Publications by authors named "Hunter G Hoffman"

54 Publications

Interacting with virtual objects via embodied avatar hands reduces pain intensity and diverts attention.

Authors:
Hunter G Hoffman

Sci Rep 2021 May 21;11(1):10672. Epub 2021 May 21.

The Virtual Reality Analgesia Research Center at the Human Photonics Lab, University of Washington, Box 352142, Seattle, WA, USA.

The current study introduces a new paradigm for exploring cognitive factors in pain. Interacting with virtual objects via embodied avatar hands increased the illusion of "being there" in the virtual world, increased VR analgesia for acute pain, and reduced accuracy on an attention demanding task. Twenty-four healthy volunteer college students participated in this within-subject randomized crossover design study. During Phase 1, each participant received brief thermal pain stimuli during interactive embodied avatar VR vs. passive VR (no avatar and no interactivity), VR treatment order randomized. After each pain stimulus, participants provided subjective 0-10 ratings of pain. Compared to the passive VR condition, during the interactive avatar VR, participants reported significant reductions in (1) worst pain, (2) pain unpleasantness, (3) time thinking about pain and (4). they had significantly more fun during the pain stimulus (p = .000 for each). During Phase 2, participants performed a divided attention task in each of the two VR conditions. Participants made significantly more errors on the divided attention task during the interactive avatar VR condition, compared to passive VR, implicating an attention mechanism for how virtual reality reduces pain and helping understand how VR influences pain perception.Trial registration: NCT04245475. Date of registration: 29/01/2020.
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http://dx.doi.org/10.1038/s41598-021-89526-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140079PMC
May 2021

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

Therapists Make the Switch to Telepsychology to Safely Continue Treating Their Patients During the COVID-19 Pandemic. Virtual Reality Telepsychology May Be Next.

Front Virtual Real 2021 Jan 15;1. Epub 2021 Jan 15.

Department of Mechanical Engineering, Radiology and Psychology, University of Washington, Seattle, WA, United States.

Before COVID-19, most therapists had concerns about telepsychology, and only treated patients in person. During the COVID-19 lockdown, patients still needed therapy, but in-person therapy sessions became unsafe. The current study measured how many therapists are using online therapy before vs. during COVID-19, how much training they have received, and their knowledge about legal restrictions on using telepsychology. A sample of 768 U.S.A. mental health professionals completed a 29-item online survey. Results show that before COVID-19, most therapists only saw their patients in person (e.g., at the therapists office), but during the COVID-19 pandemic, nearly all therapists used a wide range of telecommunication technologies to communicate with their quarantined patients, including texting, telephones, video conferences, and even virtual reality. According to within-subject related samples comparisons, 39% of survey respondents used telepsychology before COVID-19, vs. 98% during COVID-19 (χ = 450.02, < 0.001). Therapists reported high treatment effectiveness using telepsychology (7.45 on 0-10 scale). However, overall, on a 0-10 scale, therapists reported a significant increase in feeling burned out during the COVID-19 pandemic, Mean = 3.93 (SD = 1.93) before vs. 6.22 (SD = 2.27) during the pandemic ( = -18.57, < 0.001). Although the APA ethics guidelines encourage therapists to use telepsychology with their patients during the crisis, gaps in respondents' knowledge identify a need for increased specialized training and education. Although the current study showed that virtual reality is rarely used by the therapists surveyed, virtual reality is a promising new telepsychology technology. Billions of dollars are currently being invested in mass producing immersive virtual reality systems. In the future, as networked immersive Virtual Reality becomes more widely available, therapists and patients in physically different locations will be able to "meet" in a shared computer-generated world designed for therapy sessions, potentially including group sessions. Telepsychology and virtual reality have the potential to be increasingly valuable tools to help therapists mitigate the consequences of COVID-19. Research, development and training is recommended.
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http://dx.doi.org/10.3389/frvir.2020.576421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880047PMC
January 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

Decreasing Pain and Fear in Medical Procedures with a Pediatric Population (DREAM): A Pilot Randomized Within-Subject Trial.

Pain Manag Nurs 2021 Apr 22;22(2):191-197. Epub 2021 Jan 22.

CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Quebec, H3T 1C5, Canada.

