Virtual reality pain control during burn wound debridement in the hydrotank

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.     

Virtual Reality Hypnosis: A Case Report

This preliminary case report explored the use of hypnosis induced through a 3-dimensional, immersive, computer-generated virtual reality (VR) world as a means to control pain and anxiety in a patient with a severe burn injury. On hospitalization Day 40, after reports of uncontrollable pain and anxiety, the patient underwent hypnotic induction while immersed in a virtual world and received posthypnotic suggestions for decreased pain and anxiety during subsequent wound-care sessions. The patient’s pain and anxiety each dropped 40% after VR hypnosis on a Graphic Rating Scale for his Day 41 wound care. Pain dropped similar levels on Day 42 with an audio-only version of the intervention and then returned to baseline without intervention on Day 43.     

Virtual reality hypnosis: a case report

This preliminary case report explored the use of hypnosis induced through a 3-dimensional, immersive, computer-generated virtual reality (VR) world as a means to control pain and anxiety in a patient with a severe burn injury. On hospitalization Day 40, after reports of uncontrollable pain and anxiety, the patient underwent hypnotic induction while immersed in a virtual world and received posthypnotic suggestions for decreased pain and anxiety during subsequent wound-care sessions. The patient's pain and anxiety each dropped 40% after VR hypnosis on a Graphic Rating Scale for his Day 41 wound care. Pain dropped similar levels on Day 42 with an audio-only version of the intervention and then returned to baseline without intervention on Day 43.     

Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study

OBJECTIVE: The pain experienced by burn patients during physical therapy range of motion exercises can be extreme and can discourage patients from complying with their physical therapy. We explored the novel use of immersive virtual reality (VR) to distract patients from pain during physical therapy. SETTING: This study was conducted at the burn care unit of a regional trauma center. PATIENTS: Twelve patients aged 19 to 47 years (average of 21% total body surface area burned) performed range of motion exercises of their injured extremity under an occupational therapist's direction. INTERVENTION: Each patient spent 3 minutes of physical therapy with no distraction and 3 minutes of physical therapy in VR (condition order randomized and counter-balanced). OUTCOME MEASURES: Five visual analogue scale pain scores for each treatment condition served as the dependent variables. RESULTS: All patients reported less pain when distracted with VR, and the magnitude of pain reduction by VR was statistically significant (e.g., time spent thinking about pain during physical therapy dropped from 60 to 14 mm on a 100-mm scale). The results of this study may be examined in more detail at www.hitL.washington.edu/projects/burn/. CONCLUSIONS: Results provided preliminary evidence that VR can function as a strong nonpharmacologic pain reduction technique for adult burn patients during physical therapy and potentially for other painful procedures or pain populations.     

Virtual reality helmet display quality influences the magnitude of virtual reality analgesia.

Immersive Virtual Reality (VR) distraction can be used in addition to traditional opioids to reduce procedural pain. The current study explored whether a High-Tech-VR helmet (ie, a 60-degree field-of-view head-mounted display) reduces pain more effectively than a Low-Tech-VR helmet (a 35-degree field-of-view head-mounted display). Using a double-blind between-groups design, 77 healthy volunteers (no patients) aged 18-23 were randomly assigned to 1 of 3 groups. Each subject received a brief baseline thermal pain stimulus, and the same stimulus again minutes later while in SnowWorld using a Low-Tech-VR helmet (Group 1), using a High-Tech-VR helmet (Group 2), or receiving no distraction (Group 3, control group). Each participant provided subjective 0-10 ratings of cognitive, sensory, and affective components of pain, and amount of fun during the pain stimulus. Compared to the Low-Tech-VR helmet group, subjects in the High-Tech-VR helmet group reported 34% more reduction in worst pain (P < .05), 46% more reduction in pain unpleasantness (P = .001), 29% more reduction in "time spent thinking about pain" (P < .05), and 32% more fun during the pain stimulus in VR (P < .05). Only 29% of participants in the Low-Tech helmet group, as opposed to 65% of participants in the High-Tech-VR helmet group, showed a clinically significant reduction in pain intensity during virtual reality. These results highlight the importance of using an appropriately designed VR helmet to achieve effective VR analgesia (see ). PERSPECTIVE: Pain during medical procedures (eg, burn wound care) is often excessive. Adjunctive virtual reality distraction can substantially reduce procedural pain. The results of the present study show that a higher quality VR helmet was more effective at reducing pain than a lower quality VR helmet.     

