See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/262816040

Virtual Reality as a Distraction Technique in

Chronic Pain Patients

Article in Cyberpsychology, Behavior, and Social Networking · June 2014

DOI: 10.1089/cyber.2014.0207 · Source: PubMed

CITATIONS READS

8 332

4 authors, including:

Brenda Kay Wiederhold Mark D. Wiederhold

Virtual Reality Medical Center Virtual Reality Medical Center
357 PUBLICATIONS 4,022 CITATIONS 143 PUBLICATIONS 2,302 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Enhancing Exposure and Extinction (Triple E) View project

Biomarkers for MCI - AD & Evaluation of the efficacy of interventions View project

All content following this page was uploaded by Brenda Kay Wiederhold on 14 July 2015.

The user has requested enhancement of the downloaded file.

 Cyberpsychology,
Behavior, and
Social Networking
Cyberpsychology, Behavior, and Social Networking is the essential publication for understanding the social
and psychological impact of today’s social networking practices. Highly regarded as the go-to source in the
field, the Journal has followed the trend of social networking and virtual reality for the past 15 years. It is
known for its rapid communication articles, and rigorous, peer-reviewed studies surrounding the effects of
interactive technologies on behavior and society, both positive and negative.
Information for Manuscript Submission: www.liebertpub.com/cyber
Submit manuscripts online: http://mc.manuscriptcentral.com/cyberpsych
The views, opinions, findings, conclusions and recommendations set forth in any article in Cyberpsychology,
Behavior, and Social Networking are solely those of the authors of those articles and do not necessarily reflect
the views, policy or position of the Journal, its Publisher, its editorial staff, or any affiliated Societies and
should not be attributed to any of them.
Reprints: For permission to photocopy 99 copies or fewer of an article for internal purposes please request
permission and pay the appropriate fee by contacting the Copyright Clearance Center, Inc.: (978) 750-8400. If
the number of copies is 100 or greater please contact the Publisher at (914) 740-2100 or [email protected]
Advertising inquiries from North America, Europe, and the rest of the world should be addressed to: Advertising
Department, Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801, or call (914) 740-2100. Send
E-mail inquiries to: [email protected] All advertisements are subject to approval by the Publisher. The
acceptance of advertisements does not constitute an endorsement of the product or service advertised.
Indexed in: MEDLINE; Current ContentsÒ=Social & Behavioral Sciences; Social Sciences Citation IndexÒ;
Social SciSearchÒ; Journal Citation Reports=Social Sciences Edition; EMBASE=Excerpta Medica; Scopus;
PsycINFO.
Subscriptions should be addressed to the Publisher and are payable in advance. Bulk subscriptions are
available upon request from the Publisher. No refunds may be issued after publication of a volume’s first issue.
Visit our website (www.liebertpub.com=cyber) or contact our Customer Service Department for current
subscription rates and pricing information.
Cyberpsychology, Behavior, and Social Networking (ISSN: 1079–9907) is owned and published 12 times a
year by Mary Ann Liebert, Inc. Mailed in Canada under CPC CPM #40026674. Copyright Ó 2014. Printed in
the United States of America. Postmaster: Send address changes to Cyberpsychology, Behavior, and Social
Networking, c=o Subscription Department, Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY
10801-5215.
Mary Ann Liebert, Inc.
140 Huguenot Street
New Rochelle, NY 10801-5215
Telephone: (914) 740-2100
E-mail: [email protected]

www.liebertpub.com=cyber
 Cyberpsychology,
Behavior, and
Social Networking
Andrea Gaggioli, PhD Thomas D. Parsons, PhD
Editor-in-Chief Catholic University of Milan University of North Texas
Brenda K. Wiederhold, PhD, MBA, and Istituto Auxologico Italiano Denton, TX
BCB, BCN Milan, Italy
Interactive Media Institute David Rose, PhD
9565 Waples Street, Suite 200 Luciano Gamberini, PhD University of East London
San Diego, CA 92121 Human Technology Laboratories London, UK
Tel: 858-642-0267 Padova, Italy
Fax: 858-642-0285 Kathy Ning Shen, PhD
Walter J. Greenleaf, PhD
Greenleaf Medical University of Wollongong
Managing Editor Palo Alto, CA in Dubai
Dubai, U.A.E.
Ruth Kogen Goodwin
John M. Grohol, PsyD
E-mail: [email protected] John Suler, PhD
International Society
for Mental Health Online Rider University
European Editor PsychCentral.com Lawrenceville, NJ

Giuseppe Riva, PhD Terry M. Gudaitis, PhD Catalina Toma, PhD

Catholic University of Milan Global Integrity Solutions University of Wisconsin
and Istituto Auxologico Italiano Reston, VA Madison
Milan, Italy
Masatoshi Ishikawa, Dr Eng
Erik Viirre, MD, PhD
University of Tokyo
Associate Editors University of California
Japan
San Diego
Stéphane Bouchard, PhD Manolya Kavakli, PhD, MSc, BSc
Université du Québec en Outaouais Macquarie University Clyde A. Warden, PhD
Gatineau, Québec, Canada Sydney, Australia National Chung Hsing
Chia-Wen Tsai, PhD University
Ming Chuan University Sun I. Kim, PhD Taiwan, R.O.C.
Taiwan, R.O.C. College of Medicine
Hanyang University Dave Warner, MD, PhD
NPAC/Syracuse University
Editorial Board J. Matias Kivikangas
University of Helsinki Mark D. Wiederhold, MD,
Metin Akay, PhD
and Aalto University PhD, FACP
Arizona State University
Helsinki, Finland The Virtual Reality Medical Center
Tempe, AZ
(VRMC)
Murugan Anandarajan, PhD, Msc Steven E. Locke, MD San Diego, CA
Drexel University Harvard Medical School
Philadelphia, PA
Elvis Mazzoni, PhD Jiali Ye, PhD
Cristina Botella, PhD Georgia State University
University of Bologna
Universitat Jaume I Atlanta, GA
Italy
Castellon, Spain
Anthony (aka Tony) Lewis Brooks, PhD Zhenkuan Pan, PhD Kimberly S. Young, PsyD
Aalborg University Esbjerg Qingdao University Center for Online Addiction
Denmark Shandong, P.R. China Netaddiction.com

www.liebertpub.com/cyber
 Cyberpsychology,
Behavior, and
Social Networking
Volume 17 Number 6 June 2014