Background: Many children with injuries, including burns and fractures, experience moderate to severe pain during medical procedures. Recent studies claim that nonpharmacologic pain management using virtual reality (VR) could distract children from procedural pain by engaging multiple senses.

Aims: The aims of this pilot randomized clinical trial were to assess the acceptability and feasibility of VR distraction in children with burns or fractures undergoing painful medical procedures, as well as the staff nurses, and assess the preliminary efficacy of VR distraction on pain intensity, pain-related fear, and subsequent recall of both.

Materials And Method: A within-subject study design, in which participants served as their own control, was used. A total of 20 children from 7 to 17 years old with an injury were recruited at the surgical-trauma outpatient clinics of the Centre hospitalier universitaire Sainte-Justine (CHU Sainte-Justine). Each participant received both standard and experimental treatments through randomized order. Pain (numerical rating scale) and pain-related fear (Children's Fear Scale) measures were taken before the procedure and after each sequence, followed by a measure of children's (graphic rating scale) and nurses' acceptability of the intervention through their satisfaction level. Recall of pain intensity and pain-related fear were assessed 24 hours after the procedure. Wilcoxon signed-rank tests were used, with a significance level at 0.05.

Results: Results showed that VR distraction was an acceptable and feasible intervention for children and nurses of these outpatient clinics. Preliminary effects showed that, compared to standard of care, children participants reported a significant decrease in pain intensity (p = .023) and pain-related fear (p = .011) during VR as well as less recalled pain-related fear (p = .012) at 24 hours after the procedure. No side effects were reported.

Conclusion: VR is a promising intervention with children undergoing painful procedures because it is immersive and engages multiple senses. It is a low-cost intervention well accepted by children and nursing staff at this clinical site and is easy to implement in daily practice for procedural pain management.
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http://dx.doi.org/10.1016/j.pmn.2020.10.002DOI Listing
April 2021

Virtual reality hand therapy: A new tool for nonopioid analgesia for acute procedural pain, hand rehabilitation, and VR embodiment therapy for phantom limb pain.

J Hand Ther 2020 Apr - Jun;33(2):254-262. Epub 2020 May 30.

Johnson and Johnson JLABS @ US North East (NYC, Boston, & Philadelphia), NY, NY.

Introduction: Affordable virtual reality (VR) technology is now widely available. Billions of dollars are currently being invested into improving and mass producing VR and augmented reality products.

Purpose Of The Study: The purpose of the present study is to explore the potential of immersive VR to make physical therapy/occupational therapy less painful, more fun, and to help motivate patients to cooperate with their hand therapist.

Discussion: The following topics are covered: a) psychological influences on pain perception, b) the logic of how VR analgesia works, c) evidence for reduction of acute procedural pain during hand therapy, d) recent major advances in VR technology, and e) future directions-immersive VR embodiment therapy for phantom limb (chronic) pain.

Conclusion: VR hand therapy has potential for a wide range of patient populations needing hand therapy, including acute pain and potentially chronic pain patients. Being in VR helps reduce the patients' pain, making it less painful for patients to move their hand/fingers during hand therapy, and gamified VR can help motivate the patient to perform therapeutic hand exercises, and make hand therapy more fun. In addition, VR camera-based hand tracking technology may be used to help therapists monitor how well patients are doing their hand therapy exercises, and to quantify whether adherence to treatment increases long-term functionality. Additional research and development into using VR as a tool for hand therapist is recommended for both acute pain and persistent pain patient populations.
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http://dx.doi.org/10.1016/j.jht.2020.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719341PMC
May 2020

Effects of a projector-based hybrid virtual reality on pain in young children with burn injuries during hydrotherapy sessions: A within-subject randomized crossover trial.

Burns 2020 May 7. Epub 2020 May 7.

Faculty of Nursing, University of Montreal: 2375, Chemin de la Côte-Ste-Catherine, Montreal (Quebec) H3T 1A8, Canada; CHU Sainte-Justine Research Center: 3175 Chemin de la Côte-Sainte-Catherine, Montreal (Quebec) H3T 1C5, Canada. Electronic address:

Aim: The aim of this study was to examine the effect of a water-friendly Projector-Based Hybrid Virtual Reality (VR) dome environment combined with standard pharmacological treatment on pain in young children undergoing burn wound care in hydrotherapy.

