Virtual Reality: Does it decrease pain levels of children during burn therapy? By: Sarah Carlisle, Student Physical Therapist Bellarmine University DPT Program Resources 1. Chan EA PhD, Chung JWY PhD, Wong TKS PhD, Lien AS MN, Yang MD. Application of a virtual reality prototype for pain relief of pediatric burn in Taiwan. Journal of Clinical Nursing. 2007;16(4): Dahlquist LM PhD, Weiss KE PhD, Law EF MA, et al. Effects of videogame distraction and a virtual reality type head-mounted display helmet on cold pressor pain in young elementary school-aged children. Journal of Pediatric Psychology. 2010;35(6): Effgen, SK. Meeting the physical therapy needs of children. Philadelphia: F.A. Davis Company; 2005, Hoffman H PhD, Patterson D PhD ABPP ABPH, Gordon D MS RN (Ed). Virtual reality pain distraction. American Pain Society Bulletin. 2005;15(2). Assessed October 17, Hoffman H. Virtual Reality Therapy. Scientific American Magazine Assessed October 20, Hoffman HG. PhD, Patterson DR. PhD, Carrougher GJ. MN, Sharar SR. MD. Effectiveness of virtual reality--based pain control with multiple treatments. The Clinical Journal of Pain. 2001;17(3): Koenke S SPT. The effectiveness of virtual reality in controlling pain in patients with burns: a systematic review. Journal of Student Physical Therapy Research. 2010; 2(1). 8. Schmitt YS, Hoffman HG, Blough DK et al. A randomized controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns. Burns. 2011;37(1): Virtual Reality (VR) VR: patient interacts with a responsive, multi-sensory virtual environment Reason for need: Medicinal treatments (opiods) do not lower patient’s pain or anxiety to a level which allows for an effective treatment Examples of current virtual reality technologies: SnowWorld, Spiderworld, ChocolateWorld, Wii, Nitendo Theory behind VR: distract patient, leaving less cognitive function available for pain perception; “gait control” theory Interaction level & equipment use varies with each intervention Involvement vs. Immersion A pediatric burn patient shooting snowballs in SnowWorld while undergoing physical therapy (photo and copyright Hunter Hoffman, U.W. HITLab) (Hoffman, Patterson, Gordon (Ed), 2005.) Hoffman, 2004 “The fMRI results suggest that virtual reality is not just changing the way patients interpret incoming pain signals; the programs actually reduce the amount of pain-related brain activity.” Hoffman 2004 Benefits of VR Reduce reliance & side effects of drugs traditionally used during sessions 7 Allow more aggressive therapy--prevent contractures, decreased skin elasticity, & excessive scarring 8 Speed up recovery Decrease pain and anxiety levels Results not limited to burn patients 2,4,5,6 As technology increases, as does quality of VR & lead to decreased pain levels Two people able to enter into SuperSnowWorld 5 Evidence Behind VR Despite finding no statistical difference, Chan found VR produced less pain & decreased anxious behaviors during and after treatment when compared to no VR. Scmitt found immersive VR lead to increase in level of “fun,” was a useful addition to traditionally analgesia (Koenke agreed), & did not diminish with repeated use. VR did not result in significant increase in maximal ROM. Dahlquist found brief improvement in pain tolerance & predicted VR could potentially add additional 20 seconds to therapy time. Hoffman used functional magnetic resonance imaging (fMRI) to look at brain activity during VR & found pain related activity to be decreased. Compared involvement and immersion in VR and found decreased pain with complete immersion Chan 2007 Further Research VR cost effectiveness Double blinded studies Studies of VR alone Larger sample sizes Impairments from Burn Injury Decreased ROM Decreased strength Inability to participate in play or school Possible contractures ADL limitations Physical Therapy Interventions 3 ROM Positioning Debridement Dressing changes Education A pediatric burn patient shooting snowballs in SnowWorld while undergoing physical therapy (photo and copyright Hunter Hoffman, U.W. HITLab) 4 Hoffman, 2004 Why SNOWWorld? 3, 4 Wound care often recreates patient’s original burn experience; thus, a cold, “glacial,” environment “help(s) put out the fire.” Thru goggles, patient virtually slides around an icy canyon, complete with “frigid river and waterfall,” shooting snowballs with their gaze, at snowmen, igloos, robots and penguins. Interventions Utilized Wound care usually involves cleaning the skin and decreasing likelihood of infection by debridement 5 PROM exercises 8 or AAROM 6,7,8 of involved extremity during VR Staple removal with VR compared to video game 4 Wound dressing changes 1,7