Publications by authors named "David R Patterson"

69 Publications

Hypnotic Enhancement of Virtual Reality Distraction Analgesia during Thermal Pain: .

Int J Clin Exp Hypn 2021 Apr-Jun;69(2):225-245. Epub 2021 Mar 16.

Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, USA.

Excessive pain during medical procedures is a pervasive health challenge. This study tested the (additive) analgesic efficacy of combining hypnotic analgesia and virtual reality (VR) pain distraction. A single blind, randomized, and controlled trial was used to study 205 undergraduate volunteers aged 18 to 20. The individual and combined effects of hypnotic analgesia (H) and VR distraction on experimentally induced acute thermal pain were examined using a 2 X 2, between-groups parallel design (4 groups total). Participants in groups that received hypnosis remained hypnotized during the test phase pain stimulus. The main outcome measure was "worst pain" ratings. Hypnosis reduced acute pain even for people who scored low on hypnotizability. As predicted, H+ VR was significantly more effective than VR distraction alone. However, H+ VR was not significantly more effective than hypnotic analgesia alone. Being hypnotized during thermal pain enhanced VR distraction analgesia.
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http://dx.doi.org/10.1080/00207144.2021.1882259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141382PMC
March 2021

Virtual Reality Analgesia for Children With Large Severe Burn Wounds During Burn Wound Debridement.

Front Virtual Real 2020 Dec 10;1. Epub 2020 Dec 10.

Department of Radiology, University of Washington, Seattle, WA, United States.

The objective of this study was to compare the effect of adjunctive virtual reality vs. standard analgesic pain medications during burn wound cleaning/debridement. Participants were predominantly Hispanic children aged 6-17 years of age, with large severe burn injuries (TBSA = 44%) reporting moderate or higher baseline pain during burn wound care. Using a randomized between-groups design, participants were randomly assigned to one of two groups, (a) the Control Group = pain medications only or (b) the VR Group = pain medications + virtual reality. A total of 50 children (88% Hispanic) with large severe burns (mean TBSA > 10%) received severe burn wound cleaning sessions. For the primary outcome measure of worst pain (intensity) on Study Day 1, using a between groups ANOVA, burn injured children in the group that received virtual reality during wound care showed significantly less pain intensity than the No VR control group, [mean worst pain ratings for the No VR group = 7.46 (SD = 2.93) vs. 5.54 (SD = 3.56), = 4.29, <0.05, MSE = 46.00]. Similarly, one of the secondary pain measures, "lowest pain during wound care" was significantly lower in the VR group, No VR = 4.29 (SD = 3.75) vs. 1.68 (2.04) for the VR group, () = 9.29, < 0.005, MSE = 83.52 for Study Day 1. The other secondary pain measures showed the predicted pattern on Study Day 1, but were non-significant. Regarding whether VR reduced pain beyond Study Day 1, absolute change in pain intensity (analgesia = baseline pain minus the mean of the worst pain scores on Study days 1-10) was significantly greater for the VR group, = 4.88, 0.05, MSE = 34.26, partial eta squared = 0.09, but contrary to predictions, absolute change scores were non-significant for all secondary measures.
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http://dx.doi.org/10.3389/frvir.2020.602299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880045PMC
December 2020

Case Report: Virtual Reality Analgesia in an Opioid Sparing Orthopedic Outpatient Clinic Setting: A Case Study.

Front Virtual Real 2020 Dec 14;1. Epub 2020 Dec 14.

Department of Radiology, University of Washington, Seattle, WA, United States.

Immersive virtual reality is proving effective as a non-pharmacologic analgesic for a growing number of painful medical procedures. External fixator surgical pins provide adjunctive stability to a broken pelvic bone until the bones heal back together, then pins are removed. The purpose of the present case study was to measure for the first time, whether immersive virtual reality could be used to help reduce pain and anxiety during the orthopedic process of removing external fixator pins from a conscious patient in the orthopedic outpatient clinic, and whether it is feasible to use VR in this context. Using a within-subject within wound care design with treatment order randomized, the patient had his first ex-fix pin unscrewed and removed from his healing pelvic bone while he wore a VR helmet and explored an immersive snowy 3D computer generated world, adjunctive VR. He then had his second pin removed during no VR, standard of care pain medications. The patient reported having 43% less pain intensity, 67% less time spent thinking about pain, and 43% lower anxiety during VR vs. during No VR. In addition, the patient reported that his satisfaction with pain management was improved with the use of VR. Conducting simple orthopedic procedures using oral pain pills in an outpatient setting instead of anesthesia in the operating room greatly reduces the amount of opioids used, lowers medical costs and reduces rare but real risks of expensive complications from anesthesia including oversedation, death, and post-surgical dementia. These preliminary results suggest that immersive VR merits more attention as a potentially viable adjunctive non-pharmacologic form of treatment for acute pain and anxiety during medical procedures in the orthopedic outpatient clinic. Recent multi-billion dollar investments into R and D and mass production have made inexpensive immersive virtual reality products commercially available and cost effective for medical applications. We speculate that in the future, patients may be more willing to have minor surgery procedures in the outpatient clinic, with much lower opioid doses, while fully awake, if offered adjunctive virtual reality as a non-pharmacologic analgesic during the procedure. Additional research and development is recommended.
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http://dx.doi.org/10.3389/frvir.2020.553492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877803PMC
December 2020

Effects of hypnosis, cognitive therapy, hypnotic cognitive therapy, and pain education in adults with chronic pain: a randomized clinical trial.