Methods: This study was a prospective, within-subject crossover trial of 38 children aged 6 months to 7 years old (mean age=1.8 years old). Each hydrotherapy procedure was divided into two equivalent wound care segments (No hybrid VR during one segment vs. Hybrid VR during the other segment, treatment order was randomized). Pain was measured using the 0-10 FLACC (Face, Legs, Activity, Cry Consolability scale) and the 0-10 NRS-obs (Numerical Rating Scale-obs).

Results: Projector-Based Hybrid VR significantly reduced procedural pain levels measured by the FLACC (p=0.026) and significantly increased patients' comfort levels (p=0.002). Patients' pain levels rated by the nurses using the NRS-obs were non-significant between both groups (p=0.135). No side effects were reported.

Conclusion: Projector-Based Hybrid VR helped in reducing the pain related to hydrotherapy procedures in young children with burn wound injuries. This is the first study using virtual reality distraction with young children, and our findings are especially important because a large percentage of pediatric burn patients are very young. Additional research and development are recommended.

Trial Registration: ClinicalTrials.gov, NCT02986464, registered on June 12, 2016.
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http://dx.doi.org/10.1016/j.burns.2020.04.006DOI Listing
May 2020

Virtual Reality Analgesia With Interactive Eye Tracking During Brief Thermal Pain Stimuli: A Randomized Controlled Trial (Crossover Design).

Front Hum Neurosci 2019 23;13:467. Epub 2020 Jan 23.

Virtual Reality Research Center, Human Photonics Lab, University of Washington, Seattle, WA, United States.

In light of growing concerns about opioid analgesics, developing new non-pharmacologic pain control techniques has become a high priority. Adjunctive virtual reality can help reduce acute pain during painful medical procedures. However, for some especially painful medical procedures such as burn wound cleaning, clinical researchers recommend that more distracting versions of virtual reality are needed, to further amplify the potency of virtual reality analgesia. The current study with healthy volunteers explores for the first time whether interacting with virtual objects in Virtual Reality (VR) via "hands free" eye-tracking technology integrated into the VR helmet makes VR more effective/powerful than non-interactive/passive VR (no eye-tracking) for reducing pain during brief thermal pain stimuli.

Method: Forty eight healthy volunteers participated in the main study. Using a within-subject design, each participant received one brief thermal pain stimulus during interactive eye tracked virtual reality, and each participant received another thermal pain stimulus during non-interactive VR (treatment order randomized). After each pain stimulus, participants provided subjective 0-10 ratings of cognitive, sensory and affective components of pain, and rated the amount of fun they had during the pain stimulus.

Results: As predicted, interactive eye tracking increased the analgesic effectiveness of immersive virtual reality. Compared to the passive non-interactive VR condition, during the interactive eye tracked VR condition, participants reported significant reductions in worst pain ( < 0.001) and pain unpleasantness ( < 0.001). Participants reported a significantly stronger illusion of presence ( < 0.001), and significantly more fun in VR ( < 0.001) during the interactive condition compared to during passive VR. In summary, as predicted by our primary hypothesis, in the current laboratory acute pain analog study with healthy volunteers, increasing the immersiveness of the VR system via interactive eye tracking significantly increased how effectively VR reduced worst pain during a brief thermal pain stimulus. Although attention was not directly measured, the pattern of pain ratings, presence ratings, and fun ratings are consistent with an attentional mechanism for how VR reduces pain. Whether the current results generalize to clinical patient populations is another important topic for future research. Additional research and development is recommended.
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http://dx.doi.org/10.3389/fnhum.2019.00467DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990370PMC
January 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

Evaluation of a Mindfulness-Based Intervention With and Without Virtual Reality Dialectical Behavior Therapy Mindfulness Skills Training for the Treatment of Generalized Anxiety Disorder in Primary Care: A Pilot Study.

Front Psychol 2019 28;10:55. Epub 2019 Jan 28.

Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain.

