Get real: Virtual reality eases pain during wound care procedures
Hypnosis, music, and other distractions also help patients
A young boy flies over an icy canyon and shoots snowballs at igloos as a wound care nurse debrides a large burn wound on the boy’s arm. His wound care used to be unbearably painful, but now that he can experience this chilly flight, he can avoid focusing on the debridement, reducing the pain he feels. The wound cleaning ends and the boy removes his helmet. Welcome to the use of virtual reality in wound care.
In ongoing and groundbreaking studies at the University of Washington’s Harborview Burn Center in Seattle, virtual reality (VR) is significantly increasing patient tolerance and comfort levels when provided as an adjunct to opioids during wound cleaning, debridement, and dressing changes for burn wound patients. David R. Patterson, PhD, ABPP, professor in the department of rehabilitation medicine, surgery and psychology, and staff psychologist at Harborview, obtained a grant from the National Institutes of Health (NIH) for the VR research. Patterson, who receives frequent requests for pain management consults in his work as a psychologist at the burn unit, began using hypnosis in the early 1990s for adjunctive pain relief.
"When I started on the burn unit, I would see some patients whose pain was not well-controlled with medication. It was apparent to me that adjuncts were necessary. I found that some patients had dramatic responses to hypnosis."
High pain levels helped by hypnosis
Patterson knew there were few controlled studies, so he applied to NIH and received funding to study the use of hypnosis and other distractive techniques as supplementary pain control. "We know that the mind can override the pain circuits, and we’re seeing this as a very eloquent use of the mind in that capacity," Patterson says. An upcoming article details the results of the work at Harborview.1
Patterson says patients with higher-than-average levels of pain seem to derive the most benefit from hypnosis, tranquilizers, and VR. However, not everyone is a good candidate for hypnosis and other distraction techniques that cause the patient to disassociate mind from body, he notes.
"In essence, we’re using some coping techniques that might be maladaptive or ill-advised under other circumstances, but in this situation we’re actually trying to encourage them."
According to Harborview researcher Hunter Hoffman, PhD, burn wounds were chosen for the VR study because burns are generally acknowledged to be the most painful type of wound. "Anything you can do to help burn pain will probably help other kinds of pain as well, because burn wound pain is so challenging," Hoffman says. Opioid drugs usually give sufficient relief while a patient is resting. However, caring for the burn wound — which often involves removing dead tissue on a daily basis to minimize scarring and reduce infection, cleaning the wound, and applying a fresh dressing — frequently lifts pain to excruciating levels. Hoffman observes that wound care may be as painful for the patient as the injury was.
Anxiety is always a problem
"There are two elements of pain during wound cleaning and dressing changes," observes Jai Prasad, MD, medical director of the Adult Burn Center at Detroit Receiving Hospital. "One is the pain caused by the wound care itself, for which we give an opioid drug, and the other is anxiety."
Anxiety is one of the chief pain management problems for burn wound patients and their caregivers. The patient’s first experience of pain during wound care heightens anxiety about subsequent wound care sessions, and the anxiety heightens pain during subsequent sessions. Because VR removes the patient’s attention from wound care procedures, it "short circuits" this pain loop. When patients are wearing the VR helmet, as they move their heads around what they see in the virtual world changes. This creates the illusion in the patients’ minds that they are in a different place, not in the room where the wound care is going on. Instead of focusing on the wound, they find themselves traveling over a frigid waterfall. Because patients often report reliving their original burn experience during wound care, this video helps "put out the fire."
"We think the illusion of going to another place is one of the strongest factors influencing VR’s analgesic properties," Hoffman says. "It draws so much attention away from the pain — it’s really an attention-getting mechanism. Patients tend to be highly motivated to go into the virtual world because the alternative is not very pleasant. The extent to which patients participate in the VR world determines the amount of pain reduction they experience. More importantly, the amount of time they spend thinking about their pain drops dramatically when they go into VR." VR videos can be customized for the particular needs of each patient. They can be designed to appeal to each patient’s specific interests and to run as long as the wound care takes. Though the analgesic effects of VR last only as long as the patient is wearing the helmet, by the time the helmet is removed the painful procedures are over.