EDITORIAL
How Can Virtual Reality Interventions Help Reduce Prescription Opioid 331
Drug Misuse?
B.K. Wiederhold, G. Riva, and M.D. Wiederhold

GUEST EDITORIALS
Personalizing Therapy 333
R. Madelin

Virtual Reality Research Continues to Progress at the National 334

Institutes of Health
D.A. Thomas

Special Issue on Virtual Reality and Pain

Psychological Factors Influencing the Effectiveness of Virtual Reality–Based 335

Analgesia: A Systematic Review
S. Triberti, C. Repetto, and G. Riva

Virtual Reality as a Distraction Technique in Chronic Pain Patients 346

B.K. Wiederhold, K. Gao, C. Sulea, and M.D. Wiederhold

Differential Effects of Two Virtual Reality Interventions: Distraction Versus 353

Pain Control
D. Loreto-Quijada, J. Gutiérrez-Maldonado, R. Nieto, O. Gutiérrez-Martı́nez,
M. Ferrer-Garcı́a, C. Saldaña, A. Fusté-Escolano, and L. Liutsko

Clinical Use of Virtual Reality Distraction System to Reduce Anxiety and Pain 359
in Dental Procedures
M.D. Wiederhold, K. Gao, and B.K. Wiederhold

Application of Virtual Body Swapping to Patients with Complex Regional 366

Pain Syndrome: A Pilot Study
B. Jeon, S. Cho, and J.-H. Lee

(continued )
Virtual Reality for Pain Management in Cardiac Surgery 371
J.L. Mosso-Vázquez, K. Gao, B.K. Wiederhold, and M.D. Wiederhold

Virtual Reality for the Induction of Positive Emotions in the Treatment 379
of Fibromyalgia: A Pilot Study over Acceptability, Satisfaction, and the Effect
of Virtual Reality on Mood
R. Herrero, A. Garcı́a-Palacios, D. Castilla, G. Molinari, and C. Botella

Mobile Devices as Adjunctive Pain Management Tools 385

B.K. Wiederhold, K. Gao, L. Kong, and M.D. Wiederhold

Virtual Reality and Musculoskeletal Pain: Manipulating Sensory Cues 390

to Improve Motor Performance During Walking
W. Powell and M.J. Simmonds

Feasibility of Articulated Arm Mounted Oculus Rift Virtual Reality Goggles 397
for Adjunctive Pain Control During Occupational Therapy in Pediatric
Burn Patients
H.G. Hoffman, W.J. Meyer III, M. Ramirez, L. Roberts, E.J. Seibel, B. Atzori,
S.R. Sharar, and D.R. Patterson

Pain Management in Virtual Reality: A Comprehensive Research Chart 402

C. Sulea, A. Soomro, C. Boyd, and B.K. Wiederhold

CLOSING EDITORIAL
Future Directions: Advances and Implications of Virtual Environments 414
Designed for Pain Management
B.K. Wiederhold, A. Soomro, G. Riva, and M.D. Wiederhold

COLUMNS
CyberSightings 423
A. Gaggioli

CyberEurope 424
G. Riva

Instructions for Authors can be found on our website: www.liebertpub.com/cyber

www.liebertpub.com/cyber
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014 EDITORIAL
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.1512

How Can Virtual Reality Interventions Help Reduce

Prescription Opioid Drug Misuse?

Brenda K. Wiederhold, PhD, MBA, BCB, BCN,1,2 Giuseppe Riva, PhD,3,4

and Mark D. Wiederhold, MD, PhD, FACP 5

T he recent death from a heroin overdose of actor

Philip Seymour Hoffman at the age of 46 highlights the
danger of opioid addiction. However, according to the U.S.
are difficult because of different physician prescribing pat-
terns.6 Another study found that ‘‘Native Americans had
significantly greater rates of nonmedical prescription drug use
Centers for Disease Control, prescription opioids such as and drug use disorders, highlighting the need for culturally-
OxyContin, Percocet, and Vicodin may be gateway drugs for sensitive prevention and intervention programs.’’7
heroin addiction and are responsible for five times as many In addition to humanitarian reasons, there are significant
deaths. ‘‘The main driver of overdoses right now in our financial incentives to find ways to reduce the incidence of
country is from opioid medications, more than from heroin,’’ prescription opioid misuse. One study found that ‘‘mean
said Nora Volkow, director of the National Institute on Drug annual direct health care costs for opioid abusers were more
Abuse (NIDA).1 Prescription drug overdose rates have more than eight times higher than for nonabusers.’’8 Another study
than tripled since 1990, paralleling a 300% increase in sales noted, ‘‘The total cost of prescription opioid abuse in 2001
of strong prescription opioids.2 was estimated at $8.6 billion, including workplace, health
What is being done about this growing problem, and how care, and criminal justice expenditures.’’9
can virtual reality (VR)-assisted behavioral interventions Of course, this amount is a drop in the bucket compared to
help? In addition to NIDA, other U.S. agencies involved in the total cost to the U.S. economy of chronic pain, recently
the fight against prescription opioid abuse and misuse in- estimated by the Institute of Medicine at between $560 and
clude the Drug Enforcement Administration and the Food $630 billion annually.10 The European Federation of Inter-
and Drug Administration. In February, the DEA launched a national Association for the Study of Pain (IASP) Chapters
new texting initiative, TIP411, which helps the public report notes that to date, ‘‘there is no comprehensive pan-European
suspicious activity such as seeing a pharmacy tech drive off epidemiological survey laying out the scope of the pain
in an expensive car. Tipsters can use the keyword PILLTIP problem.’’11 However, a 2010 report noted that ‘‘chronic
to report anomalies that may indicate illegal prescription pain costs Europe billions of euros every year, with national
drug activity, and the message will be forwarded to a DEA costs ranging from 1.1 billion to nearly 50 billion Euros.’’12
agent for investigation. The FDA is proposing to reclassify Combinations of prescription opioids with other drugs have a
hydrocodone combination pills such as Vicodin from Sche- modest additive effect on pain relief, while combinations of
dule III to Schedule II. Adoption of the proposal would mean prescription opioids with behavioral interventions have been
that prescriptions for this type of drug couldn’t be called in shown to be effective, for example, in reducing headache
over the phone and would require reauthorization from the pain. As we researchers in the field of VR-assisted therapy
physician before being refilled.3 have been saying for many years, it would be most helpful if
Studies have concluded that only a small percentage of we could identify predictors of who will be likely treatment
people who are prescribed opioids for medical reasons will responders.12
go on to develop addictions to these drugs, and that one of the The editor and others involved in VR research have made
ways to prevent addiction is to preselect for no previous strides in showing the effectiveness of ‘‘various psycholog-
history of or current problems with drug or alcohol abuse or ical techniques, including distraction by virtual reality en-
addiction.4 Consistent with other studies on the subject, one vironments and the playing of video games, [which] are
study using Medicaid data found that about 3% of individ- being employed to treat pain.’’13 Perhaps if additional dollars
uals will graduate to abuse or dependence, with the popu- were directed to support evidence-based research on both the
lation most vulnerable to addiction being those younger than psychological and neurophysiological mechanisms related to
40.5 Studies suggest similar rates of prescription opioid misuse pain, and the effectiveness of these nondrug modalities, we
in the EU, although direct United States–Europe comparisons would be able to make a significant contribution to reducing