Generalized Anxiety Disorder (GAD) is a very prevalent disorder in primary care (PC). Most patients with GAD never seek treatment, and those who do seek treatment often drop out before completing treatment. Although it is an understudied treatment, Mindfulness-Based Interventions (MBIs) indicate preliminary efficacy for the treatment of GAD symptoms, but many patients with GAD present other associated symptoms (e.g., attention deficits) that complicate the treatment. Virtual Reality DBT Mindfulness Skills learning has recently been developed to make learning mindfulness easier for patients with emotion dysregulation who have trouble concentrating. Virtual Reality (VR) might serve as a visual guide for practicing mindfulness as it gives patients the illusion of "being there" in the 3D computer generated world. The main goal of this study was to evaluate the effect of two MBIs (a MBI in a group setting alone and the same MBI plus 10 min VR DBT Mindfulness skills training) to reduce GAD symptoms. A secondary aim was to explore the effect in depression, emotion regulation, mindfulness, and interoceptive awareness. Other exploratory aims regarding the use of VR DBT Mindfulness skills were also carried out. The sample was composed of 42 patients (roughly half in each group) with GAD attending PC visits. After treatment, both groups of patients showed significant improvements in General Anxiety Disorder measured by the GAD-7 using mixed regression models [MBI alone ( = -5.70; < 0.001; = -1.36), MBI+VR DBT Mindfulness skills ( = -4.38; < 0.001; = -1.33)]. Both groups also showed significant improvements in anxiety, depression, difficulties of emotion regulation and several aspects of mindfulness and interoceptive awareness. Patients in the group that received additional 10 min VR DBT Mindfulness Skills training were significantly more adherent to the treatment than those receiving only standard MBI (100% completion rate in MBI + VR vs. 70% completion rate in MBI alone; = 0.020). Although randomized controlled studies with larger samples are needed, this pilot study shows preliminary effectiveness of MBI to treat GAD, and preliminary evidence that adjunctive VR DBT Mindfulness Skills may reduce dropouts.
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http://dx.doi.org/10.3389/fpsyg.2019.00055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360930PMC
January 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

Virtual Reality Analgesia for Pediatric Dental Patients.

Front Psychol 2018 23;9:2265. Epub 2018 Nov 23.

Mechanical Engineering, University of Washington, Seattle, WA, United States.

Dental procedures often elicit pain and fear in pediatric dental patients. To evaluate the feasibility and effectiveness of immersive virtual reality as an attention distraction analgesia technique for pain management in children and adolescents undergoing painful dental procedures. Using a within-subjects design, five patients (mean age 13.20 years old, SD 2.39) participated. Patients received tethered immersive interactive virtual reality distraction in an Oculus Rift VR helmet (experimental condition) during one dental procedure (a single dental filling or tooth extraction). On a different visit to the same dentist (e.g., 1 week later), each patient also received a comparable dental procedure during the control condition "treatment as usual" (treatment order randomized). After each procedure, children self-rated their "worst pain," "pain unpleasantness," "time spent thinking about pain," "presence in VR," "fun," and "nausea" levels during the dental procedures, using graphic rating scales. Patients reported significantly lower "worst pain" and "pain unpleasantness," and had significantly more fun during VR, compared to a comparable dental procedure with No VR. Using Oculus Rift VR goggles, patients reported a "strong sense of going inside the computer-generated world," without side effects. The dentist preferred having the patients in VR. Results of this pilot study provide preliminary evidence of the feasibility of using immersive, interactive VR to distract pediatric dental patients and increase fun of children during dental procedures.
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http://dx.doi.org/10.3389/fpsyg.2018.02265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6265341PMC
November 2018

Virtual Reality, Augmented Reality, and In Vivo Exposure Therapy: A Preliminary Comparison of Treatment Efficacy in Small Animal Phobia.

Cyberpsychol Behav Soc Netw 2019 Jan 18;22(1):31-38. Epub 2018 Oct 18.

