A New Zealand tech company is helping chronic pain patients take back control.
This content was created in paid partnership with Exsurgo.
Chronic pain can start with a back injury, a routine surgery, an arthritis diagnosis. The body reacts to an injury: seize up, shut down, recover. The nervous system goes on high alert. It’s normal, while the body takes time to heal itself.
But for some people, the injury heals and the pain remains. The brain learns to predict pain when that part of the body is moved, or touched. It can spread: what was once a sore shoulder becomes back pain, neck pain or migraines. Persistent pain can cause anxiety and sleepless nights, which makes the pain worse. This is chronic pain. The injury is gone, but the pain is still produced by the brain, and it’s real.
Around the world, it’s estimated that one in five people suffer from chronic pain. People with chronic pain report that it affects their relationship with their kids, because they’re exhausted. Many can’t exercise, which affects their body image and self-confidence. A 2018 report estimated chronic pain is costing the New Zealand health system between $13 and $14.9 billion every year.
Kiwi company Exsurgo is using a unique approach to try to tackle chronic pain. They’ve combined traditional neuroscience, mechanical engineering and hi-tech computer science, to develop a headset that allows people with chronic pain to see their own brainwaves, on a tablet, on the table in front of them. It’s called Axon, and it’s teaching patients to control their brains in ways that will hopefully allow them to sleep, work and live, with a fraction of the pain.
Axon looks like a helmet pared back to its bones. Three long plastic fingers spread across the scalp: one straight forwards, two arching around onto the sides, wrapping round to the forehead. A chunky palm cups the back of the head, and two stubbier fingers wrap below the ears. Putting it on feels like a light head massage. Each finger contains one or two electrodes, perfectly positioned to measure the microvolt brain activity going on in your head.
Axon measures a person’s brain activity using a technique called electroencephalography, or EEG. Exsurgo’s neuroscientist Christine Ozolins became fascinated by EEG during her master’s degree, when she was using EEG to help creative workers bust through writer’s block. She worked with EDM producers, jazz musicians, writers and painters. Interestingly, the process that helps break writer’s block is similar to that which may also help chronic pain patients dull their pain.
In her project, she helped creatives “upregulate their alpha band”. The brain produces activity, known as brain waves, in distinct patterns, which are named after Greek letters: alpha, beta, gamma, delta and theta. Delta wave activity is for sleeping, theta is for drowsy states, like when you’re nodding off on the couch. Alpha wave activity dominates your brain when you’re in a calm, relaxed place – sitting down with a cup of tea, or doodling. It’s the brain activity you want for creative work. Above that you’ve got beta, which covers a whole range of brain engagement, from low stress work, easy tasks and talking, right the way up to highly engaging problem solving and stressful work tasks. Above that still, there’s gamma, which is associated with a range of functions including learning, memory, attention, and sensory integration.
When Ozolins met Exsurgo co-founder Richard Little at a neuroscience conference, they discovered that they had a common interest in using neurofeedback: showing people their brain activity, so they can learn to adjust it themselves. Ozolins for writer’s block, Little for chronic pain.
Little invited Ozolins to join Exsurgo to work on the Axon project. From the UK she ran their first Axon trial with UK clinicians Dr Nick Birch and Jon Graham. In March this year she came to New Zealand to work on the next Axon trial.
Axon’s simplicity disguises the engineering feat needed to get to this point. For EEG, electrodes are placed on the head so they can pick up brain activity through about a centimetre of bone and skin, but it’s difficult: picking up brain activity from the scalp is like trying to hear what your friend’s saying in a noisy nightclub. EEG tech is designed to cut through the noise and provide a clear picture of what your brain is trying to say. But a traditional EEG neurofeedback set-up usually dwarfs its operator, filling out whole corners of labs or hospital rooms. They’re also really expensive.
Exsurgo engineers Richard Little and Faisal Almesfer have miniaturised that set up. Each branch of the device contains one or two electrodes, placed to measure brain activity at the spots most associated with chronic pain. There’s a biopotential amplifier, amplifying the tiny whispers of brain activity collected from the scalp, and a circuit board, which acts as Axon’s on-board computer, filtering those signals to extract the important ones. A low-energy bluetooth chip fires those signals from the headset to a tablet within milliseconds – any longer than that, and it won’t feel like you’re getting real-time feedback.
Slip Axon on, and the tablet prompts you to adjust the fit until each electrode is perfectly placed to pick up your brain activity. Once it’s on your head and calibrated, you can see your brain on the screen, lighting up with activity when you think or move. It’s one of Little’s favourite features.
“For people who’ve had pain, or depression, they will plan their days around waiting and seeing what the pain’s going to be like – the pain controls them. This visualisation lets people see that they have control of their brain. When they’re playing the games, they’re getting a sense that they actually have that control back.”
You pick from one of a few different games, each of which is prompting you to increase your alpha wave activity. This state of relaxed focus is usually less common in people with chronic pain. Instead, they’ll be in an alert, stressed beta state, or, because of pain medication or bad sleep, a drowsy theta. Depending on the game, increasing your alpha wave activity opens a lotus flower, or completes a puzzle, or raises a hot air balloon above a mountain scene. The games are designed to be rewarding visually and through sound.
“It’s a form of operant conditioning. It works really well on a subconscious level,” says Ozolins.
Earlier this year, Exsurgo reported results from its first proof-of-concept trial. Ozolins was managing the trial, and was ready to start when Covid hit. “We realised this is the perfect time to test a home-based system. I trained everyone remotely via Zoom.” It was an important endorsement of Axon’s practicality; Little and Almesfer had always wanted the hardware to be accessible and able to be used without clinicians or hours of expensive lab time.
Sixteen participants, all with various types of chronic pain, used the Axon headset for 30 minutes every day, for four to six days per week, for eight weeks. It was a proof-of-concept trial, which uses a small number of participants, and provides the groundwork for larger trials in the future. Even so, the results were encouraging. After about two or three weeks of training, Ozolins says, participants reported sleeping better, and feeling more refreshed after waking.
After eight weeks, every single participant reported feeling less pain. All but one reported sleeping better, and being in a better mood. Eighty-eight percent of the patients reached the threshold required for a “clinically significant” reduction in pain, which is when their pain goes down by 30% or more.
This has potential long-term consequences. Ozolins told me about negative reinforcement cycles in chronic pain. When you feel pain, you stop moving, not wanting to aggravate the pain. Over a long period of time, you get stiff, and unfit. You don’t sleep as well, which makes the pain worse. You can become anxious or depressed, which further increases the pain. It’s a vicious cycle, and it’s hard to come out of. In the UK trial, Ozolins says that the participants would notice that it no longer hurt to do their shoelaces up, or they started moving better. They were sleeping better as well, so their mood was better, and they were feeling more resilient. It was a positive reinforcement loop, where one improvement triggered others.
“They would say that the pain is more in the background,” says Ozolins. “They were achieving more and feeling better about themselves.”
Exsurgo’s next step is to test Axon on more people, a task that’s already under way in Auckland. The company isn’t short of volunteers; Exsurgo has been inundated with requests to be included, such is the gravity of the chronic pain problem. This trial will include over a hundred volunteers, and will use a “sham” condition as a control, where half the volunteers have fake treatment. They’ll slip on the headset, play the games, but they won’t be seeing their own brain activity, or be able to control what’s on the screen. This will help the team determine that the effect they are seeing is real and not placebo. It’s common that people will feel better from simply believing that help with the pain is coming, and that’s an important effect to weed out. (Sham participants will be offered the chance to use the real Axon after the trial has been completed.)
Little believes Axon’s potential is boundless. He’s currently working with a homeless shelter in Nebraska in the United States, with families who have escaped domestic violence. “People who have suffered trauma may well be experiencing depression, anxiety or even PTSD, but they could well have a mild traumatic brain injury or concussion as well,” he explains. In this case, Axon will use different wavelengths to detect different types of brain activity, but the rationale is similar. Raise the levels of “good” kinds of brain activity, and reduce the “bad”. It’s by no means a one-stop anti-trauma treatment, but it could help people in great need get their nervous system under control.
Little also speaks excitedly about the potential for Axon to both diagnose and help treat concussion. “There’s data to suggest that with EEG we could actually diagnose concussion at the side of a rugby pitch,” he says. It often takes days or weeks for someone to recognise they may have a concussion, and see a doctor. “By that stage, you’ve got a long-term problem to deal with. We could get an early diagnosis with an Axon in the back of an ambulance,” Little says.
All of the applications fit within Little and Almesfer’s basic model: use machines with large processing power to look for things that are useful for clinicians. “Machines do a lot of these assessments better than a human can do. We can build machines to do the dumb data collection stuff, and free up the human clinicians to do the really smart human touch stuff that’s so important.”
True to Axon’s tech roots, Little wants the headsets to be made cheap enough to be offered through a subscription model. “It would be low risk for the hospitals or clinics to try, low risk for a patient to take home for a few months. They don’t have to invest in an expensive piece of equipment that may end up sitting in a corner somewhere.”
Little and Almesfer are clearly action people, impatient even, with a product they believe has huge potential. But they’re ready to be patient through the rigorous healthcare trials process that’s so important to protecting patient safety. They’ve got a lot to do – Almesfer’s already tinkering with new, custom-made electrodes. In the meantime, they all eagerly await the day where the collective dream that brought them together is realised; democratised EEG neurofeedback technology, to be used in homes, available to anyone whose brain could benefit from it.