Pain 2020 10;161(10):2284-2298

University of Washington, Seattle, WA, United States.

Chronic pain is a significant health problem worldwide with limited pharmacological treatment options. This study evaluated the relative efficacy of 4 treatment sessions each of 4 nonpharmacological treatments: (1) hypnotic cognitive therapy (using hypnosis to alter the meaning of pain); (2) standard cognitive therapy; (3) hypnosis focused on pain reduction, and (4) pain education. One hundred seventy-three individuals with chronic pain were randomly assigned to receive 4 sessions of 1 of the 4 treatments. Primary (pain intensity) and secondary outcome measures were administered by assessors unaware of treatment allocation at pretreatment, posttreatment, and 3-, 6-, and 12-month follow-up. Treatment effects were evaluated using analysis of variance, a generalized estimating equation approach, or a Fisher exact test, depending on the outcome domain examined. All 4 treatments were associated with medium to large effect size improvements in pain intensity that maintained up to 12 months posttreatment. Pretreatment to posttreatment improvements were observed across the 4 treatment conditions on the secondary outcomes of pain interference and depressive symptoms, with some return towards pretreatment levels at 12-month follow-up. No significant between-group differences emerged in omnibus analyses, and few statistically significant between-group differences emerged in the planned pairwise analyses, although the 2 significant effects that did emerge favored hypnotic cognitive therapy. Future research is needed to determine whether the significant differences that emerged are reliable.
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http://dx.doi.org/10.1097/j.pain.0000000000001943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508809PMC
October 2020

Clinical Hypnosis for Chronic Pain in Outpatient Integrative Medicine: An Implementation and Training Model.

J Altern Complement Med 2020 Feb 3;26(2):107-112. Epub 2020 Jan 3.

Department of Rehabilitation Medicine, University of Washington, Seattle, WA.

Clinical hypnosis for pain management cultivates specific skills to enhance general self-regulation and address pain. Hypnosis is well suited to integrative medicine settings; however, questions persist about its feasibility. This article describes a financially viable hypnosis practice model implemented in an integrative medicine clinic, providing initial feasibility data about rates of referral, participation, reimbursement, and provider retention. The specific processes required to establish and implement hypnosis services were detailed, including instruction in billing, reimbursement data, and a training model to enhance reach of services. Insurer reimbursement data and operational costs were examined from three hypnosis groups conducted between September 2017 and March 2018. Furthermore, information on referral patterns and enrollment in treatment was collected from program initiation in September 2017 to January 2019. Provider retention in training with the expansion of supervision in the program's second year was also examined. Of 258 individuals referred to hypnosis, 124 (48%) enrolled in group treatment. Analysis of insurer reimbursement over a subset of enrollees from three completed groups ( = 26) indicated an average collection of $95.85 per patient per session, equating to $706.86 per patient for the eight-session treatment. This extrapolates to $4,926.82 in total per seven-person group for the entirety of the eight-session treatment. After an annual training workshop, provider retention significantly increased (to 81% of eligible trained providers) with the initiation of twice-monthly clinical supervision focusing on transitioning from training to practice. This analysis indicates that a training- and practice-based research model of clinical hypnosis is feasible and financially sustainable in an integrative medicine setting.
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http://dx.doi.org/10.1089/acm.2019.0259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044758PMC
February 2020

Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study.

Front Hum Neurosci 2019 8;13:262. Epub 2019 Aug 8.

Psychiatry and Behavioral Sciences, University of Texas Medical Branch at Galveston, Galveston, TX, United States.

Using a within-subjects, within-wound care design, this pilot study tested for the first time, whether immersive virtual reality (VR) can serve as an adjunctive non-opioid analgesic for children with large severe burn wounds during burn wound cleaning in the ICU, in a regional burn center in the United States, between 2014-2016. Participants included 48 children from 6 years old to 17 years of age with >10% TBSA burn injuries reporting moderate or higher worst pain during no VR on Day 1. Forty-four of the 48 children were from developing Latin American countries. Patients played adjunctive SnowWorld, an interactive 3D snowy canyon in virtual reality during some portions of wound care, vs. No VR during comparable portions of the same wound care session (initial treatment condition randomized). Using Graphic Rating scales, children's worst pain ratings during "No VR" (treatment as usual pain medications) vs. their worst pain during "Yes VR" was measured during at least 1 day of wound care, and was measured for up to 10 study days the patient used VR. VR significantly reduced children's "worst pain" ratings during burn wound cleaning procedures in the ICU on Day 1. Worst pain during No VR = 8.52 (SD = 1.75) vs. during Yes VR = 5.10 (SD = 3.27), = 7.11, < 0.001, SD = 3.33, CI = 2.45-4.38, Cohen's d = 1.03 (indicating large effect size). Patients continued to report the predicted pattern of lower pain and more fun during VR, during multiple sessions. Immersive virtual reality can help reduce the pain of children with large severe burn wounds during burn wound cleaning in the Intensive Care Unit. Additional research and development is recommended.
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http://dx.doi.org/10.3389/fnhum.2019.00262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6694842PMC
August 2019

Virtual Reality Analgesia During Venipuncture in Pediatric Patients With Onco-Hematological Diseases.