1 Department of Basic and Clinical Psychology and Psychobiology, Jaume I University, Castellon, Spain.

This study aggregated data from three randomized control trials to explore the differential efficacy of three forms of exposure therapy, namely, in vivo (iVET), virtual reality (VRET), and augmented reality (ARET), in the treatment of small animal phobia. Additionally, baseline patient characteristics were used to detect subgroups of patients who showed a differential response to certain treatment modalities. Primary measures were distance covered, anxiety during the behavioral avoidance test (BAT), and overall fear of small animals. A repeated-measures analysis of variance was used to explore the overall treatment effect across the exposure modalities. A cluster analysis and an analysis of moderation were conducted to explore differential response to treatments. The main study finding was that the three treatment conditions were similarly efficacious in the treatment of small animal phobia for all study outcomes. Only for distance covered, our results revealed a tendency for iVET to be more effective than VRET and ARET in participants with worse performance on the BAT before treatment. The present study findings provide further evidence for the comparable efficacy of the three forms of exposure. Our results also suggest that, overall, treatments are likely to be similarly effective, regardless of the individual baseline characteristics (i.e., fear, anxiety, and age), whereas pretreatment scores on distance covered in the avoidance test might be used to personalize treatments (iVET may be preferable when participants perform worse at pretreatment).
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http://dx.doi.org/10.1089/cyber.2017.0672DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352498PMC
January 2019

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

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

Projector-based virtual reality dome environment for procedural pain and anxiety in young children with burn injuries: a pilot study.

J Pain Res 2018 14;11:343-353. Epub 2018 Feb 14.

Faculty of Nursing, University of Montreal, Montreal, QC, Canada.

Background: Virtual reality (VR) is a non-pharmacological method to distract from pain during painful procedures. However, it was never tested in young children with burn injuries undergoing wound care.

Aim: We aimed to assess the feasibility and acceptability of the study process and the use of VR for procedural pain management.

Methods: From June 2016 to January 2017, we recruited children from 2 months to 10 years of age with burn injuries requiring a hydrotherapy session in a pediatric university teaching hospital in Montreal. Each child received the projector-based VR intervention in addition to the standard pharmacological treatment. Data on intervention and study feasibility and acceptability in addition to measures on pain (Face, Legs, Activity, Cry, Consolability scale), baseline (Modified Smith Scale) and procedural (Procedure Behavior Check List) anxiety, comfort (OCCEB-BECCO [behavioral observational scale of comfort level for child burn victims]), and sedation (Ramsay Sedation Scale) were collected before, during, and after the procedure. Data analyses included descriptive and non-parametric inferential statistics.

Results: We recruited 15 children with a mean age of 2.2±2.1 years and a mean total body surface area of 5% (±4). Mean pain score during the procedure was low (2.9/10, ±3), as was the discomfort level (2.9/10, ±2.8). Most children were cooperative, oriented, and calm. Assessing anxiety was not feasible with our sample of participants. The prototype did not interfere with the procedure and was considered useful for procedural pain management by most health care professionals.

Conclusion: The projector-based VR is a feasible and acceptable intervention for procedural pain management in young children with burn injuries. A larger trial with a control group is required to assess its efficacy.
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http://dx.doi.org/10.2147/JPR.S151084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5817417PMC
February 2018

Meditation experts try Virtual Reality Mindfulness: A pilot study evaluation of the feasibility and acceptability of Virtual Reality to facilitate mindfulness practice in people attending a Mindfulness conference.

PLoS One 2017 22;12(11):e0187777. Epub 2017 Nov 22.

Red de Investigación en Atención Primaria (REDIAPP), Zaragoza, Spain.

Regular mindfulness practice benefits people both mentally and physically, but many populations who could benefit do not practice mindfulness. Virtual Reality (VR) is a new technology that helps capture participants' attention and gives users the illusion of "being there" in the 3D computer generated environment, facilitating sense of presence. By limiting distractions from the real world, increasing sense of presence and giving people an interesting place to go to practice mindfulness, Virtual Reality may facilitate mindfulness practice. Traditional Dialectical Behavioral Therapy (DBT®) mindfulness skills training was specifically designed for clinical treatment of people who have trouble focusing attention, however severe patients often show difficulties or lack of motivation to practice mindfulness during the training. The present pilot study explored whether a sample of mindfulness experts would find useful and recommend a new VR Dialectical Behavioral Therapy (DBT®) mindfulness skills training technique and whether they would show any benefit. Forty four participants attending a mindfulness conference put on an Oculus Rift DK2 Virtual Reality helmet and floated down a calm 3D computer generated virtual river while listening to digitized DBT® mindfulness skills training instructions. On subjective questionnaires completed by the participants before and after the VR DBT® mindfulness skills training session, participants reported increases/improvements in state of mindfulness, and reductions in negative emotional states. After VR, participants reported significantly less sadness, anger, and anxiety, and reported being significantly more relaxed. Participants reported a moderate to strong illusion of going inside the 3D computer generated world (i.e., moderate to high "presence" in VR) and showed high acceptance of VR as a technique to practice mindfulness. These results show encouraging preliminary evidence of the feasibility and acceptability of using VR to practice mindfulness based on clinical expert feedback. VR is a technology with potential to increase computerized dissemination of DBT® skills training modules. Future research is warranted.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0187777PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5699841PMC
December 2017

