Is Virtual Reality an Oasis for Pain?Is Virtual Reality an Oasis for Pain?

Karen KeeneKaren Keene

Jessica LamJessica Lam

Emma LeverEmma Lever

IntroductionIntroduction

Presence Presence

Applications of Virtual realityApplications of Virtual reality

-Combating phobias-Combating phobias

-Post-traumatic stress disorder (PTSD)-Post-traumatic stress disorder (PTSD)

-SpiderWorld (Hoffman)-SpiderWorld (Hoffman)

SpiderWorldSpiderWorld

Effectiveness of Virtual Effectiveness of Virtual Reality – Based Pain ControlReality – Based Pain Control

Pain = perceptionPain = perception

Use of VR to treat pain is based research that Use of VR to treat pain is based research that has found that “distraction” is a cognitive has found that “distraction” is a cognitive behavioral intervention particularly useful with behavioral intervention particularly useful with burn painburn pain

VR differs from other forms of distraction in VR differs from other forms of distraction in that it draws more of the patient’s attention that it draws more of the patient’s attention into the virtual environment (i.e., greater into the virtual environment (i.e., greater degree of distraction)degree of distraction)

Virtual reality programmes used during wound care in burn victims

Why is VR effective?Why is VR effective?

AttentionAttention

Pain thought of as a ‘gate’ that can be Pain thought of as a ‘gate’ that can be open or closed open or closed Melzack & Wall (1965)Melzack & Wall (1965)

Depends on: ascending signals from Depends on: ascending signals from peripheral nerves+descending signals peripheral nerves+descending signals from CNS+from CNS+

Water-friendly VRWater-friendly VR

Used for wound care in hydro-tanksUsed for wound care in hydro-tanks Hydro tanks = sterile baths for Hydro tanks = sterile baths for

loosening bandages & cleaning loosening bandages & cleaning woundswounds

VR use in Hydro-tankVR use in Hydro-tank

•No electricity involved to reduce risk No electricity involved to reduce risk of electric shockof electric shock•2 independent computerized images, 2 independent computerized images, one for each eyeone for each eye

Case studyCase study

40 year old man40 year old man Deep flame burns to 19% of total Deep flame burns to 19% of total

body areabody area Study = 3 minutes in VR, 3 minutes Study = 3 minutes in VR, 3 minutes

with no distractionwith no distraction Randomly assigned to VR condition Randomly assigned to VR condition

firstfirst Finger controlled joy stick to move Finger controlled joy stick to move

around virtual worldaround virtual world

Snow WorldSnow World

3D icy canyon3D icy canyon Snowy and cold to counteract fiery painSnowy and cold to counteract fiery pain Illusion of flying fighter jetIllusion of flying fighter jet Shoot snowballs with joy stickShoot snowballs with joy stick

Case study cont…Case study cont…

Pain and presence ratings on 10 Pain and presence ratings on 10 point graphic scalepoint graphic scale

Rated worst pain, amount of time Rated worst pain, amount of time spent thinking about pain etcspent thinking about pain etc

After wound care rated side effects After wound care rated side effects and ‘presence’and ‘presence’

OutcomesOutcomes

VR condition more funVR condition more fun Sense of presence = 6Sense of presence = 6 Realism of virtual objects = 7Realism of virtual objects = 7 No simulation sickness No simulation sickness Therefore evidence of effectivenessTherefore evidence of effectiveness

Sensory Sensory painpain

Affective Affective painpain

Time Time thinkingthinking

No VRNo VR 77 66 1010

VRVR 22 33 33

Methodological IssuesMethodological Issues

Only one patient includedOnly one patient included Demand characteristics, treatment Demand characteristics, treatment

order effects, novelty and order effects, novelty and expectancies not controlled forexpectancies not controlled for

VR only used for 3 minutes – in VR only used for 3 minutes – in reality, treatments can last up to 45 reality, treatments can last up to 45 minutesminutes

ControversiesControversies

Not enough studies to draw firm Not enough studies to draw firm conclusionsconclusions

Novelty value Novelty value Generally subjective measures, Generally subjective measures,

although fMRI supports findingsalthough fMRI supports findings Limited age range of participantsLimited age range of participants Expensive; issues of accessExpensive; issues of access

Controversies…Controversies…

Difficult to retain necessary Difficult to retain necessary programming to keep up to dateprogramming to keep up to date

Lead to exclusion of traditional Lead to exclusion of traditional individual coping techniquesindividual coping techniques

Reducing use of opioid painkillersReducing use of opioid painkillers Different susceptibilities to feeling of Different susceptibilities to feeling of

presencepresence

Controversies…Controversies…

Ocular-motor disturbances/ Ocular-motor disturbances/ simulation sicknesssimulation sickness

Long term consequences?Long term consequences? Detrimental effects on social skills?Detrimental effects on social skills? Confusion between reality and Confusion between reality and

fantasyfantasy DisorientationDisorientation VR distraction must end at some VR distraction must end at some

pointpoint

Controversies …Controversies …

Risk of developing dependenceRisk of developing dependence Enhancement of pain when outside Enhancement of pain when outside

VR? VR? Lack of suitability for chronic painLack of suitability for chronic pain How to decide who should be allowed How to decide who should be allowed

accessaccess

ConclusionConclusion

Ethical issues and controversies Ethical issues and controversies deserve considerationdeserve consideration

More research neededMore research needed VR in pain management = promisingVR in pain management = promising

ReferencesReferences Hoffman H.G., Doctor J.N., Patterson, D.R., Carrougher, G.J. and Hoffman H.G., Doctor J.N., Patterson, D.R., Carrougher, G.J. and

Furness, T.A. III (2000). Use of virtual reality for adjunctive Furness, T.A. III (2000). Use of virtual reality for adjunctive treatment of adolescent burn pain during wound care: A case treatment of adolescent burn pain during wound care: A case report. report. PainPain, , 8585, 305-309. , 305-309.

Hoffman H.G, Patterson D.R. and Carrougher, G.J. (2000). Use of Hoffman H.G, Patterson D.R. and Carrougher, G.J. (2000). Use of virtual reality for adjunctive treatment of adult burn pain during virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study. physical therapy: a controlled study. Clinical Journal of PainClinical Journal of Pain, , 1616(3), (3), 244-250. 244-250.

Hoffman, H.G., Patterson, D.R., Carrougher, G.J. and Sharar, S. Hoffman, H.G., Patterson, D.R., Carrougher, G.J. and Sharar, S. (2001). The effectiveness of virtual reality based pain control with (2001). The effectiveness of virtual reality based pain control with multiple treatments. multiple treatments. Clinical Journal of PainClinical Journal of Pain, , 1717, 229-235. , 229-235.

Hoffman, H. G., Patterson, D. R., Magula, J., Carrougher, G. J., Hoffman, H. G., Patterson, D. R., Magula, J., Carrougher, G. J., Zeltzer, K., Dagadakis, S., & Sharar, S. R. (2004). Water-friendly Zeltzer, K., Dagadakis, S., & Sharar, S. R. (2004). Water-friendly virtual reality pain control during wound care. virtual reality pain control during wound care. JCLP/In Session, JCLP/In Session, 60(2), 60(2), 189-195189-195

Melzack R. & Wall P. D. (1965) Pain mechanisms: a new theory. Melzack R. & Wall P. D. (1965) Pain mechanisms: a new theory. Science 150:Science 150: 971-979. 971-979.

Rauterberg, M. (2004). Positive effects of VR technology on human Rauterberg, M. (2004). Positive effects of VR technology on human behaviour. behaviour. ICATICAT, 85-88, 85-88