Front Psychol 2018 20;9:2508. Epub 2018 Dec 20.

Department of Health Sciences, University of Florence, Florence, Italy.

Venipuncture is described by children as one of the most painful and frightening medical procedures. To evaluate the effectiveness of Virtual Reality (VR) as a distraction technique to help control pain in children and adolescents undergoing venipuncture. Using a within-subjects design, fifteen patients (mean age 10.92, = 2.64) suffering from oncological or hematological diseases received one venipuncture with "No VR" and one venipuncture with "Yes VR" on two separate days (treatment order randomized). "Time spent thinking about pain", "Pain Unpleasantness", "Worst pain" the quality of VR experience, fun during the venipuncture and nausea were measured. During VR, patients reported significant reductions in "Time spent thinking about pain," "Pain unpleasantness," and "Worst pain". Patients also reported significantly more fun during VR, and reported a "Strong sense of going inside the computer-generated world" during VR. No side effects were reported. VR can be considered an effective distraction technique for children and adolescents' pain management during venipuncture. Moreover, VR may elicit positive emotions, more than traditional distraction techniques. This could help patients cope with venipuncture in a non-stressful manner. Additional research and development is needed.
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http://dx.doi.org/10.3389/fpsyg.2018.02508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6307499PMC
December 2018

The Nature of Trauma Pain and Its Association with Catastrophizing and Sleep.

Int J Behav Med 2018 Dec;25(6):698-705

Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.

Background: Nearly 2.8 million people are hospitalized in the USA annually for traumatic injuries, which include orthopedic and internal organ injuries. Early post-injury pain is predictive of poor outcomes, including inability to eventually return to work, and long-term psychological distress. The goal of the present study was to improve our scientific understanding of trauma-related pain by examining (1) the nature and frequency of inpatient trauma pain and (2) the associations between inpatient trauma pain, education, opioid analgesic equivalent use, pain catastrophizing, and sleep quality.

Method: The study included 120 patients hospitalized at a major level I regional trauma center for the care of (1) closed long bone or calcaneus fractures and/or (2) an intraabdominal injury caused by blunt force trauma and requiring surgical repair (i.e., laparotomy). Medical records were reviewed to obtain demographic information and information about opioid use during hospitalization. In addition, participants were administered measures of average pain intensity, pain catastrophizing, and sleep quality.

Results: Education, opioid analgesic equivalents, catastrophizing, and poor sleep quality together accounted for 28% of the variance of average pain intensity over a 24-h period (p < .001), with each variable making a significant independent association.

Conclusion: Two of the factors associated with pain intensity in the study sample-catastrophizing and sleep quality-are modifiable. It is therefore possible that interventions that target these variables in patients who are hospitalized for trauma could potentially result in better long-term outcomes, including a reduced risk for developing chronic pain. Research to evaluate this possibility is warranted.
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http://dx.doi.org/10.1007/s12529-018-9751-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7703726PMC
December 2018

Virtual reality analgesia for burn joint flexibility: A randomized controlled trial.

Rehabil Psychol 2018 Nov 4;63(4):487-494. Epub 2018 Oct 4.

Department of Rehabilitation Medicine.

Objective: We conducted a randomized controlled study to determine the effects of virtual reality (VR) distraction on pain and range of motion (ROM) in patients hospitalized for burn care during active physical therapy exercises.

Method: Thirty-nine participants aged 15 to 66 (M = 36) years with significant burn injuries (mean burn size = 14% TBSA) participated. Under therapist supervision, using a within-subjects design, participants performed unassisted active ROM exercises both with and without VR distraction in a randomized order. Therapists provided participants with instructions but did not physically assist with stretches. Maximum active ROM was measured using a goniometer. A 0-100 Graphic Rating Scale (GRS) was used to assess the cognitive, affective, and sensory components of pain. A GRS rating of the amount of "fun" during stretching served as a measure of positive experience.

Results: Participants reported lower mean GRS ratings during VR, relative to No VR, for worst pain, pain unpleasantness, and time spent thinking about pain. They also reported having a more positive experience during VR than during No VR. However, patients did not show greater ROM during VR.

Conclusion: Immersive VR reduced pain during ROM exercises that were under the control of the patient. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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http://dx.doi.org/10.1037/rep0000239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6235624PMC
November 2018

KETAMINE AS A POSSIBLE MODERATOR OF HYPNOTIZABILITY: A FEASIBILITY STUDY.

Int J Clin Exp Hypn 2018 Jul-Sep;66(3):298-307

a University of Washington School of Medicine , Seattle , USA.

This pilot study explored the feasibility of using ketamine to increase hypnotizability scores. Ketamine, classified as a dissociative hallucinogen, is used clinically as an anesthetic in high doses and as a treatment for chronic pain and depression in lower doses. Low-dose ketamine can contribute to dissociation and heightened perceptions and feelings of detachment, arguably hypnotic-like states. The authors predicted that a low dose of ketamine in healthy volunteers who scored in the low hypnotizable range on the Stanford Clinical Hypnotizability Scale would (a) cause an increase in subjective ratings of dissociation and (b) lead to an increase in hypnotizability. The findings were in the predicted direction, warranting further investigation into the use of this agent to increase hypnotizability.
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http://dx.doi.org/10.1080/00207144.2018.1460559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6181123PMC
April 2019

The Association Between Mindfulness and Hypnotizability: Clinical and Theoretical Implications.

