Transcript - Catalyst

Virtually Pain Free
Non-pharmacologically
Virtual Reality: an Adjunct for Acute Pain Control
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QR
14 yr M w/ Hx Autism, developmental delay, and Crohn’s colitis with colonic perforation
s/p resection and colostomy. Due to continued colitis despite maximum medical therapy
this was eventually followed by APR, and end-ileostomy.
• Ultimately developed dehiscence and infections of the midline, gastrostomy,
colostomy, and perineal wounds, requiring frequent dressing changes.
• Due to the extensive nature of his wounds and his underlying intellectual disabilities,
he required dressing changes to be performed under general anesthesia.
• After 90 days of hospitalization, he had undergone induction 55 times.
Side effects of pain medications
Narcotics
Non-Narcotics
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Tylenol
• Hepatotoxicity
• ATN
• Anemia
• Thrombocytopenia
Nausea
Vomiting
Pruritus
Constipation
Respiratory depression
Hallucination
Delirium
Hypotension
Headache
Urinary retention
Bradycardia
Dyspepsia
Anxiety
NSAIDs
• Nephrotoxicity
• GIB
• Hematoma
• HTN
• Bronchospasm
• Pancytopenia
Non-Pharmacologic Pain Management
• Hypnosis
• Acupuncture
• Bio-feedback
• Distraction
• Art therapy
• Music Therapy
• Pet Therapy
• Virtual Reality
Video
Virtual Reality for Pain Control
Snow World Helps Military Vets Recover from Burns
History of Virtual Reality
1950’s Douglas Engelbart,
naval radar tech
Real-time display of
radar data on screen
1960’s Ivan Sutherland, MIT
Sketchpad, Head
mounted display
1970’s David Evans &
Sutherland (UT), MIT
flight simulation,
Aspen Movie Map
1980’s Thomas Zimmerman,
Jaron Lanier, Atari
data glove,
PowerGlove
1990’s Senthil Nathan,
Imperial College
PROBOT, first purely
robotic surgery
2000
Virtual “snow world”
during burn care
Hunter Hoffman, UW
1. "A Brief History of Virtual Reality." A Brief History of Virtual Reality. 29 Sept. 2013 <http://www.bilawchuk.com/mark/history.html>.
2. "VIRTUAL REALITY - History." VIRTUAL REALITY - History. 01 Oct. 2013 <http://archive.ncsa.illinois.edu/Cyberia/VETopLevels/VR.History.html>.
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Pilot Study: Snow World vs Mario ‘64
16 yr M 5 % TBSA flash
burn to leg. 12 mg HM
• Worst pain decreased
80mm and 30mm
• Average pain
decreased 66mm,
31mm
• Anxiety decreased
58mm, 22mm
• Time thinking about
pain 93mm, 53mm
17 yr M 34% TBSA flash
burn to face, chest, back.
14 mg HM
• Worst pain decreased
47mm
• Average pain decreased
35mm
• Anxiety decrease 27
mm
• Time thinking about
pain 61mm
3. Hunter G. Hoffman, Jason N. Doctor, David R. Patterson, Gretchen J. Carrougher, Thomas A. Furness III, Virtual reality as an adjunctive pain control during burn wound care
in adolescent patients, Pain, Volume 85, Issues 1–2, 1 March 2000, Pages 305-309, ISSN 0304-3959, http://dx.doi.org/10.1016/S0304-3959(99)00275-4.
Dental Pain Relief
Two adult patients undergoing periodontal scaling and root planing
• VR vs. Movie vs. No distraction.
• Average of 5 different pain scales
• Patient 1:
• Pain with no distraction = 7.2
• Pain during “Casablanca” = 7.2
• Pain in “Snow World” = 1.2
• Patient 2:
• Pain with no distraction = 4.4
• Pain during “Casablanca” = 1.2
• Pain in “Snow World” = 0.6
4. Hunter G. Hoffman, Azucena Garcia-Palacios, David R. Patterson, Mark Jensen, Thomas Furness III, and William F. Ammons Jr. CyberPsychology & Behavior. August 2001,
4(4): 527-535. doi:10.1089/109493101750527088.