Pain has a strong psychological component
Hoffman and Patterson note that pain perception is largely psychological, and the depth of the pain experienced depends in part on the attention the patient pays to the pain. While opioid drugs remain necessary for pain during wound care, cognitive-behavioral techniques offer another type of pain intervention. In essence, cognitive interventions treat internal thoughts as modifiable behaviors that can alter the patient’s attention to physical pain signals. Hoffman compares conscious attention to a spotlight that, without pain intervention techniques, will be focused solely on the pain being experienced during wound care. Being drawn into the VR world requires most of the patient’s attention, leaving less attention available to process pain signals. For many patients in VR, rather than having pain as the focus of their attention, the wound care becomes more of an annoyance, distracting them from their primary goal of exploring the virtual world.
VR, like hypnosis and guided imagery, is a distractive technique. In her work as a burn nurse, Gretchen J. Carrougher, RN, MN, has successfully used the distractive techniques of hypnosis, visualization, and guided imagery in her work, such as having patients picture themselves without pain or solving math problems during a painful procedure. Carrougher, who is also a research nurse on the Harborview VR project, has found that "whenever you’re treating pain, you’re also treating some of the emotional aspects of pain. When we’ve optimized the pharmacological means for pain relief, we should be looking at non-pharmacological treatment strategies."
These techniques can be applied to patients with other kinds of wounds. "Patients can be taught self-hypnosis, and then they can use that strategy on their own with a little bit of support from nursing personnel who help them through the steps to induce their self-hypnotic state during wound care," Carrougher says. "With children, distraction works pretty well. As one gets older, the effectiveness of distraction depends largely on the patient’s willingness to participate." Music the patient finds soothing and conversation are also frequently used as distractives at Harborview.
Distractive techniques such as hypnosis, guided imagery, and music now are frequently used adjuncts to pharmacological pain relief in many burn care centers, and psychological counseling is now the norm. Francis V. Winski, MD, assistant professor of surgery at New York Medical College in Valhalla, NY, and attending staff member of the university’s burn center, says, "We use a clinical nurse specialist who is not quite a psychologist. She has a typical nursing background, but also has the experience of dealing with the families and the patients as well. We also use the support of the college’s psychiatry department with some patients, and we rely quite heavily on them, especially in cases where we think there may be problems with drug or alcohol dependency prior to the burn incident."
A portable VR unit in the future?
The Harborview study suggests that VR reduces pain intensity, unpleasantness, and anxiety, and diminishes the amount of time patients think about their pain during wound care. The analgesic effects of VR for pain control appear to be significant. So, what about making a virtual reality system available to wound caregivers outside of hospitals with patients at home or in skilled nursing facilities?
Hoffman says he thinks it will happen. "There are a number of factors that are quickly reducing the size of VR systems. The VR system I used in 1993 was the size of a refrigerator and weighed several hundred pounds. Now, a computer of comparable power is about the size of a personal computer. Right now, it’s still a pain in the neck to move it around, but it’s much easier than it was a few years ago, and it’s going to get easier in the future." Hoffman says prices for VR systems have fallen precipitously in the last two or three years. His 1993 system cost about $175,000. The 1999 version is around $50,000. He says there’s a new system out that’s under $20,000. Granted, these prices still are out of reach for many facilities. But, Hoffman asks, "remember how widely affordable and available personal computers became — and how quickly — only a few years ago? I think that a system wound care nurses can take with them when they go out to treat patients is not far off."
Reference
1. Hoffman HG, Doctor JN, Patterson DR, et al. Virtual Reality as an adjunctive pain control during burn wound care in adolescent patients: A case report. Pain (in press).
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