1
Virtual Reality Medical Institute, Brussels, Belgium.
2
Interactive Media Institute, San Diego, California.
3
Department of Psychology, Catholic University of Milan, Italy.
4
Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Milan, Italy.
5
The Virtual Reality Medical Center (VRMC), San Diego, California.

331
332 EDITORIAL

the need for opioid prescriptions and the deadly conse- 7. Huang B, Dawson DA, Stinson FS, et al. Prevalence, corre-
quences of their abuse. As recently suggested by Herta Flor, lates, and comorbidity of nonmedical prescription drug use and
‘‘The analysis of neurophysiological mechanisms may also drug use disorders in the United States: results of the National
lead to the development of new psychological interventions Epidemiologic Survey on Alcohol and Related Conditions.
that can target these changes in a much more specific manner Journal of Clinical Psychiatry 2006; 67:1062–1073.
than pharmacological interventions.’’14 8. White AG, Birnbaum HG, Mareva MN, et al. Direct costs of
opioid abuse in an insured population in the United States.
References Journal of Managed Care Pharmacy 2005; 11:469–479.
9. Strassels SA. Economic burden of prescription opioid
1. Achenbach J. Philip Seymour Hoffman’s death points to misuse and abuse. Journal of Managed Care Pharmacy
broader opioid drug epidemic. The Washington Post, Feb. 2009; 15:556–562.
7, 2014. 10. Institute of Medicine. (2011) Relieving pain in America: a
2. Christensen J. DEA turns to texting to fight prescription blueprint for transforming prevention, care, education, and
drug abuse. CNN.com, Feb. 21, 2014. research. Washington, DC: National Academies Press.
3. CNN Staff. FDA aims to tighten control of hydrocodone. 11. European Pain Federation. Costs of chronic pain. www.efic
CNN.com, Oct. 25, 2013. .org/index.asp?sub = B47GFCF5J4H43I (accessed Feb. 24,
4. Fishbain DA, Cole B, Lewis J, et al. What percentage of 2014).
chronic nonmalignant pain patients exposed to chronic opi- 12. Jensen MP, Turk DC. Contributions of psychology to the
oid analgesic therapy develop abuse/addiction and/or aber- understanding and treatment of people with chronic pain:
rant drug-related behaviors? A structured evidence-based why it matters to ALL psychologists. American Psycholo-
review. Pain Medicine 2008; 9:444–459. gist 2014; 69:105–111.
5. Edlund MJ, Martin BC, Fan M-Y, et al. Risks for opioid 13. Wiederhold MD, Wiederhold BK. Virtual reality and in-
abuse and dependence among recipients of chronic opioid teractive simulation for pain distraction. Pain Medicine
therapy: results from the TROUP study. Drug & Alcohol 2007; 8:S182–S188.
Dependence 2010; 112:90–98. 14. Flor H. Psychological pain interventions and neurophysi-
6. Denisco RA, Chandler RK, Compton WM. Addressing the ology. American Psychologist 2014; 69:188–196.
intersecting problems of opioid misuse and chronic pain
treatment. Experimental & Clinical Psychopharmacology Profs. Brenda K. Wiederhold, Giuseppe Riva,
2008; 16:417–428. and Mark D. Wiederhold
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014 GUEST EDITORIALS
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.1513

Personalizing Therapy

Robert Madelin, MA (Oxon)

H ealth and well-being are prime beneficiaries of the

convergence of the sciences, as cognitive, computa-
tional, bio-, and nanotechnologies intermingle. But our so-
incorporated into polypractice. Liability regimes, made strict
by the penumbra of Thalidomide, discourage physicians and
may in practice completely rule out any personal choice to
cieties and health systems are struggling to bring to market follow their physician in less established therapies.
the deep innovations that result. We struggle to do this in Despite the obstacles, best-in-class, innovative practition-
large part because we are prisoners of systems built for a ers, for example Dr. Peter Hutton, Consultant Anaesthetist in
different model, governed by responsible professional pre- Birmingham, United Kingdom, have at least achieved a lia-
scription of blockbuster, one-shot solutions, based on the bility regime allowing real-time telemedicine deployment of
evidence of randomized trials for safety and efficacy. variable dosages for pain relief medication. The fact that even
After a decade spent observing, as a non-specialist, the this is not yet mainstream hints at the obstacles to be overcome
fields of medical innovation and e-health in its broadest sense, in broader polytherapy. But the facts emerging from such ex-
including virtual reality (VR), I see with increasing clarity the periences will reinforce the case, one hopes, for more forward-
opportunity cost imposed by the prevailing paradigm on what leaning attitudes from health managers and regulators.
could otherwise be an explosion of health innovation. At the EU level, too, innovators are nibbling at the
I do not feel alone. On the disproportionate dominance obstacles. The highly successful European Innovation Part-
of the gold standard, Sir Michael Rawlings, the then UK nership on Active and Healthy Aging covers pain manage-
Clinical Excellence czar, laid out in his 2008 Harveian Oration ment. So does the Horizon 2020 Research and Innovation
the need to respect all evidence as evidence, from random- Strategy: in its 2014–2015 Health Work Programme, calls
ized double-blinded control trials down to individual experi- will cover ‘‘underdiagnosed or untreated pain . new therapies
ence of ‘‘what worked’’: evidence was always ‘‘valid,’’ and the for chronic non-communicable diseases, self-management of
weight to be given to it in each case was the crucial judgment health . mobile health . patient empowerment supported by
call. ICT.’’
The need to embrace less general evidence is nowhere Within this word cloud of opportunity, I hope we will
clearer than in a field such as pain, where complementary receive from around the world good proposals addressing the
treatments are available, and individual responses will vary. question of chronic pain management using ICT tools. Our
In what we might call the polypractice of pain therapy, we first deadlines are in April 2014, but most of the elements
see increasing recourse to combinations of drugs, at varying quoted above stretch into next year, and the program as a
daily rhythm and dosage, alone and in combination with whole lasts until 2020.
other therapies, for example VR over the Internet, full im- To conclude, any successful approach to pain-related in-
mersion clinical VR, or talking support. Polytherapy is used novation needs to be broad enough to cover the full range of
because it works. But it will necessarily work differently for conceivable polypractice. We need to open the field for inno-
different conditions in different individuals at different stages. vation. We cannot in future await blockbuster breakthroughs.
This complexity is increasingly well understood and ac- We must rather open multiple paths for personalized pain relief.
commodated in end-of-life scenarios, at least in specialized
palliative settings. But non-specialized professionals lack good Robert Madelin
decision support mechanisms that would allow them to be Director General, European Commission