The Neurobiological Mechanism of Chemical Aversion (Emetic) Therapy for Alcohol Use Disorder: An fMRI Study.

Front Behav Neurosci 2017 28;11:182. Epub 2017 Sep 28.

Department of Radiology, Integrated Brain Imaging Center, University of Washington, Seattle, WA, United States.

A recent NIH epidemiology study found the lifetime prevalence of alcohol use disorder in the United States to be 29%. Alcohol drinking behavior is strongly "learned" via pleasure center activation/reinforcement. Alcohol craving is a powerful desire to drink alcoholic beverages. Craving was added as one of the defining criteria for alcohol use disorder in DSM5, and craving reduction is becoming an increasingly important treatment goal. In the current study, patients with alcohol use disorder received 10 days of inpatient multi-modal treatments at Schick Shadel Hospital (SSH) of Seattle. The treatments included five chemical aversion conditioning sessions that associated alcohol cues (and alcohol) with nausea and emesis. All patients met DSM4 criteria for alcohol use disorder, were heavy drinkers, and reported craving alcohol pre-treatment. Craving reduction was one of the primary treatment goals. This is the first fMRI study to measure the effects of chemical aversion therapy on alcohol craving-related brain activity. Patients were recruited as subjects for the University of Washington (UW) brain scan study following SSH admission but before treatment onset. Prior to treatment, patients reported craving/desire for alcohol. After treatment (after four SSH chemical aversion treatments, again after five SSH chemical treatments, 30 and 90-days post-discharge), these same patients reported avoidance/aversion to alcohol. Most of the participants (69%) reported being still sober 12 months post-treatment. Consistent with a craving reduction mechanism of how chemical aversion therapy facilitates sobriety, results of the UW fMRI brain scans showed significant pre- to post-treatment reductions in craving-related brain activity in the occipital cortex. Additional fMRI brain scan studies are needed to further explore the neurobiological mechanism of chemical aversion therapy treatment for alcohol use disorder, and other substance use disorders for which chemical aversion therapy is used (e.g., opioid dependence and cocaine dependence). Substance use disorders are estimated to affect well over one billion people worldwide.
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http://dx.doi.org/10.3389/fnbeh.2017.00182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5625029PMC
September 2017

The Use of Virtual Reality Facilitates Dialectical Behavior Therapy® "Observing Sounds and Visuals" Mindfulness Skills Training Exercises for a Latino Patient with Severe Burns: A Case Study.

Front Psychol 2017 25;8:1611. Epub 2017 Sep 25.

Behavioral Research and Therapy Clinics, Department of Psychology, University of WashingtonSeattle, WA, United States.