Similar results in a disabled patient
16 yr M w/ CP s/p SEMLS
• 6 physiotherapy sessions
• Epidural vs epidural + VR x3
days
• Oxycodone vs Oxy + VR x3
days
41.2% reduction in
pain with VR
Patient/Parent Satisfaction
“The pain was not worrying him- he
seemed almost to participate more with the
treatment when the VR was on.” – parent
Mom also noted that she felt less anxious,
since she could see her son was relaxed.
5. Emily Steele, Karen Grimmer, Bruce Thomas, Barrie Mulley, Ian Fulton, and Hunter Hoffman. CyberPsychology & Behavior. December 2003, 6(6): 633-638.
doi:10.1089/109493103322725405.
RCT’s
Average pain of 7 pediatric burn patients,
ages 5-18 yrs (Avg 11.1 yrs), during 11
dressing changes.
Average pain of 86 adult burn patients, ages
18-80 (Avg 38.6 yrs) during 86 dressing
changes.
• medications only = 4.1 / 5 (SD 2.9)
• mPCA alone vs mPCA + VR before dressing
• Meds + VR = 1.3 / 5 (SD 1.8)
changes
• Per child mean change was 3.2 (p <0.01)
6. Das DA, Grimmer KA, Sparon AL, et al: The efficacy of playing a virtual reality game in modulating pain for children with acute burn injuries: a randomized controlled trial.
BioMed Pediatr 5:1-10, 2005. [ISRCTN87413556].
7. A.H. Konstantatos, M. Angliss, V. Costello, H. Cleland, S. Stafrace, Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine
in patients having burns dressings changes, Burns, Volume 35, Issue 4, June 2009, Pages 491-499, ISSN 0305-4179, http://dx.doi.org/10.1016/j.burns.2008.08.017.
Systematic Review in Burns Patients
Age
Study Type
Procedure
# of Pt’s
VR > no VR?
16-17
Case Report
Dressing Change
2
Yes
19-47
Controlled, within Pt
study design (WPD)
Physical Therapy
12
Yes, 47(100)
rdxn (P = 0.002)
40
Case Report
Dressing Change
1
Yes
5-16
RCT, WPD
Dressing Change
9
Yes, 3.2(5) rdxn
(P < 0.01)
8-65
WPD
Dressing Change
19
Yes, 56(100)
rdxn (P<0.05)*
M 6.54 WPD
Dressing Change
8
No
6-65
RCT, WPD
Physical Therapy
88
Yes, 11(100)
rdxn (P 0.003)
9-40
WPD
Debridement
11
Yes, 2.5(10)
rdxn (P=0.015)
21-22
WPD
Dressing Change
2
Yes
8. (adapted from) Morris LD, Louw QA, Grimmer-Somers K. The effectiveness of virtual reality on reducing pain and anxiety in burn injury patients: a systematic review. Clin J
Pain. 2009; 25(9):815-826. [PMID: 19851164]
Theoretical Mechanism
Gate Control Theory
• CNS “Nerve Gates” can only process a limited amount of PNS stimuli
• VR diverts attention away from noxious stimuli
• More pleasant stimuli are additive
• End result is decreased perception of pain to equivalent stimuli
High Tech vs. Low Tech
Double-blind study of 77 volunteers (age 18-23) receiving equivalent painful thermal
stimuli at baseline and with the VR HMD
- “low tech” - 800 x 600 pixel VR display
- “high tech” - 1280 x 1024 pixel VR display
• High-tech group had 34% reduction in worst pain (P <.05), 46% reduction in average
pain (P = .001), 29% less time thinking about pain
• 65% of High-tech group had significant reduction in pain during VR vs. 29% in low-tech
9. Hoffman HG, Seibel EJ, Richards TL, Furness TA, Patterson DR, Sharar SR. Virtual reality helmet display quality influences the magnitude of virtual reality analgesia. J Pain.