333
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.1509

Virtual Reality Research Continues to Progress

at the National Institutes of Health

David A. Thomas, PhD

T he National Institute on Drug Abuse (NIDA), part

of the National Institutes of Health (NIH), is among the
leading funders of pain research at the NIH. By law, the NIH
Second, while opioids can be effective in the treatment of
pain, they have a significant side effect profile, and the rates of
misuse and addiction are staggering. In the United States
must issue announcements of areas of research interest. One alone, according to the Centers for Disease Control and Pre-
major series of pain research funding announcements, issued vention, approximately 16,000 people die each year from a
by 11 Institutes and developed in cooperation with the NIH prescription opioid overdose. That exceeds deaths from co-
Pain Consortium, is titled Mechanisms, Models, Measure- caine and heroin overdoses combined. The last decade of re-
ment, and Management in Pain Research (see http://grants search has established that VR, in a variety of situations, offers
.nih.gov/grants/guide/pa-files/PA-13-118.html). a safe and effective treatment of pain, without the possibility
In these announcements, the NIH states that they are in- of drug addiction or many side effects common to opioids.
terested in research on ‘‘.non-pharmacological and novel And progress has accelerated in the development of using
(e.g. virtual reality) therapies for pain treatment in diverse VR for the treatment of pain. This special issue of Cyber-
populations such as ethnic minority groups and persons with psychology, Behavior, & Social Networking is just another
disabilities.’’ The specific mention of virtual reality (VR) is demonstration of how this field has developed and grown,
not by chance. There is a genuine understanding at the NIH and what a positive impact VR can have in alleviating pain. I
of VR’s potential to treat pain, and this has translated to the expect advancements in this field to continue for many years
NIH funding a substantial amount of VR pain research. to come.
Using the NIH RePORT system (www.report.nih.gov/) to
search NIH funded projects VR and pain projects, dozens of Reference
funded projects can be found, representing tens of millions of 1. Institute of Medicine. Relieving Pain in America: a blueprint
dollars in funding over the past decade. for transforming prevention, care, education, and research.
Why such an interest at NIDA, and across the NIH, in VR Report Brief. June 2011.
to treat pain? First, there is a huge need for new pain treat-
ments. Approximately 100 million people in the United States Dr. David A. Thomas
suffer from chronic pain,1 and each case is somewhat dif- Division of Clinical and Behavioral Research
ferent. No single pain treatment exists that is good for ev- National Institute on Drug Abuse
eryone, or even the majority of people. VR is proving itself National Institutes of Health
as one viable option for reducing pain in suffering, and thus
its development must be a priority. E-mail: [email protected]

334
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014 SPECIAL ISSUE
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0054

Psychological Factors Influencing the Effectiveness

of Virtual Reality–Based Analgesia:
A Systematic Review

Stefano Triberti, MA,1 Claudia Repetto, PhD,1 and Giuseppe Riva, PhD1,2

Abstract

The experience of pain is affected by remarkable psychological factors. The concept of neuromatrix suggests
that pain is an amalgam of affect, cognition, and sensation mediated through diverse brain regions. Moreover,
the experience of pain appears to be reduced by environmental stimuli that drive attention away from the
noxious events. Accordingly, immersion in a computer-generated, three-dimensional virtual environment has
been used as an efficient distraction tool in a number of studies on pain management. However, no systematic
approaches have explored the psychological factors that influence the effectiveness of virtual reality (VR) as a
distraction technology. This review aims to outline the fundamental psychological factors involved in the use of
VR to provide pain management. An analysis of the literature revealed some important elements associated
with the patients’ subjective experience. Eleven studies met the inclusion criteria and were included in the
review. The results suggest the importance of different psychological factors in the effectiveness of the anal-
gesic distraction. While sense of presence influence the effectiveness of VR as a distraction tool, anxiety as well
as positive emotions directly affect the experience of pain. Future challenges for pain management via VR
include adopting properly validated measures to assess psychological factors and using different experimental
conditions to better understand their complex effects.

Introduction logical,4 such as the level of attention paid to the pain, the
emotion associated with it, and related experiences.5

C lassic research characterizes pain as an automatic

access to consciousness1 and a powerful demand for
attentional resource.2 While pain is a reaction to painful
The role of psychological factors in the experience of pain
has become even more critical in light of recent work related
to the neuromatrix.6–8 The neuromatrix is an extensive neural
stimuli, it is still a controlled process. Therefore, any task network representing the cerebral signature for pain per-
that demands a similar or greater amount of cognitive re- ception. This network is deemed to mediate the pain expe-
sources could possibly interfere with the perception of pain. rience itself,9 and the authors use a biopsychosocial model7
The phenomenon of pain relief via distraction emerged after to describe pain as an amalgam of affect, cognition, and
the rise of the gate control theory.3 According to this theory, sensation mediated through diverse brain regions.10 In the
nociceptive signals do not travel directly from the area of original model, parallel networks contribute to the sensory-
injury to the brain but have to pass through a ‘‘gate’’ discriminative (S), affective-motivational (A), and evalua-
mechanism located in the spinal cord. Depending on how tive-cognitive (E) dimensions of the pain experience.8 In this
open the gate is, a signal is perceived as more or less painful. view, pain is not only an unpleasant sensory experience, but
Many factors could open or close the gate. Some are sen- also a multisystem output that is aimed to action11 with the
sory; for example, if one gets a cut on his or her skin but puts primary goal of restoring the brain’s homeostatic regulation
the injured area under fresh water, that action stimulates system.8,12,13
large-diameter fibers in the spinal cord, which inhibits the Recent research10,14,15 has partially challenged the con-
activity of small-diameter fibers and closes the gate, thus cept of neuromatrix; pain intensity can be dissociated from
relieving the pain. Other factors that could influence whe- the magnitude of response in the matrix, and the neural
ther the gate opens or closes are behavioral and psycho- configuration of the matrix also appears responsive to

1
Psychology Department, Università Cattolica del Sacro Cuore, Milan, Italy.
2
Applied Technology for NeuroPsychology Lab, Istituto Auxologico Italiano, Milan, Italy.