Am J Clin Hypn 2018 Jul;61(1):4-17

a The University of Queensland , Brisbane , Australia.

Mindfulness-based interventions and hypnosis are efficacious treatments for addressing a large number of psychological and physical conditions, including chronic pain. However, there continues to be debate surrounding the relative uniqueness of the theorized mechanisms of these treatments-reflected by measures of mindfulness facets and hypnotizability-with some concern that there may be so much overlap as to make the mechanism constructs (and, therefore, the respective interventions) redundant. Given these considerations, the primary aim of the current study was to examine the degree of unique versus shared variance between two common measures of mindfulness facets and hypnotizability: the Five Facet Mindfulness Questionnaire and the Stanford Hypnotic Clinical Scale. A cross-sectional survey was conducted with a sample of (N = 154) veterans with heterogeneous chronic pain conditions. Bivariate Pearson correlations were used to examine the associations between the target scales. Results showed that the correlations between the Five Facet Mindfulness Questionnaire scales and Stanford Hypnotic Clinical Scale total score were uniformly weak, although significant negative correlations were found between mindfulness facets of observe and nonreact with hypnotizability (ps < 0.05). Thus, not only are the mindfulness and hypnotizability constructs unique, but when significantly associated, hypnotic suggestibility corresponds with a tendency to be less mindful. These findings have important implications for future research aimed toward matching patients to the treatment most likely to be of benefit, and suggest that matching patients on the basis of these theoretically derived "unique" moderators may hold potential.
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http://dx.doi.org/10.1080/00029157.2017.1419458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6263151PMC
July 2018

Using a Biopsychosocial Model to Understand Long-Term Outcomes in Persons With Burn Injuries.

Arch Phys Med Rehabil 2020 01 2;101(1S):S55-S62. Epub 2018 Mar 2.

Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA.

Objective: To determine the importance of preburn adjustment, injury-related variables, and selection of coping style in various outcome measures using a biopsychosocial model.

Design: Longitudinal study.

Setting: Outpatient burn clinics.

Participants: Burn survivors (N=231) who participated in this study as part of a larger burn model system study of 645 patients with major burn injuries.

Interventions: Not applicable.

Main Outcome Measures: The 36-Item Short-Form Health Survey was used to assess preburn adjustment. Other outcome measures entered into the model included the Ways of Coping Checklist Revised, the Brief Symptom Inventory, the Beck Depression Inventory-II, and the Davidson Trauma Scale.

Results: Correlational and mediational analyses revealed that preburn emotional health predicted better adjustment at year 1 and more posttraumatic stress disorder symptoms at year 2. Better preburn emotional health was also related to less use of avoidance coping strategies, which was found to be a mediator of the effect of preburn emotional health and posttraumatic stress disorder symptoms. Burn injury characteristics were not significantly associated with psychological adjustment at either year 1 or year 2.

Conclusions: The results indicate that there is a complex relation between premorbid mental health and the selection of coping strategies that affect long-term adjustment in persons recovering from a burn injury. This relation seems to have greater effect on long-term outcomes than does preburn emotional or physical health alone or the severity of the burn.
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http://dx.doi.org/10.1016/j.apmr.2018.01.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6119641PMC
January 2020

Circumplex Model of Affect: A Measure of Pleasure and Arousal During Virtual Reality Distraction Analgesia.

Games Health J 2016 Jun 12;5(3):197-202. Epub 2016 May 12.

3 Department of Rehabilitation Medicine, University of Washington School of Medicine , Seattle, Washington.

Objective: Immersive virtual reality (VR) distraction provides clinically effective pain relief and increases subjective reports of "fun" in medical settings of procedural pain. The goal of this study was to better describe the variable of "fun" associated with VR distraction analgesia using the circumplex model (pleasure/arousal) of affect.

Materials And Methods: Seventy-four healthy volunteers (mean age, 29 years; 37 females) received a standardized, 18-minute, multimodal pain sequence (alternating thermal heat and electrical stimulation to distal extremities) while receiving immersive, interactive VR distraction. Subjects rated both their subjective pain intensity and fun using 0-10 Graphic Rating Scales, as well as the pleasantness of their emotional valence and their state of arousal on 9-point scales.

Results: Compared with pain stimulation in the control (baseline, no VR) condition, immersive VR distraction significantly reduced subjective pain intensity (P < 0.001). During VR distraction, compared with those reporting negative affect, subjects reporting positive affect did so more frequently (41 percent versus 9 percent), as well as reporting both greater pain reduction (22 percent versus 1 percent) and fun scores (7.0 ± 1.9 versus 2.4 ± 1.4). Several factors-lower anxiety, greater fun, greater presence in the VR environment, and positive emotional valence-were associated with subjective analgesia during VR distraction.

Conclusions: Immersive VR distraction reduces subjective pain intensity induced by multimodal experimental nociception. Subjects who report less anxiety, more fun, more VR presence, and more positive emotional valence during VR distraction are more likely to report subjective pain reduction. These findings indicate VR distraction analgesia may be mediated through anxiolytic, attentional, and/or affective mechanisms.
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http://dx.doi.org/10.1089/g4h.2015.0046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4931759PMC
June 2016

Feasibility of articulated arm mounted Oculus Rift Virtual Reality goggles for adjunctive pain control during occupational therapy in pediatric burn patients.