Sustaining a burn injury increases an individual's risk of developing psychological problems such as generalized anxiety, negative emotions, depression, acute stress disorder, or post-traumatic stress disorder. Despite the growing use of Dialectical Behavioral Therapy® (DBT®) by clinical psychologists, to date, there are no published studies using standard DBT® or DBT® skills learning for severe burn patients. The current study explored the feasibility and clinical potential of using Immersive Virtual Reality (VR) enhanced DBT® mindfulness skills training to reduce negative emotions and increase positive emotions of a patient with severe burn injuries. The participant was a hospitalized (in house) 21-year-old Spanish speaking Latino male patient being treated for a large (>35% TBSA) severe flame burn injury. The patient looked into a pair of Oculus Rift DK2 virtual reality goggles to perceive the computer-generated virtual reality illusion of floating down a river, with rocks, boulders, trees, mountains, and clouds, while listening to DBT® mindfulness training audios during 4 VR sessions over a 1 month period. Study measures were administered before and after each VR session. As predicted, the patient reported increased positive emotions and decreased negative emotions. The patient also accepted the VR mindfulness treatment technique. He reported the sessions helped him become more comfortable with his emotions and he wanted to keep using mindfulness after returning home. Dialectical Behavioral Therapy is an empirically validated treatment approach that has proved effective with non-burn patient populations for treating many of the psychological problems experienced by severe burn patients. The current case study explored for the first time, the use of immersive virtual reality enhanced DBT® mindfulness skills training with a burn patient. The patient reported reductions in negative emotions and increases in positive emotions, after VR DBT® mindfulness skills training. Immersive Virtual Reality is becoming widely available to mainstream consumers, and thus has the potential to make this treatment available to a much wider number of patient populations, including severe burn patients. Additional development, and controlled studies are needed.
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http://dx.doi.org/10.3389/fpsyg.2017.01611DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5622494PMC
September 2017

The Use of Virtual Reality to Facilitate Mindfulness Skills Training in Dialectical Behavioral Therapy for Borderline Personality Disorder: A Case Study.

Front Psychol 2016 2;7:1573. Epub 2016 Nov 2.

Behavioral Research & Therapy Clinics, University of Washington Seattle, WA, USA.

Borderline personality disorder (BPD) is a severe mental disorder characterized by a dysfunctional pattern of affective instability, impulsivity, and disturbed interpersonal relationships. Dialectical Behavior Therapy (DBT®) is the most effective treatment for Borderline Personality Disorder, but demand for DBT® far exceeds existing clinical resources. Most patients with BPD never receive DBT®. Incorporating computer technology into the DBT® could help increase dissemination. Immersive Virtual Reality technology (VR) is becoming widely available to mainstream consumers. This case study explored the feasibility/clinical potential of using immersive virtual reality technology to enhance DBT® mindfulness skills training of a 32 year old female diagnosed with BPD. Prior to using VR, the patient experienced difficulty practicing DBT® mindfulness due to her emotional reactivity, and difficulty concentrating. To help the patient focus her attention, and to facilitate DBT® mindfulness skills learning, the patient looked into virtual reality goggles, and had the illusion of slowly "floating down" a 3D computer-generated river while listening to DBT® mindfulness training audios. Urges to commit suicide, urges to self harm, urges to quit therapy, urges to use substances, and negative emotions were all reduced after each VR mindfulness session and VR mindfulness was well accepted/liked by the patient. Although case studies are scientifically inconclusive by nature, results from this feasibility study were encouraging. Future controlled studies are needed to quantify whether VR-enhanced mindfulness training has long term benefits e.g., increasing patient acceptance and/or improving therapeutic outcome. Computerizing some of the DBT® skills treatment modules would reduce cost and increase dissemination.
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http://dx.doi.org/10.3389/fpsyg.2016.01573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089996PMC
November 2016

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

The effectiveness of VR exposure therapy for PTSD in returning warfighters.

Stud Health Technol Inform 2012 ;181:128-32

U.S. Army Pacific Regional Medical Command, Honolulu, HI, USA.

In the decade following the attack on the World Trade Center, over 2.3 million American military personnel were deployed to Iraq and Afghanistan. Lengthy tours of duty and multiple re-deployments were characteristic of these operations. Research findings demonstrate that prolonged exposure to combat increases the risk of developing posttraumatic stress disorder (PTSD). The current study was a randomized controlled clinical trial designed to assess the effectiveness of a novel intervention to treat combat-related PTSD in returning Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) warfighters. A cognitive behavior treatment approach augmented with virtual reality exposure therapy (VRE) was developed, and administered for 10 treatment sessions over 5 weeks. Comparisons with a control group receiving minimal attention (MA) for 5 weeks revealed that the VRE group had significant reductions in the avoidance/numbing symptoms on the Clinician Administered PTSD Scale (CAPS). The VRE group also had significant reductions in guilt at post-treatment compared to the control group.
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January 2013

Virtual reality for persistent pain: a new direction for behavioral pain management.

Pain 2012 Nov 4;153(11):2163-2166. Epub 2012 Jul 4.