335
336 TRIBERTI ET AL.

non-nociceptive stimuli. However, the idea of a complex analgesia in order to provide insights and guidelines for fu-
pain network is still fundamental to understand how the final ture implementation. In general, psychological factors in-
experience of pain is mediated by different factors, including fluence both the experience of pain and the treatment
cognitive and emotional factors.16,17 According to the review outcome,18 so they must be properly assessed in pain man-
by Linton and Shaw,18 psychological factors involved in agement interventions. Focusing on the particular interven-
pain experience deserve to be recognized and treated inde- tion of VR-based analgesia, we then propose a theoretical
pendently of physiological factors. Attention is particularly discussion about the different effects of the psychological
important because pain perception requires that cognitive factors upon the process.
resources be directed toward the painful stimulus. A patient’s
interpretation of the events surrounding the painful stimu- Methods
lus, expectations about pain, cognitive sets, and preexisting
beliefs and attitudes all play a role in the way a patient ex- We followed guidelines from the preferred strategies to
periences and copes with pain. Furthermore, emotional ac- report items in systematic reviews (PRISMA34).
tivations have a strong effect on pain experience. Not only
does pain generate negative emotions such as fear and anx- Search strategy
iety,19 but also emotions actively mediate the experience of A preliminary search performed independently by two of
pain (e.g., they are associated with higher self-reported pain19,20).
the authors identified several psychological factors analyzed
Moreover, recent research suggests that anticipatory anxiety
in past research on VR-based pain management. Some fac-
related to difficult incoming situations could directly gen- tors are related to the subjective experience of the virtual
erate pain experiences, even in the absence of actual painful
environment, such as sense of presence or immersion; others
stimuli in the environment.21
are emotional and concern patients’ individual reactions to
Given that distraction and other psychological factors the pain management situation, such as anxiety or fun. We
influence the experience of pain, numerous interventions
then performed an extensive review of the scientific litera-
aimed to reduce pain in medical procedures are based on
ture to identify articles investigating psychological factors,
distraction techniques.22,23 Patients are engaged in tasks at specifically immersion, presence, fun, and anxiety. A com-
the same time of their pain experience. Patients report puter-based search was carried out (updated January 2014)
significant pain reduction when they allocate cognitive and
on scientific databases (Scopus and PubMed) using the fol-
attentional resources to the distractor stimulus. To date,
lowing search string: (pain control OR pain management OR
distraction techniques have used many types of materials analgesia AND virtual reality) AND (presence OR immer-
and activities to engage patients’ attentional system and
sion OR fun OR anxiety).
help them to manage their pain. Past research has found
that relaxation, hypnosis,24 cognitive tasks,25–27 movies,
and nurse coaching28 all reduce patients’ experience of Systematic review flow
pain. More recently, virtual reality (VR) has emerged as an Figure 1 illustrates the flow diagram of the review process.
innovative and very efficient distraction tool. In VR, a In total, 156 publications emerged from an initial search. All
patient is fully immersed into a simulated environment by publications were individually abstract-screened by the au-
using a head-mounted display, headphones with environ- thors on the basis of the following inclusion criteria:
mental sound and/or noise reduction, and a head-tracking
system that allows the patient to naturally move in the a. Research article
virtual environment. Moreover, VR can be interactive, so b. Experimental design (either between or within sub-
that the user is able to act within the virtual environment to jects) with at least one group of participants (single-
achieve a goal. case studies excluded)
Several reviews about the efficacy of VR-based analgesia c. Measured at least one of the psychological factors of
have already been published,5,29,30 and some of these re- interest
views recognize the importance of properly understanding After this screening, 19 nonduplicated citations emerged.
the role of patients’ individual characteristics31 and subjec- A deeper investigation of these 19 articles was performed by
tive experience32 when considering the effectiveness of VR two authors in order to select articles that met the full criteria,
as a pain reliever. If pain distraction is a psychological resolving disagreements by consensus. This analysis ex-
process, then psychological factors need to be considered to cluded eight articles because VR was used for purposes other
improve its efficacy. For this reason practitioners and re- than distraction or the virtual system used was a video game
searchers have experimented with distraction in different without immersion devices. Ultimately, 11 articles met the
forms by manipulating its intensity and adapting their full criteria and were included in this review (see Table 1 for
methods to different types of pain through different contexts. the summary of the features of each article included).
Additionally, VR methods vary in the technology that they
employ, and experience in a VR simulator can vary based on
Results
the active contribution of the user’s cognitive and emotional
characteristics.33 VR functioning and effectiveness are sen- The selected articles will be analyzed considering each
sitive to the user’s expectations, emotions, and engagement psychological factor separately. Thus, each of the following
in the activity. To our knowledge, no reviews of VR-based sections will take into account one psychological factor and
analgesia have directly assessed the effects of psychological will describe the relevant results. If one article has consid-
factors. Thus, we decided to focus our review on these fac- ered more than one factor, then it will be discussed in dif-
tors to outline the psychological validation of VR-based ferent sections.
PSYCHOLOGICAL FACTORS AND VR-BASED ANALGESIA 337

FIG. 1. The flow diagram of the

review process.