Cyberpsychol Behav Soc Netw 2014 Jun;17(6):397-401

1 Human Photonics Laboratory, Mechanical Engineering, University of Washington , Seattle, Washington.

For daily burn wound care and therapeutic physical therapy skin stretching procedures, powerful pain medications alone are often inadequate. This feasibility study provides the first evidence that entering an immersive virtual environment using very inexpensive (∼$400) wide field of view Oculus Rift Virtual Reality (VR) goggles can elicit a strong illusion of presence and reduce pain during VR. The patient was an 11-year-old male with severe electrical and flash burns on his head, shoulders, arms, and feet (36 percent total body surface area (TBSA), 27 percent TBSA were third-degree burns). He spent one 20-minute occupational therapy session with no VR, one with VR on day 2, and a final session with no VR on day 3. His rating of pain intensity during therapy dropped from severely painful during no VR to moderately painful during VR. Pain unpleasantness dropped from moderately unpleasant during no VR to mildly unpleasant during VR. He reported going "completely inside the computer generated world", and had more fun during VR. Results are consistent with a growing literature showing reductions in pain during VR. Although case studies are scientifically inconclusive by nature, these preliminary results suggest that the Oculus Rift VR goggles merit more attention as a potential treatment for acute procedural pain of burn patients. Availability of inexpensive but highly immersive VR goggles would significantly improve cost effectiveness and increase dissemination of VR pain distraction, making VR available to many more patients, potentially even at home, for pain control as well as a wide range of other VR therapy applications. This is the first clinical data on PubMed to show the use of Oculus Rift for any medical application.
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http://dx.doi.org/10.1089/cyber.2014.0058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4043256PMC
June 2014

Hypnotic approaches for chronic pain management: clinical implications of recent research findings.

Am Psychol 2014 Feb-Mar;69(2):167-77

Department of Rehabilitation Medicine, University of Washington.

The empirical support for hypnosis for chronic pain management has flourished over the past two decades. Clinical trials show that hypnosis is effective for reducing chronic pain, although outcomes vary between individuals. The findings from these clinical trials also show that hypnotic treatments have a number of positive effects beyond pain control. Neurophysiological studies reveal that hypnotic analgesia has clear effects on brain and spinal-cord functioning that differ as a function of the specific hypnotic suggestions made, providing further evidence for the specific effects of hypnosis. The research results have important implications for how clinicians can help their clients experience maximum benefits from hypnosis and treatments that include hypnotic components.
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http://dx.doi.org/10.1037/a0035644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465776PMC
August 2014

Repeated use of immersive virtual reality therapy to control pain during wound dressing changes in pediatric and adult burn patients.

J Burn Care Res 2013 Sep-Oct;34(5):563-8

From the *Department of Medical Psychology, Martini Hospital, Groningen, the Netherlands; †Department of Rehabilitation Medicine, University of Washington, Seattle; and ‡the Burn Centre, Martini Hospital, Groningen, the Netherlands.

The current study explored whether immersive virtual reality (VR) continues to reduce pain (via distraction) during more than one wound care session per patient. Thirty-six patients aged 8 to 57 years (mean age, 27.7 years), with an average of 8.4% TBSA burned (range, 0.25-25.5 TBSA) received bandage changes, and wound cleaning. Each patient received one baseline wound cleaning/debridement session with no-VR (control condition) followed by one or more (up to seven) subsequent wound care sessions during VR. After each wound care session (one session per day), worst pain intensity was measured using a visual analog thermometer, the dependent variable. Using a within-subjects design, worst pain intensity during wound care with no-VR (baseline, day 0) was compared with pain during wound care while using immersive VR (up to 7 days of wound care during VR). Compared with pain during no-VR baseline (day 0), pain ratings during wound debridement were statistically lower when patients were in VR on days 1, 2, and 3, and although not significant beyond day 3, the pattern of results from days 4, 5, and 6 are consistent with the notion that VR continues to reduce pain when used repeatedly. Results from the present study suggest that VR continues to be effective when used for three (or possibly more) treatments during severe burn wound debridement.
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http://dx.doi.org/10.1097/BCR.0b013e3182777904DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3770783PMC
April 2014

Virtual reality hypnosis pain control in the treatment of multiple fractures: a case series.

Am J Clin Hypn 2012 Jan;54(3):184-94

Department of Rehabilitation Medicine, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Box 359612, Seattle, WA 98104, USA.

This case series evaluated the use of virtual reality hypnosis (VRH) for the treatment of pain associated with multiple fractures from traumatic injuries. VRH treatment was administered on 2 consecutive days, and pain and anxiety were assessed each day before and after VRH treatment as well as on Day 3, which was 24 hours after the second treatment session. Pain reduction from baseline to Day 3 was from 70% to 30%, despite opioid analgesic use remaining stable. The subjective pain reduction reported by patients was encouraging, and the results of this case series suggest the importance of further study of VRH with larger samples using randomized controlled trials.
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http://dx.doi.org/10.1080/00029157.2011.619593DOI Listing
January 2012

Virtual reality as an adjunctive non-pharmacologic analgesic for acute burn pain during medical procedures.

Ann Behav Med 2011 Apr;41(2):183-91

University of Washington, Seattle, USA.

Introduction: Excessive pain during medical procedures is a widespread problem but is especially problematic during daily wound care of patients with severe burn injuries.