Effectiveness of virtual reality-based pain control with multiple treatments

OBJECTIVE: The current study explored whether immersive virtual reality continues to reduce pain (via distraction) with repeated use. SETTING: The study was conducted in a burn care unit at a regional trauma center. PATIENTS: Seven patients aged 9-32 years (mean age of 21.9 years; average of 23.7% total body surface area burned [range, 3-60%]) performed range-of-motion exercises of their injured extremity under an occupational therapist's direction on at least 3 separate days each. INTERVENTION: For each physical therapy session, each patient spent equal amounts of time in virtual reality and in the control condition (no distraction). The mean duration of physical therapy in virtual reality was 3.5, 4.9, and 6.4 minutes for the first, second, and third session, respectively. Condition order was randomized and counter-balanced. OUTCOME MEASURES: For each of the three physical therapy sessions, five visual analog pain scores for each treatment condition served as the dependent variables. RESULTS: Pain ratings were statistically lower when patients were in virtual reality, and the magnitude of pain reduction did not diminish with repeated use of virtual reality. The results of this study may be examined in more detail at www.vrpain.com. CONCLUSIONS: Although the small sample size limits generalizability. results provide converging preliminary evidence that virtual reality can function as a strong nonpharmacological pain reduction technique for burn patients during physical therapy. Results suggest that virtual reality does not diminish in analgesic effectiveness with three (and possibly more) uses. Virtual reality may also have analgesic potential for other painful procedures or pain populations. Practical implications are discussed.     

Virtual reality intervention as a support method during wound care and rehabilitation after burns: A systematic review and meta-analysis

ObjectiveThis systematic review and meta-analysis aimed to analyze and synthesize the evidence on the effectiveness of virtual reality (VR) interventions in the prevention of pain, fear and anxiety during burn wound care procedures.MethodsIn September and October 2021, PubMed, Scopus, Cochrane Library and Web of Science were searched for relevant randomized controlled and crossover studies. Two independent authors described the following inclusion criteria for the search: patients undergoing burn wound care with applied VR treatment compared to any other or non-VR intervention. From a total of 1171 records, 25 met the inclusion criteria. After full-text screening, seven publications were excluded. The risk of bias was assessed for 18 studies by two independent authors. RevMan 5.4 was used for the statistical analysis, meta-analysis and visual presentation of the results.ResultsThe meta-analysis showed a significant difference between VR treatment and standard care when analyzing pain outcome during wound care procedures (SMD = −0.49; 95% CI [−0.78, −0.15]; I² = 41%) and in subgroup analysis when immersive VR was incorporated (SMD = −0.71; 95% CI [−1.07, −0.36]; I² = 0%). No significant differences were found between VR treatment and standard care for range of motion outcome (SMD = 0.44; 95% CI [−0.23, 1.11]; I² = 50%).ConclusionsVR seems to be an effective therapeutic support in burn wound care procedures for reducing pain. However, this systematic review and meta-analysis highlights the need for more research into the use of VR as a distraction method. Studies on larger groups using similar conditions can provide unequivocal evidence of the effectiveness of VR and enable the inclusion of such intervention in standard medical procedures.     

Exposure to an Immersive Virtual Reality Environment can Modulate Perceptual Correlates of Endogenous Analgesia and Central Sensitization in Healthy Volunteers