Immersion/presence control variable. This happens when the design of a study

uses an experimental group of participants who are exposed
There is sometimes confusion between the concepts of to VR distraction and a control group that either is or is not
immersion and presence.35 Immersion is defined as the exposed to another type of distraction. Some studies only
physical/sensorial stimulation provided by the virtual envi- measured presence in the VR condition, given that presence
ronment35,36 and the degree of perceptual realism that the vir- is an important control for the efficacy of VR.53–57
tual system is able to achieve.37,38 A sense of presence is Gutierrez-Martinez and colleagues54 investigated the ef-
defined as the illusion of actually being in the virtual envi- fects of VR-based analgesia in a group of 37 volunteers who
ronment. From an experiential viewpoint, a VR user could were exposed to experimentally induced pain by placing
feel more or less present in the environment he or she is their hand in a cold pressor. All volunteers participated in
interacting with.39–41 The sense of presence could be con- two consecutive sessions, one session using VR (Surreal
sidered as the psychological equivalent of immersion,42 World, a presentation of 3D environments with strange and
though presence may not be described only in technical evocative images) and the other session using only a blank
terms. If technological advancements in the VR machinery screen. The session with VR produced significant reductions
influence the sensation of ‘‘being there,’’ the state of mind of in pain compared with the control condition. The authors
the user, the user’s personality traits, and the arrangement of found a significant negative correlation between subjective
a narrative context within the virtual experience also play a pain ratings and presence ratings: The greater the sense of
fundamental role.33,43–45 For this reason, the sense of pres- presence in the VR condition, the more attention drawn to the
ence measured in users has been often considered as sort of VR environment, and consequently the perceived pain is
‘‘ecological validity’’ for VR implementations.45,46 reduced. Similar results were found by Hoffman et al. (11
There is surely debate about how to measure the sense of participants with burn wounds)58 and by Tse and colleagues
presence. Past studies have considered behavioral re- (72 participants with experimentally induced pain).59 Pre-
sponses,47 physiological correlates,48,49 and qualitative in- sence ratings (or, in the case of Tse et al.,59 ‘‘the degree of
terviews,50 but self-report instruments are the most immersion’’) were positively correlated with an increase of
frequently used method to assess presence. Users are asked the pain threshold. Furthermore, in three different studies
to report their presence level on a scale when answering with 88 total participants of different ages, Sharar et al.57
questions about how much they felt immersed into the virtual measured presence in the VR conditions. Interestingly,
environment. Moreover, a number of validated question- children reported higher levels of presence (and also of
naires to evaluate presence are available.51,52 Ten out of the perceived ‘‘realness’’ of the environment) than adults.
11 studies included in this review evaluated presence. How- A few studies tested participants who were already ex-
ever, presence is sometimes analyzed only as a one-condition periencing pain, rather than inducing pain experimentally.
 Table 1. Features of the Included Studies
Results for Results for Results for
psychological factors: psychological psychological
Reference Pain type Sample Design VR content presence/immersion factors: fun factors: anxiety
1. Hoffman Experimentally 39 students, age Between-subjects SnowWorld High-tech VR mitigated Patients rated how much X
et al.61 induced range 18–20 design (high-tech pain confronted with fun they had during the
VR vs. low-tech low-tech VR; sense of most recent pain
VR) presence was higher in stimulus. FUN ratings
subjects in high-tech were higher in high-tech
VR condition. condition and correlated
with high presence.
2. Gutierrez- Experimentally 37 subjects Within-subjects Surreal World High presence correlated X X
Martinez induced design; VR vs. (auditory and visual with low pain intensity.
et al.54 non-VR inputs based on art
images)
3. Hoffman Real pain (burn 11 subjects Within-subjects SnowWorld Patients with the highest Patients with the highest X
et al.58 wound design; VR vs. presence ratings showed presence ratings also
debridement in the non-VR significant reductions in reported the highest
hydrotherapy tank) worst pain ratings. levels of perceived fun.
4. Maani Real pain 12 soldiers Mixed design (high SnowWorld Presence was considered Participants were asked X
et al.55 (combat-related pain ratings vs. low only as a control how much fun they had

338
burn injuries) pain ratings · VR vs. variable for VR during VR. Those with
non-VR) condition’s efficacy; highest ratings of pain
participants reported reported a 100%
moderate levels of it. increase of fun; those
with lower pain ratings
also reported significant
fun level.
5. Van Twillert Real pain (burn 19 subjects Within-subjects design SnowWorld X X For 13 of 19 patients, VR
et al.75 injuries) (VR vs. non-VR and produced significant
other distraction reductions in pain. Trait
methods) anxiety and state
anxiety were measured.
Reductions of it were
found in VR and
television conditions,
but not significant.
6. Tse et al.59 Experimentally 72 subjects Within-subjects design A VR system to watch ‘‘Degree of immersion’’ X The participants having a
induced (pain is measured videos of natural results correlated with lower level of anxiety
every 20 seconds of environments such the improvement in prior to experiment had
the intervention) as mountains and pain threshold. better improvement in
falls pain management.

(continued)
 Table 1. (Continued)
Results for Results for Results for
psychological factors: psychological psychological
Reference Pain type Sample Design VR content presence/immersion factors: fun factors: anxiety
7. Gold et al.53 Real pain (during 20 children Between-subjects ‘‘Street Luge,’’ a fast- Presence was considered X Anticipatory anxiety
IV placement) design: VR vs. moving only as a control regarding IV placement
non-VR virtual world in variable for VR positively correlated
which the player condition efficacy; with general anxiety of
races downhill participants reported children and anxiety
on a skateboard ‘‘sufficient’’ levels of it. during past procedures.
8. Chan et al.62 Real pain (burn 8 children Between-subjects An interactive game Presence did not show X Qualitative interviews to
injuries) design; VR vs. taking place in an significant correlations nurses: children in VR
non-VR · before, ice cream factory with pain ratings; also condition showed
during, and after pain ratings did not reduced anxiety in their
the treatment significantly differ observable behavior.
between VR and non-
VR conditions.
9. Sharar Real pain (burn 88 subjects Within-subjects SnowWorld Sense of presence was Fun related to VR was X
et al.57 injuries) (different design; VR vs. measured only in VR analyzed only in studies

339
ages through non-VR condition as a control 2 and 3. VR condition
three different variable; it resulted obtained significantly
studies) higher in children. higher fun scores than
non-VR.
10. Wender Experimentally 21 subjects Between-subjects SnowWorld Interactive VR resulted Fun during the most recent X
et al.60 induced design; interactive more effective in pain stimulus.
VR vs. passive VR reducing pain ratings, Interactive VR
but sense of presence condition obtained
showed no significant significantly higher fun
differences between scores than
conditions. noninteractive VR.
11. Schmitt Real pain (burn 54 subjects Within-subjects SnowWorld Sense of presence was Fun ratings were X
et al.56 injuries) design; standard measured as a control significantly higher in
pharmacologic variable in VR VR condition than in
therapy + VR vs. condition; it remained non-VR condition.
standard constant through the 5 They remained constant
pharmacologic days of the study. through the 5 days of
therapy + non-VR the study.

