Is Virtual Reality an Oasis for Pain? Karen Keene Jessica Lam Emma Lever

Introduction Presence Presence Applications of Virtual reality Applications of Virtual reality -Combating phobias -Post-traumatic stress disorder (PTSD) -SpiderWorld (Hoffman)

SpiderWorld

Effectiveness of Virtual Reality – Based Pain Control Pain = perception Pain = perception Use of VR to treat pain is based research that has found that distraction is a cognitive behavioral intervention particularly useful with burn pain Use of VR to treat pain is based research that has found that distraction is a cognitive behavioral intervention particularly useful with burn pain VR differs from other forms of distraction in that it draws more of the patients attention into the virtual environment (i.e., greater degree of distraction) VR differs from other forms of distraction in that it draws more of the patients attention into the virtual environment (i.e., greater degree of distraction)

Virtual reality programmes used during wound care in burn victims

Why is VR effective? Attention Attention Pain thought of as a gate that can be open or closed Melzack & Wall (1965) Pain thought of as a gate that can be open or closed Melzack & Wall (1965) Depends on: ascending signals from peripheral nerves+descending signals from CNS+ Depends on: ascending signals from peripheral nerves+descending signals from CNS+

Water-friendly VR Used for wound care in hydro-tanks Used for wound care in hydro-tanks Hydro tanks = sterile baths for loosening bandages & cleaning wounds Hydro tanks = sterile baths for loosening bandages & cleaning wounds

VR use in Hydro-tank No electricity involved to reduce risk of electric shockNo electricity involved to reduce risk of electric shock 2 independent computerized images, one for each eye2 independent computerized images, one for each eye

Case study 40 year old man 40 year old man Deep flame burns to 19% of total body area Deep flame burns to 19% of total body area Study = 3 minutes in VR, 3 minutes with no distraction Study = 3 minutes in VR, 3 minutes with no distraction Randomly assigned to VR condition first Randomly assigned to VR condition first Finger controlled joy stick to move around virtual world Finger controlled joy stick to move around virtual world

Snow World 3D icy canyon 3D icy canyon Snowy and cold to counteract fiery pain Snowy and cold to counteract fiery pain Illusion of flying fighter jet Illusion of flying fighter jet Shoot snowballs with joy stick Shoot snowballs with joy stick

Case study cont… Pain and presence ratings on 10 point graphic scale Pain and presence ratings on 10 point graphic scale Rated worst pain, amount of time spent thinking about pain etc Rated worst pain, amount of time spent thinking about pain etc After wound care rated side effects and presence After wound care rated side effects and presence

Outcomes VR condition more fun VR condition more fun Sense of presence = 6 Sense of presence = 6 Realism of virtual objects = 7 Realism of virtual objects = 7 No simulation sickness No simulation sickness Therefore evidence of effectiveness Therefore evidence of effectiveness Sensory pain Affective pain Time thinking No VR 7610 VR233

Methodological Issues Only one patient included Only one patient included Demand characteristics, treatment order effects, novelty and expectancies not controlled for Demand characteristics, treatment order effects, novelty and expectancies not controlled for VR only used for 3 minutes – in reality, treatments can last up to 45 minutes VR only used for 3 minutes – in reality, treatments can last up to 45 minutes

Controversies Not enough studies to draw firm conclusions Not enough studies to draw firm conclusions Novelty value Novelty value Generally subjective measures, although fMRI supports findings Generally subjective measures, although fMRI supports findings Limited age range of participants Limited age range of participants Expensive; issues of access Expensive; issues of access

Controversies… Difficult to retain necessary programming to keep up to date Difficult to retain necessary programming to keep up to date Lead to exclusion of traditional individual coping techniques Lead to exclusion of traditional individual coping techniques Reducing use of opioid painkillers Reducing use of opioid painkillers Different susceptibilities to feeling of presence Different susceptibilities to feeling of presence

Controversies… Ocular-motor disturbances/ simulation sickness Ocular-motor disturbances/ simulation sickness Long term consequences? Long term consequences? Detrimental effects on social skills? Detrimental effects on social skills? Confusion between reality and fantasy Confusion between reality and fantasy Disorientation Disorientation VR distraction must end at some point VR distraction must end at some point

Controversies … Risk of developing dependence Risk of developing dependence Enhancement of pain when outside VR? Enhancement of pain when outside VR? Lack of suitability for chronic pain Lack of suitability for chronic pain How to decide who should be allowed access How to decide who should be allowed access

Conclusion Ethical issues and controversies deserve consideration Ethical issues and controversies deserve consideration More research needed More research needed VR in pain management = promising VR in pain management = promising

References Hoffman H.G., Doctor J.N., Patterson, D.R., Carrougher, G.J. and Furness, T.A. III (2000). Use of virtual reality for adjunctive treatment of adolescent burn pain during wound care: A case report. Pain, 85, Hoffman H.G., Doctor J.N., Patterson, D.R., Carrougher, G.J. and Furness, T.A. III (2000). Use of virtual reality for adjunctive treatment of adolescent burn pain during wound care: A case report. Pain, 85, Hoffman H.G, Patterson D.R. and Carrougher, G.J. (2000). Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study. Clinical Journal of Pain, 16(3), Hoffman H.G, Patterson D.R. and Carrougher, G.J. (2000). Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study. Clinical Journal of Pain, 16(3), Hoffman, H.G., Patterson, D.R., Carrougher, G.J. and Sharar, S. (2001). The effectiveness of virtual reality based pain control with multiple treatments. Clinical Journal of Pain, 17, Hoffman, H.G., Patterson, D.R., Carrougher, G.J. and Sharar, S. (2001). The effectiveness of virtual reality based pain control with multiple treatments. Clinical Journal of Pain, 17, Hoffman, H. G., Patterson, D. R., Magula, J., Carrougher, G. J., Zeltzer, K., Dagadakis, S., & Sharar, S. R. (2004). Water-friendly virtual reality pain control during wound care. JCLP/In Session, 60(2), Hoffman, H. G., Patterson, D. R., Magula, J., Carrougher, G. J., Zeltzer, K., Dagadakis, S., & Sharar, S. R. (2004). Water-friendly virtual reality pain control during wound care. JCLP/In Session, 60(2), Melzack R. & Wall P. D. (1965) Pain mechanisms: a new theory. Science 150: Melzack R. & Wall P. D. (1965) Pain mechanisms: a new theory. Science 150: Rauterberg, M. (2004). Positive effects of VR technology on human behaviour. ICAT, Rauterberg, M. (2004). Positive effects of VR technology on human behaviour. ICAT, 85-88