Department of Psychiatry and Behavioral Sciences, Duke Pain Prevention and Treatment Research Program, Duke University, Suite 340, 2200 W Main St., Durham, NC 27705, USA Department of Psychology and Neuroscience, Duke Pain Prevention and Treatment Research Program, Duke University, Suite 340, 2200 W Main St., Durham, NC 27705, USA Department of Computer Science and Engineering, University of Minnesota, 4-192 Keller Hall, 200 Union St. SE, Minneapolis, MN 55455, USA Department of Mechanical Engineering, University of Washington, Box 352142, Seattle, WA 98195, USA.

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http://dx.doi.org/10.1016/j.pain.2012.05.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3472118PMC
November 2012

Virtual reality pain control during burn wound debridement of combat-related burn injuries using robot-like arm mounted VR goggles.

J Trauma 2011 Jul;71(1 Suppl):S125-30

US Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam, Houston, Texas, USA.

Background: This is the first controlled study to explore whether adjunctive immersive virtual reality (VR) can reduce excessive pain of soldiers with combat-related burn injuries during wound debridement.

Methods: Patients were US soldiers burned in combat attacks involving explosive devices in Iraq or Afghanistan. During the same wound care session using a within-subject experimental design, 12 patients received half of their severe burn wound cleaning procedure (~6 minutes) with standard of care pharmacologies and half while in VR (treatment order randomized). Three 0 to 10 Graphic Rating Scale pain scores for each of the treatment conditions served as the primary variables.

Results: Patients reported significantly less pain when distracted with VR. "Worst pain" (pain intensity) dropped from 6.25 of 10 to 4.50 of 10. "Pain unpleasantness" ratings dropped from "moderate" (6.25 of 10) to "mild" (2.83 of 10). "Time spent thinking about pain" dropped from 76% during no VR to 22% during VR. Patients rated "no VR" as "no fun at all" (<1 of 10) and rated VR as "pretty fun" (7.5 of 10). Follow-up analyses showed VR was especially effective for the six patients who scored 7 of 10 or higher (severe to excruciating) on the "worst pain" (pain intensity) ratings.

Conclusions: These preliminary results provide the first evidence from a controlled study that adjunctive immersive VR reduced pain of patients with combat-related burn injuries during severe burn wound debridement. Pain reduction during VR was greatest in patients with the highest pain during no VR. These patients were the first to use a unique custom robot-like arm mounted VR goggle system.
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http://dx.doi.org/10.1097/TA.0b013e31822192e2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4460976PMC
July 2011

Combining ketamine and virtual reality pain control during severe burn wound care: one military and one civilian patient.

Pain Med 2011 Apr 11;12(4):673-8. Epub 2011 Apr 11.

U.S. Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX, USA.

Background: US soldiers injured in Iraq, and civilian burn trauma patients are treated at the US Army Institute of Surgical Research. Burn patients experience extreme pain during wound care, and they typically receive opioid analgesics and anxiolytics for debridement. Virtual Reality (VR) has been applied as an adjunct to opioid analgesics for procedural pain. We describe the first use of ketamine combined with immersive VR to reduce excessive pain during wound care.

Case Report: A 21-year-old male US Army soldier stationed in Iraq, and a 41-year-old civilian male sustained a 13% and 50% total body surface area (TBSA) burn, respectively. Each patient received 40 mg ketamine intraveneous (IV) for wound care. Using a within-subject design, nurses conducted half of a painful segment of wound care treatments with no VR and the other half with immersive VR. Graphic pain rating scores for each of the two treatment conditions served as the dependent variables.

Results: Compared to ketamine + no VR, both patients reported less pain during ketamine + VR for all three pain ratings. Both patients rated wound care during no VR as "no fun at all", but those same patients rated wound care during virtual reality as either "pretty fun" or "extremely fun", and rated nausea as either "mild" or "none".

Conclusions: Results from these first two cases suggest that a moderate dose of ketamine combined with immersive virtual reality distraction may be an effective multimodal analgesic regimen for reducing acute procedural pain during severe burn wound cleaning.
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http://dx.doi.org/10.1111/j.1526-4637.2011.01091.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4460983PMC
April 2011

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

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