2006; 7(11):843–850. [PubMed: 17074626]
Interactivity matters
Double blind study of 21 healthy volunteers receiving thermal stimuli without distraction
initially, then with distraction.
- 12 volunteers could control the direction they were traveling in the virtual world
- 9 volunteers traveled on a predetermined route within the virtual world
• Difference of 2.57 (10) greater reduction in average pain (P < .005)
• Difference of 2.39 (10 greater reduction in worst pain (P < .005)
• No significant difference in how “present” participants felt in the virtual world
10. Wender R, Hoffman H, Hunner H, Seibel E, Patterson D, Sharar S. Interactivity influences the magnitude of virtual reality analgesia. J Cyberther
Rehab. 2009;2(1):27–34.
Summary & Future Directions
• Multiple therapies exist to help reduce the amount of medications (and side effects)
used for pain control
• Virtual reality is a continually developing therapy that can be used as an adjunct
• Studies show mixed results, but overall VR seems to improve pain control for multiple
patient populations
• The “Gate Theory” of pain perception states that more stimuli are better
 Larger studies, and studies using VR during additional types of painful procedures
would be useful
 Development of different types of “virtual worlds” may help improve “presence” for
different patient populations
 Future studies about the amount of medication used with VR vs without VR would be
interesting to see
Sources
1.
2.

"A Brief History of Virtual Reality." A Brief History of Virtual Reality. 29 Sept. 2013 <http://www.bilawchuk.com/mark/history.html>.
"VIRTUAL REALITY - History." VIRTUAL REALITY - History. 01 Oct. 2013
<http://archive.ncsa.illinois.edu/Cyberia/VETopLevels/VR.History.html>.
3. Hunter G. Hoffman, Jason N. Doctor, David R. Patterson, Gretchen J. Carrougher, Thomas A. Furness III, Virtual reality as an adjunctive pain
control during burn wound care in adolescent patients, Pain, Volume 85, Issues 1–2, 1 March 2000, Pages 305-309, ISSN 0304-3959,
http://dx.doi.org/10.1016/S0304-3959(99)00275-4.
4. Hunter G. Hoffman, Azucena Garcia-Palacios, David R. Patterson, Mark Jensen, Thomas Furness III, and William F. Ammons Jr.
CyberPsychology & Behavior. August 2001, 4(4): 527-535. doi:10.1089/109493101750527088.
5. Emily Steele, Karen Grimmer, Bruce Thomas, Barrie Mulley, Ian Fulton, and Hunter Hoffman. CyberPsychology & Behavior. December 2003,
6(6): 633-638. doi:10.1089/109493103322725405.
6. Das DA, Grimmer KA, Sparon AL, et al: The efficacy of playing a virtual reality game in modulating pain for children with acute burn injuries:
a randomized controlled trial. BioMed Pediatr 5:1-10, 2005. [ISRCTN87413556].
7. A.H. Konstantatos, M. Angliss, V. Costello, H. Cleland, S. Stafrace, Predicting the effectiveness of virtual reality relaxation on pain and
anxiety when added to PCA morphine in patients having burns dressings changes, Burns, Volume 35, Issue 4, June 2009, Pages 491-499,
ISSN 0305-4179, http://dx.doi.org/10.1016/j.burns.2008.08.017.
8. Morris LD, Louw QA, Grimmer-Somers K. The effectiveness of virtual reality on reducing pain and anxiety in burn injury patients: a
systematic review. Clin J Pain. 2009; 25(9):815-826. [PMID: 19851164]
9. Hoffman HG, Seibel EJ, Richards TL, Furness TA, Patterson DR, Sharar SR. Virtual reality helmet display quality influences the magnitude of
virtual reality analgesia. J Pain. 2006; 7(11):843–850. [PubMed: 17074626]
10. Wender R, Hoffman H, Hunner H, Seibel E, Patterson D, Sharar S. Interactivity influences the magnitude of virtual reality analgesia. J
Cyberther Rehab. 2009;2(1):27–34.