Methods: Burn patients report 35-50% reductions in procedural pain while in a distracting immersive virtual reality, and fMRI brain scans show associated reductions in pain-related brain activity during VR. VR distraction appears to be most effective for patients with the highest pain intensity levels. VR is thought to reduce pain by directing patients' attention into the virtual world, leaving less attention available to process incoming neural signals from pain receptors.

Conclusions: We review evidence from clinical and laboratory research studies exploring Virtual Reality analgesia, concentrating primarily on the work ongoing within our group. We briefly describe how VR pain distraction systems have been tailored to the unique needs of burn patients to date, and speculate about how VR systems could be tailored to the needs of other patient populations in the future.
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http://dx.doi.org/10.1007/s12160-010-9248-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465767PMC
April 2011

VIRTUAL REALITY HYPNOSIS FOR PAIN CONTROL IN A PATIENT WITH GLUTEAL HIDRADENITIS:A CASE REPORT().

Contemp Hypn Integr Ther 2011 ;28(2):142-147

University of Washington, Harborview Medical Center, Seattle, WA, USA.

This case report describes the use of hypnotic analgesia induced through immersive three-dimensional computer-generated virtual reality, better known as virtual reality hypnosis (VRH), in the treatment of a patient with ongoing pain associated with gluteal hidradenitis, The patient participated in the study for two consecutive days white hospitalized at a regional trauma centre. At pretreatment, she reported severe pain intensity and unpleasantness as well as high levels of anxiety and nervousness. She was then administered two sessions of virtual reality hypnotic treatment for decreased pain and anxiety. The patient's ratings of 'time spent thinking about pain', pain intensity, 'unpleasantness of pain', and anxiety decreased from before to after each daily VRH session, as well as from Day One to Day Two. The findings indicate that VRH may benefit individuals with severe, ongoing pain from a chronic condition, and that a controlled clinical trial examining its efficacy is warranted.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509742PMC
January 2011

A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.

Burns 2011 Feb 7;37(1):61-8. Epub 2010 Aug 7.

Department of Anesthesiology, University of Washington, Seattle, WA, USA.

This randomized, controlled, within-subjects (crossover design) study examined the effects of immersive virtual reality as an adjunctive analgesic technique for hospitalized pediatric burn inpatients undergoing painful physical therapy. Fifty-four subjects (6-19 years old) performed range-of-motion exercises under a therapist's direction for 1-5 days. During each session, subjects spent equivalent time in both the virtual reality and the control conditions (treatment order randomized and counterbalanced). Graphic rating scale scores assessing the sensory, affective, and cognitive components of pain were obtained for each treatment condition. Secondary outcomes assessed subjects' perception of the virtual reality experience and maximum range-of-motion. Results showed that on study day one, subjects reported significant decreases (27-44%) in pain ratings during virtual reality. They also reported improved affect ("fun") during virtual reality. The analgesia and affect improvements were maintained with repeated virtual reality use over multiple therapy sessions. Maximum range-of-motion was not different between treatment conditions, but was significantly greater after the second treatment condition (regardless of treatment order). These results suggest that immersive virtual reality is an effective nonpharmacologic, adjunctive pain reduction technique in the pediatric burn population undergoing painful rehabilitation therapy. The magnitude of the analgesic effect is clinically meaningful and is maintained with repeated use.
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http://dx.doi.org/10.1016/j.burns.2010.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2980790PMC
February 2011

Virtual reality hypnosis for pain associated with recovery from physical trauma.

Int J Clin Exp Hypn 2010 Jul;58(3):288-300

Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98104, USA.

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.
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http://dx.doi.org/10.1080/00207141003760595DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913598PMC
July 2010

INTERACTIVITY INFLUENCES THE MAGNITUDE OF VIRTUAL REALITY ANALGESIA.

J Cyber Ther Rehabil 2009 ;2(1):27-33

Department of Anesthiology, University of Washington, Seattle, Washington 98195 USA.

Despite medication with opioids and other powerful pharmacologic pain medications, most patients rate their pain during severe burn wound care as severe to excruciating. Excessive pain is a widespread medical problem in a wide range of patient populations. Immersive virtual reality (VR) distraction may help reduce pain associated with medical procedures. Recent research manipulating immersiveness has shown that a high tech VR helmet reduces pain more effectively than a low tech VR helmet. The present study explores the effect of interactivity on the analgesic effectiveness of virtual reality. Using a double blind design, in the present study, twenty-one volunteers were randomly assigned to one of two groups, and received a thermal pain stimulus during either interactive VR, or during non-interactive VR. Subjects in both groups individually glided through the virtual world, but one group could look around and interact with the environment using the trackball, whereas participants in the other group had no trackball. Afterwards, each participant provided subjective 0-10 ratings of cognitive, sensory and affective components of pain, and the amount of fun during the pain stimulus. Compared to the non-interactive VR group, participants in the interactive VR group showed 75% more reduction in pain unpleasantness (p < .005) and 74% more reduction in worst pain (p < .005). Interactivity increased the analgesic effectiveness of immersive virtual reality.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2853033PMC
January 2009

THE EFFICACY OF HYPNOTIC ANALGESIA IN ADULTS: A REVIEW OF THE LITERATURE.

