain would be very different than somebody who has what’s called complex regional pain syndrome (CRPS). CRPS is a close cousin of phantom limb pain where either suddenly or because of a trauma there’s pain radiating 24-hours-a-day from a limb or extremity due to an overly sensitized nervous system.

Karuna Labs provides pain education, visual augmentations that exert a cognitive demand on the brain to promote renormalization of neural circuitry, and activities of daily living. We package it all up in a protocol that has a session for each day that includes pieces of all of these different modalities so that the patient isn’t just receiving one type of therapy. It’s not just physical therapy in VR. It’s not just education in VR. It’s not just behavioral health in VR.
It’s a combination of lots of different things so that we’re fitting into this biopsychosocial approach. We see really good outcomes because we’re not just doing one thing. Every patient is different. Everyone’s pain is different. We treat the whole person, not just the injury or location of pain.
Jon Weinberg
COO, Karuna Labs
How do the Karuna Labs virtual reality experiences actually work to relieve chronic pain?
We are a movement-related modality. All of the experiences are about getting the patient up and moving, or if they are unable to stand up, moving in place. It all starts with pain science education. The first thing in any session that a patient does or sees is related to educating them on how chronic pain works. We heard from clinicians all across the board that they see the best outcomes when patients actually know how pain works in their brains and their bodies. They are able to consciously digest the information and move in the right direction. This is endlessly fascinating and really inspiring because sometimes all it takes is a bit of education to get folks on the right path. Sometimes we provide patients with in a flyby experience of the nervous system. Or we’ll show them how pain originates in the body but is really manifested in the brain. We also teach them the differences between acute and chronic pain.
Next, we move on to graded, functional exercises. One thing that distinguishes Karuna Labs’ Virtual Embodiment Training™ from anything else out there is that we’re not just getting patients to participate in physical or occupational therapy using a VR medium, we have actually created a whole new modality. We see doctors that have already purchased VR headsets to do distraction therapy and then at some point, they kind of run out of options for pain management with their patients. Clinicians want a full suite of therapeutic solutions for their patient. That’s what Karuna Labs delivers.
Chronic pain can be debilitating, limiting the range of motion. How does Karuna Labs Virtual Embodiment Training™ help these patients get up and moving?
Graded Motor Imagery (GMI) is the inspiration for a lot of our applications. GMI is the discipline from which mirror box therapy comes, but it’s more complicated than just mirroring from side-to-side. There’s a lot to do with imagination and visualizing and attacking. It is neuroscience-based. For example, a golf instructor might tell you to visualize what you’re about to do to prime your nervous system to swing well. You visualize your swing. You close your eyes if you need to. You really see yourself do it and then the neural circuitry that produces the movement is “warmed up” so to speak so that the neurons in the circuit fire more reliably
This approach can work for anything that’s movement-based. It’s not just practice; it’s also a concentration technique which can be hard for some people, especially those in pain. What VR allows us to do is take the visualization out of your mind. Maybe you don’t have a great imagination or maybe the visualization technique just isn’t as effective for you as it is for other people. Our virtual reality embodiment therapies do the visualizing on your behalf. For people who have very limited range of motion, we start with just animations where you see yourself doing the movement before you’re able to do it. Even that has the potential to improve range of motion and function. The premise is if you are able to see a VR avatar do something on your behalf, you’re more likely to be in a better position to actually regain motor function. It leads your brain to a place where you can do it yourself.

And have you seen patients successfully use your virtual reality applications to increase their range of motion despite their pain?
Yes, it’s really fascinating. Our whole suite of experiences utilizes physics that don’t exist in real space and only exist in VR space. This helps a patient increase their range of motion and function by showing them something that’s different than what they’re doing in real space.
I’ll give you an example. Let’s say you have a very limited, 30% range of motion in your right arm because you had an injury that lead to chronic pain. In VR, we can amplify that movement to 35%. We show you where you should be vs where you are. And if you have guarding behavior, if you have compensatory movements that are associated with it such as shaking, you can’t really make the movement in a smooth, fluid way, we’ll show you that you’re making it in a smooth, fluid way. You’re seeing that visualization in a very different way than you would see your own body doing it even though it’s related to and based on your own movement. Over time, we just keep moving the goal posts. When you reach 35% in real space, we can move the visualization in virtual space to 40%.

How can virtual reality “trick” the brain for a long-term reduction in chronic pain?
Over time this grading and pacing improves range of motion. And it’s based on what are essentially visual tricks. We humans are very visual creatures. The brain has a visual-system dominance that takes over and when you experience these things. It’s kind of like going to a scary movie. There is a visceral reaction to the images you see, despite the images not being real.
It’s the same thing when you’re in VR. You know that you’re in VR. You know that it’s not real, but your brain registers it as having happened to you. To ensure long-term success, we also add on activities of daily living. Chronic pain patients oftentimes have a fear of movement, or kinesiaphobia. Our activities of daily living are a type of exposure therapy to increase confidence and overcome fears. Usually we start off just with a simple activity or task. It might be playing fetch with a dog, stacking dishes, doing gardening work, or doing work around the house. All of these suggestions come from occupational therapists who say that these are the most difficult or triggering for patients.