Virtual reality (VR) has been shown to produce analgesic effects during different experimental and clinical pain states. Despite this, the top-down mechanisms are still poorly understood. In this study, we examined the influence of both a real and sham (ie, the same images in 2D) immersive arctic VR environment on conditioned pain modulation (CPM) and in a human surrogate model of central sensitization in 38 healthy volunteers. CPM and acute heat pain thresholds were assessed before and during VR/sham exposure in the absence of any sensitization. In a follow-on study, we used the cutaneous high frequency stimulation model of central sensitization and measured changes in mechanical pain sensitivity in an area of heterotopic sensitization before and during VR/sham exposure. There was an increase in CPM efficiency during the VR condition compared to baseline (P < .01). In the sham condition, there was a decrease in CPM efficiency compared to baseline (P < .01) and the real VR condition (P < .001). Neither real nor sham VR had any effect on pain ratings reported during the conditioning period or on heat pain threshold. There was also an attenuation of mechanical pain sensitivity during the VR condition indicating a lower sensitivity compared to sham (P < .05). We conclude that exposure to an immersive VR environment has no effect over acute pain thresholds but can modulate dynamic CPM responses and mechanical hypersensitivity in healthy volunteers.PerspectiveThis study has demonstrated that exposure to an immersive virtual reality environment can modulate perceptual correlates of endogenous pain modulation and secondary hyperalgesia in a human surrogate pain model. These results suggest that virtual reality could provide a novel mechanism-driven analgesic strategy in patients with altered central pain processing.     

Decreasing Pain Ratings in Chronic Arm Pain Through Changing a Virtual Body: Different Strategies for Different Pain Types

Modifying the visual aspect of a virtual arm that is felt as one's own using immersive virtual reality (VR) modifies pain threshold in healthy subjects, but does it modify pain ratings in chronic pain patients? Our aim was to investigate whether varying properties of a virtual arm co-located with the real arm modulated pain ratings in patients with chronic arm/hand pain because of complex regional pain syndrome (CRPS) type I (without nerve injury) or peripheral nerve injury (PNI). CRPS (n = 9) and PNI (n = 10) patients were immersed in VR and the virtual arm was shown at 4 transparency levels (transparency test) and 3 sizes (size test). We evaluated pain ratings throughout the conditions and assessed the virtual experience, finding that patients with chronic pain can achieve levels of ownership and agency over a virtual arm similar to healthy participants. All 7 conditions globally decreased pain ratings by half. Increasing transparency decreased pain in CRPS but did the opposite in PNI, whereas increasing size slightly increased pain ratings only in CRPS. We conclude that embodiment in VR can decrease pain ratings in chronic arm pain, although the type of pain determines which strategy to decrease pain is most useful. We discuss this through the interactions between body image and pain perception.Perspective“Embodiment” in VR is useful to decrease pain ratings in chronic pain patients, but the best strategy needs to be tuned to the pain etiology. This approach could potentially help patients with chronic pain and clinicians who seek alternatives to pain management for patients.     

Highly immersive virtual reality laparoscopy simulation: development and future aspects

Purpose

Virtual reality (VR) applications with head-mounted displays (HMDs) have had an impact on information and multimedia technologies. The current work aimed to describe the process of developing a highly immersive VR simulation for laparoscopic surgery.

Methods

We combined a VR laparoscopy simulator (LapSim) and a VR-HMD to create a user-friendly VR simulation scenario. Continuous clinical feedback was an essential aspect of the development process. We created an artificial VR (AVR) scenario by integrating the simulator video output with VR game components of figures and equipment in an operating room. We also created a highly immersive VR surrounding (IVR) by integrating the simulator video output with a \(360{^{\circ }}\) video of a standard laparoscopy scenario in the department’s operating room.

Results

Clinical feedback led to optimization of the visualization, synchronization, and resolution of the virtual operating rooms (in both the IVR and the AVR). Preliminary testing results revealed that individuals experienced a high degree of exhilaration and presence, with rare events of motion sickness. The technical performance showed no significant difference compared to that achieved with the standard LapSim.

Conclusion

Our results provided a proof of concept for the technical feasibility of an custom highly immersive VR-HMD setup. Future technical research is needed to improve the visualization, immersion, and capability of interacting within the virtual scenario.