VR, virtual reality.

340 TRIBERTI ET AL.

Maani et al.55 compared VR and a control condition without the most recent painful sensation. Participants in the inter-
VR in 12 soldiers with combat related burn injuries; Gold active VR condition showed significantly higher ratings of
et al.53 used a similar protocol with 20 children who were fun compared with participants in the noninteractive VR
experiencing pain from intravenous placement. Both exper- condition. Taken together, these studies suggest that partici-
iments were successful in reducing pain using VR and pants’ experience of fun is a critical component of the ef-
showed that participants reported sufficient levels of pres- fectiveness of VR as a pain reliever.
ence in the VR condition. In particular, Gold and col-
leagues53 consider a good presence level as an important
Anxiety
indicator to validate their virtual environment (Street Luge)
for future applications. In the context of pain management, negative emotions of
Schmitt et al.56 considered the integration of VR with patients are also an important factor. Anticipatory anxiety is
standard pharmacological pain therapy in a 5-day study with a well-known problem for patients who are involved in
repeated sessions. Participants were 54 pediatric patients bothersome or painful medical procedures.68,69 In the field of
with burn injuries. Researchers found a meaningful reduction VR-based pain reduction, a number of studies have consid-
in pain ratings in the VR condition starting on the first day, ered the particular moment of wound care treatments in pa-
and the reduction was maintained over the subsequent ther- tients with burn injuries, events that are often characterized
apy sessions. Presence ratings were also affected on the first by anticipatory anxiety regarding the upcoming pain (see70
day of treatment and maintained over the course of the for a review). Despite the great amount of studies measuring
experiment. anxiety during VR-based interventions for pain reduction,
Wender et al.60 tried to understand the importance of in- none of them considered anxiety as a mediator of VR effi-
teractivity in the analgesia effect of VR, so they compared cacy. For this reason we selected studies that either provided
the use of an interactive VR and a noninteractive VR with 21 a measure of anxiety changes between pretreatment and
subjects (pain was experimentally induced). Interactive VR treatment, investigated the difference between state and trait
showed an increase of 75% in the perceived analgesia effect anxiety, or analyzed the correlations between anxiety and
compared with noninteractive VR. Presence ratings did not other variables affecting the virtual experience.
significantly differ between interactive and noninteractive Chan et al.62 considered anticipatory anxiety in their ex-
VR. However, the opposite was found by Hoffman and periment, which involved eight children with burn injuries.
colleagues.61 Noninteractive high-technology VR showed The children played an interactive VR game while nurses
stronger pain reduction and higher presence ratings con- changed their dressing. The researchers used qualitative in-
fronted with low-technology VR in 39 students with exper- terviews with the nurses, a common method to understand
imentally induced pain. the relationship between pain and anxiety in medical pro-
The only other negative result was reported by Chan cedures.71,72 The authors report important reductions in
et al.62: Eight children with burn injuries were divided be- anxiety: During VR exposure, patients stopped crying and
tween a VR condition and a non-VR control. Children in the kicking and, with little encouragement by the nurses, started
VR condition played an interactive game featuring an ice concentrating on the game without showing negative reac-
cream factory. Although a general reduction in perceived tions to the procedure. Gold et al.53 used validated measures
pain emerged, it did not discriminate between VR and non- to analyze affective pain (i.e., worry about the pain) and the
VR and so sense of presence showed no significant correla- Childhood Anxiety Sensitivity index73 to assess trait anxiety
tions with pain ratings. in their sample of children undergoing intravenous place-
ment. Anticipatory anxiety related to the procedure was also
assessed. The analysis showed multiple significant correla-
Fun
tions between measures. Affective pain increased in the
Users’ emotional responses are fundamental for the ef- control condition with no VR, but remained identical in VR
fective functioning of a virtual environment,63 and surely an condition, and was also significantly correlated with pain
emotional involvement appears to be strongly connected to a intensity. Anticipatory anxiety regarding the procedure
sense of presence and perceived realism in VR.41,43,64 For this positively correlated with child’s general anxiety, and also
reason, many researchers consider the concept of ‘‘fun’’ and with the anxiety they experienced during past intravenous
evaluate positive emotions and delight in virtual applications. placements.
To date, fun has been considered in many user experience State and trait anxiety may influence the effectiveness of
studies65,66 to the point that some usability experts describe VR differently. Tse et al.59 induced a controlled pain in 72
their work as ‘‘funology.’’67 Six out of the 11 studies in the participants using a tourniquet technique. They assessed
present review evaluated participants’ experience of fun, all anxiety with a single Likert scale (1–10 level of anxiety)
obtaining strong positive results. Hoffman and colleagues58,61 before the experiment and found that participants’ ratings
found that fun ratings positively correlated with presence were negatively correlated with their improvement in pain
ratings and pain reduction. Similarly, soldiers with high pain threshold during the VR stimulation. Participants with a
ratings also experienced more fun when exposed to VR.55 In lower level of anxiety had better improvement in pain re-
the experiments by Sharar et al.57 and Schmitt et al.,56 par- duction; therefore, it may be important to use proper in-
ticipants in the VR condition obtained significantly higher fun struments to evaluate dispositional anxiety in patients before
ratings compared with participants who participated in a non- VR interventions, such as STAI.74 In fact, Van Twillert
VR condition. Wender et al.60 compared interactive VR and et al.75 were the only researchers to measure trait and state
noninteractive VR in 21 healthy participants with experi- anxiety using the STAI questionnaire. Patients with burn
mentally induced pain and asked them to rate their fun during injuries (N = 19) were either not distracted or were exposed
PSYCHOLOGICAL FACTORS AND VR-BASED ANALGESIA 341

