Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: preliminary results from 3 ongoing studies.

Department of Anesthesiology, University of Washington, Seattle, WA, USA. sharar@u.washington.edu

OBJECTIVE: To assess the efficacy and side effects of immersive virtual reality (VR) distraction analgesia, as well as patient factors associated with VR analgesic efficacy in burn patients who require passive range-of-motion (ROM) physical therapy (PT).

DESIGN: Prospective, randomized, controlled, within-subject trials.

SETTING: Regional level I burn center in a university-affiliated urban hospital.

PARTICIPANTS: Patients (age range, 6-65y) who required passive ROM PT in sessions lasting 3 to 15 minutes after cutaneous burn injury.

INTERVENTIONS: Standard analgesic (opioid and/or benzodiazepine) care and standard analgesic care plus immersive VR distraction. MAIN OUTCOME MEASURE: Self-reported subjective pain ratings (0 to 100 graphic rating scale).

RESULTS: A total of 146 treatment comparisons were made in 88 subjects, 75% of whom were children ages 6 to 18 years. Compared with standard analgesic treatment alone, the addition of VR distraction resulted in significant reductions in subjective pain ratings for worst pain intensity (20% reduction), pain unpleasantness (26% reduction), and time spent thinking about pain (37% reduction). Subjects' age, sex, ethnicity, size of initial burn injury, or duration of therapy session did not affect the analgesic effects of VR distraction. Nausea with the standard care plus VR distraction condition was infrequent (15%) and mild, with 85% of the subjects reporting no nausea. Children provided higher subjective reports of "presence" in the virtual environment and "realness" of the virtual environment than did adults, but age did not affect the analgesic effects of VR distraction.

CONCLUSIONS: When added to standard analgesic therapy, VR distraction provides a clinically meaningful degree of pain relief to burn patients undergoing passive ROM PT. Multiple patient factors do not appear to affect the analgesic effect. Immersive VR distraction is a safe and effective nonpharmacologic technique with which to provide adjunctive analgesia to facilitate patient participation in rehabilitation activities.

Department of Psychology, University of Washington, Seattle, USA.

For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic.

Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16-year-old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17-year-old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care).

We contend that VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.

The effectiveness of virtual reality for dental pain control: a case study.

Human Interface Technology Laboratory, University of Washington, Seattle 98195, USA.

The present study explored whether immersive virtual reality can serve as an effective non-pharmacologic analgesic for dental pain.

Two patients (aged 51 and 56 years old) with adult periodontitis, a chronic, progressive inflammatory disease that affects gums, ligaments, and bones around the teeth, were studied in the treatment room of a periodontist. Each patient received periodontal scaling and root planing (scraping off/removing plaque deposits below the gum line, hereafter referred to as scaling) under three treatment conditions: (1) virtual reality distraction, (2) movie distraction, and (3) a no-distraction control condition. Condition order was randomized and counterbalanced. For each of the three treatment conditions, five visual analog pain scores for each treatment condition served as the dependent variables. On 0-10 labeled scales, both patients provided sensory and affective pain ratings, and subjective estimates of time spent thinking about his pain during the procedure. For patient 1, mean pain ratings were in the severe range while watching a movie (7.2), or no distraction (7.2) but in the mild pain range (1.2) during the VR condition. Patient 2 reported mild to moderate pain with no distraction (mean = 4.4), mild pain while watching the movie (3.3), and essentially no pain while in VR (0.6) during his periodontal scaling.

Although the small sample size limits generalizability, we contend that virtual reality is a uniquely attention-grabbing medium capable of maximizing the amount of attention drawn away from the "real world," allowing patients to tolerate painful dental procedures.

These preliminary results suggest that immersive VR merits more attention as a potentially viable adjunctive nonpharmacologic analgesia for procedural dental/periodontal pain. Virtual reality may also have analgesic potential for other painful procedures or pain populations.

Virtual reality pain control during burn wound debridement in the hydrotank.

Human Interface Technology Laboratory, Departments of Mechanical Engineering, University of Washington, Seattle, WA, USA. hunter@hitL.washington.edu

OBJECTIVE: Most burn-injured patients rate their pain during burn wound debridement as severe to excruciating. We explored the adjunctive use of water-friendly, immersive virtual reality (VR) to distract patients from their pain during burn wound debridement in the hydrotherapy tank (hydrotank).

SETTING: This study was conducted on inpatients at a major regional burn center.

PATIENTS: Eleven hospitalized inpatients ages 9 to 40 years (mean age, 27 y) had their burn wounds debrided and dressed while partially submerged in the hydrotank.

INTERVENTION: Although a nurse debrided the burn wound, each patient spent 3 minutes of wound care with no distraction and 3 minutes of wound care in VR during a single wound care session (within-subject condition order randomized).

OUTCOME MEASURES: Three 0 to 10 graphic rating scale pain scores (worst pain, time spent thinking about pain, and pain unpleasantness) for each of the 2 treatment conditions served as the primary dependent variables.

RESULTS: Patients reported significantly less pain when distracted with VR [eg, "worst pain" ratings during wound care dropped from "severe" (7.6) to "moderate" (5.1)]. The 6 patients who reported the strongest illusion of "going inside" the virtual world reported the greatest analgesic effect of VR on worst pain ratings, dropping from severe pain (7.2) in the no VR condition to mild pain (3.7) during VR.

CONCLUSIONS: Results provide the first available evidence from a controlled study that immersive VR can be an effective nonpharmacologic pain reduction technique for burn patients experiencing severe to excruciating pain during wound care. The potential applications of VR analgesia to other painful procedures (eg, movement or exercise therapy) and other pain populations are discussed.

Computer-generated virtual reality to control pain and anxiety in paediatric and adult burn patients during wound dressing changes.

Department of Medical Psychology, Martini Hospital, Groningen, The Netherlands.

Changing daily wound dressings provokes a substantial amount of pain in patients with severe burn wounds. Pharmacological analgesics alone often are inadequate to solve this problem. This study explored whether immersive virtual reality (VR) can reduce the procedural pain and anxiety during an entire wound care session and compared VR to the effects of standard care and other distraction methods.

Nineteen inpatients ages 8 to 65 years (mean, 30 years) with a mean TBSA of 7.1% (range, 0.5-21.5%) were studied using a within-subject design. Within 1 week of admission, standard care (no distraction), VR, or another self-chosen distraction method was administered during the wound dressing change. Each patient received the normal analgesic regimen. Pain was measured with visual analog thermometer scores, and anxiety was measured with the state-version of the Spielberger State Trait Anxiety Inventory.

After comparing different distraction methods, only VR and television showed significant pain reductions during wound dressing changes. The effects of VR were superior, but not statistical significant, to that of television. Thirteen of 19 patients reported clinically meaningful (33% or greater) reductions in pain during VR distraction.

No side effects were reported. No correlations were found between the reduction in pain ratings and patient variables like age, sex, duration of hospital stay, or percentage of (deep) burns. There was no significant reduction of anxiety ratings.