     

Morphine-Infused silver sulfadiazine (MISS) cream for burn analgesia: a pilot study

Pain is considered the most distressing symptom of a burn wound, with analgesia usually provided via oral or parenteral medications. Use of systemic opioids can be complicated by fluctuations in bioavailability, absorption, and clearance of drugs caused by the burn. There has been little research done in the area of topical medications for burn analgesia. The following is a double-blind, placebo-controlled pilot study assessing the safety (side effects) and efficacy (pain ratings and medications administered) of morphine-infused silver sulfadiazine cream for burn pain. Four patients are reported on (2 in each group). Only participants taking placebo reported side effects related to morphine and necessitated anxiolytic medications. Pain ratings in the treatment group ranged from 0 to 7 with a mean of 2.1, whereas the placebo group's ratings ranged from 2 to 8 with a mean of 5.6. The placebo group averaged 55.3 mg oral morphine per half day, whereas the treatment group averaged 42.9 mg.     

Burn injury pain: the continuing challenge.

The development of more effective methods of relieving pain associated with burn injury is a major unmet medical need. Not only is acute burn injury pain a source of immense suffering, but it has been linked to debilitating chronic pain and stress-related disorders. Although pain management guidelines and protocols have been developed and implemented, unrelieved moderate-to-severe pain continues to be reported after burn injury. One reason for this is that the intensity of pain associated with wound care and rehabilitation therapy, the major source of severe pain in this patient population, varies widely over the 3 phases of burn recovery, making it difficult to estimate analgesic requirements. The effects of opioids, the most commonly administered analgesics for burn injury procedural pain, are difficult to gauge over the course of burn recovery because the need for an opioid may change rapidly, resulting in the overmedication or undermedication of burn-injured patients. Understanding the mechanisms that contribute to the intensity and variability of burn injury pain over time is crucial to its proper management. We provide an overview of the types of pain associated with a burn injury, describe how these different types of pain interfere with the phases of burn recovery, and summarize pharmacologic pain management strategies across the continuum of burn care. We conclude with a discussion and suggestions for improvement. Rational management, based on the underlying mechanisms that contribute to the intensity and variability of burn injury pain, is in its infancy. The paucity of information highlights the need for research that explores and advances the identification of mechanisms of acute and chronic burn injury pain. PERSPECTIVE: Researchers continue to report that burn pain is undertreated. This review examines burn injury pain management across the phases of burn recovery, emphasizing 3 types of pain that require separate assessment and management. It provides insights and suggestions for future research directions to address this significant clinical problem.     

A distraction technique for control of burn pain.

Research has indicated that analgesics alone do not adequately relieve pain for 75% of patients with burns. The purpose of this study was to determine the effects of a distraction therapy, in which videos were used in combination with administration of analgesics, on intensity and quality of pain and on levels of anxiety in adults during burn dressing changes. The sample consisted of 17 patients who were randomly assigned to the treatment or the control group. The treatment group viewed video programs that were composed of scenic beauty accompanied by music. Each was asked to score his or her present pain intensity and pain rating index with the McGill questionnaire and anxiety with the Spielberger questionnaire before and after the dressing change. A nested general linear model using the "F" test in multiple regression analysis was adjusted for age, percent partial-thickness burn, and choice of topical agent demonstrated that the use of videos during the dressing changes significantly reduced pain and anxiety: present pain intensity (F = 8.69; p = 0.01), pain rating index (F = 5.57; p = 0.03), anxiety (F = 9.10; p = 0.01). It is recommended that the use of pain medication be augmented by use of videos during burn dressing changes.     

Manipulating presence influences the magnitude of virtual reality analgesia

Excessive pain during medical procedures performed in unanesthetized patients is frequently reported, but can be reduced with virtual reality (VR) distraction. Increasing the person's illusion of going into the virtual world may increase how effectively VR distracts pain. Healthy volunteers aged 18-20 years participated in a double-blind between-groups design. Each subject received a brief baseline thermal pain stimulus, and the same stimulus again minutes later with either a Low Tech or a High Tech VR distraction. Each subject provided subjective 0-10 ratings of cognitive, sensory and affective components of pain, and rated their illusion of going inside the virtual world. Subjects in the High Tech VR group reported a stronger illusion of going into the virtual world (VR presence) than subjects in the Low Tech VR group, (4.2 vs. 2.5, respectively, P = 0.009) and more pain reduction (reduction of worst pain is 3.1 for High Tech VR vs. 0.7 for Low Tech VR, P < 0.001). Across groups, the amount of pain reduction was positively and significantly correlated with VR presence levels reported by subjects ( r = 0.48 for 'worst pain', P < 0.005).     

Gabapentin for pain control in cancer patients' wound dressing care

A patient with mycosis fungoides illustrates the problem of pain management during wound care and suggests the utility of a novel treatment, gabapentin. Skin lesions, be they induced through necrosis of tumor, therapy (e.g., radiotherapy), or by pressure ulceration, are often the cause of continuous pain or acute wound dressing pain. Optimizing the analgesic treatment in those patients is thus of major importance. Anti-inflammatory drugs and opioids are the cornerstones in the treatment of cancer pain but are rarely sufficient to control wound pain. Different adjuvant techniques can be used, including topical analgesics, psychological distraction techniques, anxiolytics, and co-analgesics. There is growing evidence that anticonvulsants, and sodium channel blockers in particular, are effective not only in neuropathic but also in inflammatory pain. Gabapentin, a voltage sensitive sodium and calcium channel blocker, was used as a co-analgesic to supplement morphine in this case of cancer wound dressing pain.     

Virtual Reality Hypnosis for Pain Associated With Recovery From Physical Trauma

Pain following traumatic injuries is common, can impair injury recovery and is often inadequately treated. In particular, the role of adjunctive nonpharmacologic analgesic techniques is unclear. The authors report a randomized, controlled study of 21 hospitalized trauma patients to assess the analgesic efficacy of virtual reality hypnosis (VRH)—hypnotic induction and analgesic suggestion delivered by customized virtual reality (VR) hardware/software. Subjective pain ratings were obtained immediately and 8 hours after VRH (used as an adjunct to standard analgesic care) and compared to both adjunctive VR without hypnosis and standard care alone. VRH patients reported less pain intensity and less pain unpleasantness compared to control groups. These preliminary findings suggest that VRH analgesia is a novel technology worthy of further study, both to improve pain management and to increase availability of hypnotic analgesia to populations without access to therapist-provided hypnosis and suggestion.     

Three-Month Follow-Up Results of a Double-Blind,Randomized Placebo-Controlled Trial of 8-Week Self-Administered At-Home Behavioral Skills-Based Virtual Reality (VR) for Chronic Low Back Pain

Prior work established post-treatment efficacy for an 8-week home-based therapeutic virtual reality (VR) program in a double-blind, parallel arm, randomized placebo-controlled study. Participants were randomized 1:1 to 1 of 2 56-day VR programs: 1) a therapeutic immersive pain relief skills VR program; or 2) a Sham VR program within an identical commercial VR headset. Immediate post-treatment results demonstrated clinically meaningful and superior reduction for therapeutic VR compared to Sham VR for average pain intensity, indices of pain-related interference (activity, mood, stress but not sleep), physical function, and sleep disturbance. The objective of the current report was to quantify treatment effects to post-treatment month 3 and describe durability of effects. Intention-to-treat analyses revealed sustained benefits for both groups and superiority for therapeutic VR for pain intensity and multiple indices of pain-related interference (activity, stress, and newly for sleep; effect sizes ranged from d_rm = .56–.88) and physical function from pre-treatment to post-treatment month 3. The between-group difference for sleep disturbance was non-significant and pain-interference with mood did not survive multiplicity correction at 3 months. For most primary and secondary outcomes, treatment effects for therapeutic VR showed durability, and maintained superiority to Sham VR in the 3-month post-treatment period.PerspectiveWe present 3-month follow-up results for 8-week self-administered therapeutic virtual reality (VR) compared to Sham VR in adults with chronic low back pain. Across multiple pain indices, therapeutic VR had clinically meaningful benefits, and superiority over Sham VR. Home-based, behavioral skills VR yielded enduring analgesic benefits; longer follow-up is needed.     

Rehabilitation of burn injuries

Burn rehabilitation is a complex and difficult process for the burn survivor, his or her family, and the entire treatment team. This article describes the best approaches in burn care, including the use of a multidisciplinary team that emphasizes functional restoration through aggressive wound care, pain management, mobilization, and psychologic support.