to different distraction methods, including VR (SnowWorld), sense of presence may not have a direct impact on pain
during their dressing change. A state anxiety reduction (2%) experience per se; however, presence could allow VR to be
was present in conditions with VR and television, but this distractive from a perceptual point of view. Some recent
reduction was not significant. accounts strongly link presence to attention,76 and measuring
presence informs experimenters whether their virtual repre-
Discussion sentation is perceived as an environment by users. It is a
place where they could have experiences, watching, hearing,
The findings of the reviewed literature indicate that psy-
and interacting with things. They could experience imagi-
chological factors influenced the effectiveness of VR-based
nary adventures in the VR environment and enact their in-
analgesia. These studies suggest that elements related to the
tentions through the mediation of connected peripherals.41 In
subjective experience of VR influence or are related to the
conclusion, VR is a very rich stimulus that is also able to
outcomes of interventions. In the few studies that did not find
distract people from their pain, but for VR to be effective,
significant differences for what regard the psychological
users must have the feel of being in it. For this reason, it
factors, such as Chan et al.62 with presence, the analgesic
is important to measure presence to monitor VR-based
effect is not significant too. The reviewed studies suggest that
interventions.
a high sense of presence is associated with desirable anal-
Ten of the 11 articles considered in this review measured
gesia effects. It is also important that participants have fun in
the sense of presence. Unfortunately, all but two studies53,62
the virtual experience, as pleasant virtual environments tend
used a single question, such as, ‘‘To what extent did you feel
to generate better distraction outcomes. Subjects who expe-
like you ‘went into’ the virtual world?’’ Chan et al.62 used the
rience less pain also report having more fun. The role of
Presence Questionnaire, while Gold and colleagues53 used a
anxiety must also be considered, as anxiety related to the
Child Presence Questionnaire whose reference is not pro-
intervention could be reduced by VR, and participants with
vided. Research and debate on the sense of presence suggests
low anxiety are more responsive to VR-based analgesia.
that a number of factors generate or influence presence (see39
Psychological factors, considered broadly, might interact
for a review), so some complex questionnaires are now
with VR-based analgesia in two ways. On the one hand, they
available to properly assess this construct. A single question
could directly modify the experienced pain, regardless of the
may not be a complete way to measure the sense of presence,
VR system (e.g., high anticipatory anxiety increases the
since the sensation of ‘‘being there’’ normally emerges from
amount of perceived pain). On the other hand, they could
several different elements of the experience. Reducing
influence the efficacy of the VR technology involved in the
presence to a unique question risks preventing the participant
process of pain management via distraction (e.g., high at-
from evaluating the complexity of his or her sensations. For
tention devoted to the VR increases its distractive proper-
example, the Presence Questionnaire by Witmer and Sing-
ties). Figure 2 shows a schema of how the psychological
er52 measures different dimensions such as involvement,
factors considered here impact the VR-based analgesia pro-
perceived control, naturalness/realness of the virtual repre-
cess. However, we think that the study of psychological
sentation, and interface quality. In contrast, the ITC-SOPI by
factors in VR-based analgesia is in its infancy and, to date, it
Lessiter and colleagues51 considers additional elements, such
has not been performed with validated and solid instruments.
as characteristics of the user (previous experience with
In the following sections, analyzing the psychological factors
technology and virtual devices) and possible negative effects
one by one, we provide some guidelines to develop and
that interfere with the sense of presence (symptoms related to
improve the study of VR-based analgesia in the future.
simulator sickness).
Another issue is that researchers often measured the sense
Presence
of presence as only a one-condition control variable. This is
Presence may be the most important psychological factor understandable because, in these cases, they compared VR
that is directly linked to the experience of VR. The results of with non-VR or with other distraction tools that do not
the reviewed studies showed that a high level of presence promote immersion. However, to really advance knowledge
appears to be associated with desirable analgesia effects. The about the effectiveness of VR-based analgesia, different

FIG. 2. The virtual reality–based analgesia process. The experience of pain by the individual is mediated by the virtual
environment. Sense of presence affects the effectiveness of the virtual environment as a distraction tool, while anxiety and
emotional responses affect directly the perceived pain.
342 TRIBERTI ET AL.

virtual environments have to be compared. Certainly, nu- sure the emotional response in its entirety, without forcing
merous experiments and reviews today offer support to the participants into in predesigned categories. Also, psycho-
efficacy of VR-based analgesia. However, guidelines about physiological measures could provide researchers with a
how exactly a virtual environment has to be conceived and more objective monitoring of emotions during the experi-
designed are generally missing from past research. Hoffman mental tasks. The use of similar instruments and the refer-
et al.61 compared high-tech VR with low-tech VR (i.e., dif- ence to dimensional models of emotions in future research on
ferently advanced machineries for VR), while Wender and VR-based analgesia could answer interesting research
colleagues60 compared interactive VR with noninteractive questions. How intense are emotions during treatment, and
VR. Other comparisons are necessary in order to identify the how could a high or low emotional intensity influence patient
best-performing type of technology to be used in pain outcomes? Are emotions with positive valence (fun) or
management. Is one type of device better than others? Does emotions with negative valence (anxiety) predominant dur-
narrative/cinematic VR provide more distraction than a ing pain management? Can these emotions coexist, and with
simple exploratory design? Are there differences in gender or what effects?
age regarding the response to different types of contents in
VR? In the context of similar research objectives focused on Conclusions
the different types of VR, measuring the sense of presence
with proper instruments could be a fundamental variable, The present review analyzed the impact of psychological
given its strong links with efficacy. factors on the effectiveness of VR-based interventions de-
signed to distract from pain. The necessity to consider the
phenomenon of pain as multifaceted is supported by the
Fun and anxiety neuromatrix hypothesis.12 According to this theoretical
We combine fun and anxiety here into a single section as framework, pain is an amalgam of affect, cognition, and
emotional responses. Both fun and anxiety were related to sensation mediated through widespread brain regions, and is
VR-based analgesia’s efficacy and the two responses were likely to be influenced by several factors. A review of the
always analyzed independently. The association between psychological factors involved in VR-based pain distraction
anxiety and pain is a well-known phenomenon in clinical reveals that psychological factors (specifically, presence,
settings. Scientific findings supported this common experi- fun, and anxiety) influence VR efficacy. However, this re-
ence: Some studies demonstrated that anxiety levels can view also reveals some gaps and limitation in the literature,
predict pain intensity.77,78 Furthermore, anxiety enhances the namely, that few studies in the extensive literature on the use
different components related to the experience of pain, in- of VR for pain management specifically considered these
cluding pain threshold, pain discrimination, and pain inten- psychological factors, and sometimes these factors were not
sity. A possible explanation for the effect of anxiety on pain analyzed as influencing the effectiveness of VR. Given the
has been proposed by Ploghaus and colleagues.79 The authors present findings, we made only the first steps to predict
conducted a functional magnetic resonance imaging experi- which psychological state should be promoted during virtual
ment in which they compared activation responses to noxious experience in order to achieve a greater reduction in pain.
thermal stimulation while perceived pain intensity was ma- Upon recognizing the importance of these psychological
nipulated by changes in either physical intensity or induced factors, it is now necessary to measure them with validated
anxiety. