Factors Influencing the Efficacy of Virtual Reality Distraction Analgesia During Postburn Physical Therapy: Preliminary Results from 3 Ongoing Studies


      Sharar SR, Carrougher GJ, Nakamura D, Hoffman HG, Blough DK, Patterson DR. Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: preliminary results from 3 ongoing studies.


      To assess the efficacy and side effects of immersive virtual reality (VR) distraction analgesia, as well as patient factors associated with VR analgesic efficacy in burn patients who require passive range-of-motion (ROM) physical therapy (PT).


      Prospective, randomized, controlled, within-subject trials.


      Regional level I burn center in a university-affiliated urban hospital.


      Patients (age range, 6−65y) who required passive ROM PT in sessions lasting 3 to 15 minutes after cutaneous burn injury.


      Standard analgesic (opioid and/or benzodiazepine) care and standard analgesic care plus immersive VR distraction.

      Main Outcome Measure

      Self-reported subjective pain ratings (0 to 100 graphic rating scale).


      A total of 146 treatment comparisons were made in 88 subjects, 75% of whom were children ages 6 to 18 years. Compared with standard analgesic treatment alone, the addition of VR distraction resulted in significant reductions in subjective pain ratings for worst pain intensity (20% reduction), pain unpleasantness (26% reduction), and time spent thinking about pain (37% reduction). Subjects’ age, sex, ethnicity, size of initial burn injury, or duration of therapy session did not affect the analgesic effects of VR distraction. Nausea with the standard care plus VR distraction condition was infrequent (15%) and mild, with 85% of the subjects reporting no nausea. Children provided higher subjective reports of “presence” in the virtual environment and “realness” of the virtual environment than did adults, but age did not affect the analgesic effects of VR distraction.


      When added to standard analgesic therapy, VR distraction provides a clinically meaningful degree of pain relief to burn patients undergoing passive ROM PT. Multiple patient factors do not appear to affect the analgesic effect. Immersive VR distraction is a safe and effective nonpharmacologic technique with which to provide adjunctive analgesia to facilitate patient participation in rehabilitation activities.