Contemp Hypn 2009 Mar;26(1):24-39

University of Washington School of Medicine, Department of Rehabilitation Medicine, Seattle, WA, USA.

This article both summarizes the previous reviews of randomized, controlled trials of hypnotic analgesia for the treatment of chronic and acute pain in adults, and reviews similar trials which have recently been published in the scientific literature. The results indicate that for both chronic and acute pain conditions: (1) hypnotic analgesia consistently results in greater decreases in a variety of pain outcomes compared to no treatment/standard care; (2) hypnosis frequently out-performs non-hypnotic interventions (e.g. education, supportive therapy) in terms of reductions in pain-related outcomes; and (3) hypnosis performs similarly to treatments that contain hypnotic elements (such as progressive muscle relaxation), but is not surpassed in efficacy by these alternative treatments. Factors that may influence the efficacy of hypnotic analgesia interventions are discussed, including, but not limited to, the patient's level of suggestibility, treatment outcome expectancy, and provider expertise. Based upon this body of literature, suggestions are offered for practitioners who are using, or would like to use, hypnosis for the amelioration of pain problems in their patients or clients.
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http://dx.doi.org/10.1002/ch.370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2753288PMC
March 2009

Pain management in patients with burn injuries.

Int Rev Psychiatry 2009 Dec;21(6):522-30

University of Washington School of Medicine, Harborview Medical Center, Department of Rehabilitation Medicine, Seattle, Washington 98104, USA.

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http://dx.doi.org/10.3109/09540260903343844DOI Listing
December 2009

The effect of virtual reality on pain and range of motion in adults with burn injuries.

J Burn Care Res 2009 Sep-Oct;30(5):785-91

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

Few studies have empirically investigated the effects of immersive virtual reality (VR) on postburn physical therapy pain control and range of motion (ROM). We performed a prospective, randomized controlled study of the effects of adding VR to standard therapy in adults receiving active-assisted ROM physical therapy, by assessing pain scores and maximal joint ROM immediately before and after therapy on two consecutive days. Thirty-nine inpatients, aged 21 to 57 years (mean 35 years), with a mean TBSA burn of 18% (range, 3-60%) were studied using a within-subject, crossover design. All patients received their regular pretherapy pharmacologic analgesia regimen. During physical therapy sessions on two consecutive days (VR one day and no VR the other day; order randomized), each patient participated in active-assisted ROM exercises with an occupational or physical therapist. At the conclusion of each session, patients provided 0 to 100 Graphic Rating Scale measurements of pain after each 10-minute treatment condition. On the day with VR, patients wore a head-position-tracked, medical care environment-excluding VR helmet with stereophonic sound and interacted in a virtual environment conducive to burn care. ROM measurements for each joint exercised were recorded before and after each therapy session. Because of nonsignificant carryover and order effects, the data were analyzed using simple paired t-tests. VR reduced all Graphic Rating Scale pain scores (worst pain, time spent thinking about the pain, and pain unpleasantness by 27, 37, and 31% respectively), relative to the no VR condition. Average ROM improvement was slightly greater with the VR condition; however, this difference failed to reach clinical or statistical significance (P = .243). Ninety-seven percent of patients reported zero to mild nausea after the VR session. Immersive VR effectively reduced pain and did not impair ROM during postburn physical therapy. VR is easily used in the hospital setting and offers a safe, nonpharmacologic adjunctive analgesic treatment.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880576PMC
http://dx.doi.org/10.1097/BCR.0b013e3181b485d3DOI Listing
January 2010

Pain, depression, and physical functioning following burn injury.

Rehabil Psychol 2009 May;54(2):211-6

Department of Rehabilitation Medicine, University of Washington.

Objective: Little is known about how pain and depression after burn injury may influence long-term outcomes such as physical functioning. This prospective study examined associations between pain, depression, and physical functioning in a sample of burn injury survivors.

Design And Participants: Questionnaires assessing pain, depression, and physical functioning were completed by 64 (52% of original sample) adult burn survivors shortly after discharge from burn care and at 1- and 2-year follow-ups.

Results: Pain and physical functioning improved over the 2 years of the study, whereas depression levels were stable. Pain and depression were associated with poorer physical functioning over time, but associations varied according to the time span under consideration. Also, the association between pain and physical functioning was strongest among persons with higher depression scores.

Conclusions: Pain and depression may contribute independently to compromises in physical functioning. The co-occurrence of pain and depression represents even greater risk for reduced physical functioning over time among burn survivors.
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http://dx.doi.org/10.1037/a0015613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872144PMC
May 2009

Effects of self-hypnosis training and EMG biofeedback relaxation training on chronic pain in persons with spinal-cord injury.

Int J Clin Exp Hypn 2009 Jul;57(3):239-68

Department of Rehabilitation Medicine, University of Washington, Seattle, Washington 98195-6490, USA.

Thirty-seven adults with spinal-cord injury and chronic pain were randomly assigned to receive 10 sessions of self-hypnosis (HYP) or EMG biofeedback relaxation (BIO) training for pain management. Participants in both treatment conditions reported substantial, but similar, decreases in pain intensity from before to after the treatment sessions. However, participants in the HYP condition, but not the BIO condition, reported statistically significant decreases in daily average pain pre- to posttreatment. These pre- to posttreatment decreases in pain reported by the HYP participants were maintained at 3-month follow-up. Participants in the HYP condition, but not the BIO condition, also reported significant pre- to posttreatment increases in perceived control over pain, but this change was not maintained at the 3-month follow-up.
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http://dx.doi.org/10.1080/00207140902881007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730649PMC
July 2009

VIRTUAL REALITY HYPNOSIS.