Karuna Labs provides pain education, visual augmentations that exert a cognitive demand on the brain to promote renormalization of neural circuitry, and activities of daily living. We package it all up in a protocol that has a session for each day that includes pieces of all of these different modalities so that the patient isn’t just receiving one type of therapy. It’s not just physical therapy in VR. It’s not just education in VR. It’s not just behavioral health in VR.
It’s a combination of lots of different things so that we’re fitting into this biopsychosocial approach. We see really good outcomes because we’re not just doing one thing. Every patient is different. Everyone’s pain is different. We treat the whole person, not just the injury or location of pain.
Are there assessments and tracking for the doctor to see how the patient is doing?
Yes. And the care plan usually starts with a goal. We have designed our program around goal attainment. A goal related to chronic pain and disability might be “I’d love to be able to pick up grandkids again before they get too big.” Then, as the sessions progress our platform provides data and feedback to both clinician and patient.
Before we start treatment with a patient there’s a calibration session. We use the whole suite of calibration tools to continuously measure multiple things at once while the patient is going through their plan of care. We try to do as much of the assessments organically in the application. This means we can measure folks without asking a long series of questions—but by taking lots of different measurements solely from their movements.
As they go through their plan of care, we provide feedback to the clinician and the patient that they’re doing well and show how it’s related through our goal-attainment design. We always want to show patients that they’re working towards a goal.

Is Karuna Virtual Embodiment Training™ only available in a clinician’s office? Or will it be available on a home version as well?
Our patients have asked us for a home version ever since we launched the clinical version. Several of our providers are very interested in that, too. Until Oculus Quest came out, we didn’t have access to a wireless headset that actually provided six degrees of freedom in a way that was usable for us.
In the clinic, we have used the HTC Vive and it’s been the best commercially available tool that’s also easy to use and inexpensive enough for us to deploy.
The Quest is really a revolution in wireless headsets that have six degrees of freedom because it is not tethered to a PC. We have been working on the Quest version of Karuna Labs since we first received the Santa Cruz Dev Kit. We know that we are able to measure most of the same things using the Quest, and our entire business will likely be transformed. Patients will able to do the same exercises and have the same experience as they would in a clinician’s office.
We’ve been extremely excited to launch our Quest application. I feel like VR developers, and especially healthcare VR developers, are shouting from the rooftops of how Quest will help solve the problem of function, cost and accessibility.
Not only that, Quest finally offers a VR form factor that’s so consumer-friendly and so visually appealing both from the outside. It’s very easy to introduce somebody to VR using the Quest. For most of our patients, this is their first time in VR. They’re not early adopters; they’re just folks who have a doctor or a therapist who is interested in new types of care.

We’ve been extremely excited to launch our Quest application. I feel like VR developers, and especially healthcare VR developers, are shouting from the rooftops of how Quest will help solve the problem of function, cost and accessibility.
Jon Weinberg
COO, Karuna Labs
Since your patients are new to virtual reality, are they generally receptive to trying it out?
There’s never any hesitation on the patient side because a lot of these folks are at their wits’ end or at the end of their rope to begin with because they’ve tried everything. They’ve tried pills, physical therapy, Eastern medicine, everything under the rainbow of Western medicine, injections and whatnot, and they’re still in chronic pain. Just as there’s an opioid epidemic, we’re also seeing a surgery epidemic where people are electing to have surgeries that don’t end up helping with their pain. We see a lot of people who have had these so-called failed surgeries.
As a result of having tried everything, chronic pain patients are very willing to try virtual reality. They’re very pleasantly surprised when it’s easy, it’s not painful, and there’s no injection.
Clinicians and patients share thoughts on Karuna Labs’ adjunctive virtual reality therapy for chronic pain.
For more patient testimonials and to download case studies click here.
Thank you Jon, it was really interesting to hear how Karuna is approaching chronic pain management using virtual reality. It is powerful to see how your suite of Virtual Embodiment Training™ therapies can help patient’s trick their brain into new habits, feelings and movements.
Karuna Labs has captured into its VR suite of tools a proved process of education, graded image visualization and activities that combat fear of movement. And, they have addressed some critical needs in keeping patients motivated through goal setting, analytics and feedback. I look forward to seeing more patients be able to take part in these therapies on the Oculus Quest as part of their doctor’s at-home plan of care.
For more information on Karuna Labs, please visit https://karunavr.com/.

About Kristi Hansen Onkka
Kristi is the founder of healthiAR and is focused on the impact virtual and augmented reality has on healthcare. Visit her at getkristi.com.
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