      Key Words

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        • Ward R.S.
        Physical rehabilitation.
        in: Carrougher G.J. Burn care and therapy. Mosby, St. Louis1998: 293-327
        • Esselman P.C.
        • Thombs B.D.
        • Magyar-Russell G.
        • Fauerbach J.A.
        Burn rehabilitation: state of the science.
        Am J Phys Med Rehabil. 2006; 85: 383-413
        • Ehde D.M.
        • Patterson D.R.
        • Fordyce W.E.
        The quota system in burn rehabilitation.
        J Burn Care Rehabil. 1998; 14: 436-440
        • Cherny N.
        • Ripamonti C.
        • Pereira J.
        • et al.
        ; Expert Working Group of the European Association of Palliative Care Network.
        J Clin Oncol. 2001; 19: 2542-2554
        • Patterson D.R.
        • Sharar S.R.
        Burn pain.
        in: Loeser J.D. Butler S.H. Chapman C.R. Turk D.C. Bonica’s management of pain. Lippincott, Philadelphia2001: 780-787
        • Chapman R.C.
        Introduction: psychologic techniques.
        in: Loeser J.D. Butler S.H. Chapman C.R. Turk D.C. Bonica’s management of pain. Lippincott, Philadelphia2001: 1743-1744
        • Fernandez E.
        • Turk D.C.
        The utility of cognitive coping strategies for altering pain perception: a meta-analysis.
        Pain. 1989; 38: 123-135
        • Farrar J.T.
        • Portenoy R.K.
        • Berlin J.A.
        • Kinman J.L.
        • Strom B.L.
        Defining the clinically important difference in pain outcome measures.
        Pain. 2000; 88: 287-294
        • Hoffman H.G.
        • Doctor J.N.
        • Patterson D.R.
        • Carrougher G.J.
        • Furness 3rd, T.A.
        Use of virtual reality for adjunctive treatment of adolescent burn pain during wound care: a case report.
        Pain. 2000; 85: 305-309
        • Hoffman H.G.
        • Patterson D.R.
        • Magula J.
        • et al.
        Water-friendly virtual reality pain control during wound care.
        J Clin Psychol. 2004; 60: 189-195
        • Das D.A.
        • Grimmer K.A.
        • Sparnon A.L.
        • McRae S.E.
        • Thomas B.H.
        The efficacy of playing a virtual reality game in modulating pain for children with acute burn injuries: a randomized controlled trial.
        BMC Pediatr. 2005; 5: 1
        • Steele E.
        • Grimmer K.
        • Thomas B.
        • Mulley B.
        • Fulton I.
        • Hoffman H.
        Virtual reality as a pediatric pain modulation technique: a case study.
        Cyberpsychol Behav. 2003; 6: 633-638
        • Wright J.L.
        • Hoffman H.G.
        • Sweet R.M.
        Virtual reality as an adjunctive pain control during transurethral microwave thermotherapy.
        Urology. 2005; 66: 1320
        • Hoffman H.G.
        • Garcia-Palacios A.
        • Patterson D.R.
        • Jensen M.
        • Furness 3rd, T.
        • Ammons Jr, W.F.
        The effectiveness of virtual reality for dental pain control: a case study.
        Cyberpsychol Behav. 2001; 4: 527-535
        • Gershon J.
        • Zimand E.
        • Pickering M.
        • Rothbaum B.O.
        • Hodges L.
        A pilot and feasibility study of virtual reality as a distraction for children with cancer.
        J Am Acad Child Adolesc Psychiatry. 2004; 43: 1243-1249
        • Gershon J.
        • Zimand E.
        • Lemos R.
        • Rothbaum B.O.
        • Hodges L.
        Use of virtual reality as a distractor for painful procedures in a patient with pediatric cancer: a case study.
        Cyberpsychol Behav. 2003; 6: 657-661
        • Schneider S.M.
        • Prince-Paul M.
        • Allen M.J.
        • Silverman P.
        • Talaba D.
        Virtual reality as a distraction intervention for women receiving chemotherapy.
        Oncol Nurs Forum. 2004; 31: 81-88
        • Schneider S.M.
        • Ellis M.
        • Coombs W.T.
        • Shonkwiler E.L.
        • Folsom L.C.
        Virtual reality intervention for older women with breast cancer.
        Cyberpsychol Behav. 2003; 6: 301-307
        • Schneider S.M.
        • Workman M.L.
        Virtual reality as a distraction intervention for older children receiving chemotherapy.
        Pediatr Nurs. 2000; 26: 593-597
        • Hoffman H.G.
        • Patterson D.R.
        • Carrougher G.J.
        Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study.
        Clin J Pain. 2000; 16: 244-250
        • Hoffman H.G.
        • Patterson D.R.
        • Carrougher G.J.
        • Sharar S.R.
        Effectiveness of virtual reality-based pain control with multiple treatments.
        Clin J Pain. 2001; 17: 229-235
        • Jensen M.P.
        The validity and reliability of pain measures in adults with cancer.
        J Pain. 2003; 4: 2-21
        • Jensen M.P.
        • Karoly P.
        Self-report scales and procedures for assessing pain in adults.
        in: Turk D.C. Melzack R. Handbook of pain assessment. 2nd ed. Guilford Pr, New York2001: 15-34
        • Gracely R.H.
        • McGrath P.A.
        • Dubner R.
        Ratio scales of sensory and affective verbal pain descriptors.
        Pain. 1978; 5: 5-18
        • Slater M.
        • Wilbur S.
        A framework for immersive virtual environments (FIVE): speculations on the role of presence in virtual environments.
        Presence Teleoper Virtual Environ. 1997; 6: 603-616
        • Slater M.
        • Usoh M.
        • Steed A.
        Depth of presence in immersive virtual environments.
        Presence Teleoper Virtual Environ. 1994; 3: 130-144
        • Miller S.F.
        • Bessey P.Q.
        • Schurr M.J.
        • et al.
        National burn repository 2005: a ten-year review.
        J Burn Care Res. 2006; 27: 411-436
        • Klein M.B.
        • Nathens A.B.
        • Heimbach D.M.
        • Gibran N.S.
        An outcome analysis of patients transferred to a regional burn center: transfer status does not impact survival.
        Burns. 2006; 32: 940-945
        • Ferguson S.L.
        • Voll K.V.
        Burn pain and anxiety: the use of music relaxation during rehabilitation.
        J Burn Care Rehabil. 2004; 25: 8-14
        • Hoffman H.G.
        • Garcia-Palacious A.
        • Kapa V.A.
        • Beecher J.
        • Sharar S.R.
        Immersive virtual reality for reducing experimental ischemic pain.
        Int J Human Comput Interact. 2003; 15: 469-486
        • Patterson D.R.
        • Hoffman H.G.
        • Garcia-Palacios A.
        • Jensen M.P.
        Analgesic effects of post-hypnotic suggestions and virtual reality distraction on thermal pain.
        J Abnormal Psychol. 2006; 115: 834-841
        • Palermo T.M.
        • Drotar D.
        Prediction of children’s postoperative pain: the role of presurgical expectations and anticipatory emotions.
        J Pediatr Psychol. 1996; 21: 683-698
        • Claar R.L.
        • Walker L.S.
        • Smith C.A.
        The influence of appraisals in understanding children’s experiences with medical procedures.
        J Pediatr Psychol. 2002; 27: 553-563
        • Tsao J.C.
        • Myers C.D.
        • Craske M.G.
        • Bursch B.
        • Kim S.C.
        • Zeltzer L.K.
        Role of anticipatory anxiety and anxiety sensitivity in children’s and adolescents’ pain responses.
        J Pediatr Psychol. 2004; 29: 379-388
        • Prothero J.
        • Hoffman H.
        Widening the field of view increases the sense of presence in immersive virtual environments.
        Univ Washington, Human Interface Technology, Seattle1995 (Technical Report TR-95-5)
        • van Shaik P.
        • Turnbull T.
        • van Wersch A.
        • Drummond S.
        Presence within a mixed reality environment.
        Cyberpsychol Behav. 2004; 7: 540-552
        • Hoffman H.G.
        • Sharar S.R.
        • Everett J.
        • Ciol M.A.
        • Richards T.L.
        • Coda B.A.
        Manipulating presence influences the magnitude of virtual reality analgesia.
        Pain. 2004; 111: 162-168
        • Hoffman H.
        • Seibel E.J.
        • Richards T.L.
        • Furness T.A.
        • Patterson D.P.
        • Sharar S.R.
        VR helmet display quality influences the magnitude of virtual reality analgesia.
        J Pain. 2006; 7: 843-850
        • Hoffman H.G.
        • Richards T.L.
        • Coda B.A.
        • et al.
        Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI.
        NeuroReport. 2004; 15: 1245-1248