Contemp Hypn 2009 Mar;26(1):40-47

University of Washington School of Medicine, Department of Rehabilitation Medicine.

Scientific evidence for the viability of hypnosis as a treatment for pain has flourished over the past two decades (Rainville, Duncan, Price, Carrier and Bushnell, 1997; Montgomery, DuHamel and Redd, 2000; Lang and Rosen, 2002; Patterson and Jensen, 2003). However its widespread use has been limited by factors such as the advanced expertise, time and effort required by clinicians to provide hypnosis, and the cognitive effort required by patients to engage in hypnosis.The theory in developing virtual reality hypnosis was to apply three-dimensional, immersive, virtual reality technology to guide the patient through the same steps used when hypnosis is induced through an interpersonal process. Virtual reality replaces many of the stimuli that the patients have to struggle to imagine via verbal cueing from the therapist. The purpose of this paper is to explore how virtual reality may be useful in delivering hypnosis, and to summarize the scientific literature to date. We will also explore various theoretical and methodological issues that can guide future research.In spite of the encouraging scientific and clinical findings, hypnosis for analgesia is not universally used in medical centres. One reason for the slow acceptance is the extensive provider training required in order for hypnosis to be an effective pain management modality. Training in hypnosis is not commonly offered in medical schools or even psychology graduate curricula. Another reason is that hypnosis requires far more time and effort to administer than an analgesic pill or injection. Hypnosis requires training, skill and patience to deliver in medical centres that are often fast-paced and highly demanding of clinician time. Finally, the attention and cognitive effort required for hypnosis may be more than patients in an acute care setting, who may be under the influence of opiates and benzodiazepines, are able to impart. It is a challenge to make hypnosis a standard part of care in this environment.Over the past 25 years, researchers have been investigating ways to make hypnosis more standardized and accessible. There have been a handful of studies that have looked at the efficacy of using audiotapes to provide the hypnotic intervention (Johnson and Wiese, 1979; Hart, 1980; Block, Ghoneim, Sum Ping and Ali, 1991; Enqvist, Bjorklund, Engman and Jakobsson, 1997; Eberhart, Doring, Holzrichter, Roscher and Seeling, 1998; Perugini, Kirsch, Allen, et al., 1998; Forbes, MacAuley, Chiotakakou-Faliakou, 2000; Ghoneim, Block, Sarasin, Davis and Marchman, 2000). These studies have yielded mixed results. Generally, we can conclude that audio-taped hypnosis is more effective than no treatment at all, but less effective than the presence of a live hypnotherapist. Grant and Nash (1995) were the first to use computer-assisted hypnosis as a behavioural measure to assess hypnotizability. They used a digitized voice that guided subjects through a procedure and tailored software according to the subject's unique responses and reactions. However, it utilized conventional two-dimensional screen technology that required patients to focus their attention on a computer screen, making them vulnerable to any type of distraction that might enter the environment. Further, the two-dimensional technology did not present compelling visual stimuli for capturing the user's attention.
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http://dx.doi.org/10.1002/ch.371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2925392PMC
March 2009

A comparison of self-hypnosis versus progressive muscle relaxation in patients with multiple sclerosis and chronic pain.

Int J Clin Exp Hypn 2009 Apr;57(2):198-221

University of Washington School of Medicine, Seattle, Washington 98195-6490, USA.

Twenty-two patients with multiple sclerosis (MS) and chronic pain we recruited into a quasi-experimental trial comparing the effects of self-hypnosis training (HYP) with progressive muscle relaxation (PMR) on pain intensity and pain interference; 8 received HYP and the remaining 14 participants were randomly assigned to receive either HYP or PMR. HYP-condition participants reported significantly greater pre- to postsession as well as pre- to posttreatment decreases in pain and pain interference than PMR-condition participants, and gains were maintained at 3-month follow-up. Most of the participants in both conditions reported that they continued to use the skills they learned in treatment and experienced pain relief when they did so. General hypnotizability was not significantly related to treatment outcome, but treatment-outcome expectancy assessed before and after the first session was. The results support the efficacy of self-hypnosis training for the management of chronic pain in persons with MS.
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http://dx.doi.org/10.1080/00207140802665476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758639PMC
April 2009

Effect of acute and chronic alcohol abuse on pain management in a trauma center.

Expert Rev Neurother 2009 Feb;9(2):271-7

University of Washington School of Medicine, Department of Rehabilitation Medicine, Harborview Medical Center, 325 Ninth Avenue, Box 359740, Seattle, WA 98104, USA.

The proper management of acute pain has been identified as a primary indicator of quality assurance in US trauma centers. Nearly half of all trauma patients are injured while intoxicated and 75% of these patients have chronic alcohol problems. The management of pain caused by injuries in patients with alcohol problems poses unique challenges. Biases exist regarding the crosstolerance effects of ethanol and opioids and the pain thresholds of patients with substance abuse histories. The purpose of this review is to examine some of the factors that inform our decisions of how to manage acute pain in this population and to review the empirical evidence that exists.
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http://dx.doi.org/10.1586/14737175.9.2.271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2703452PMC
February 2009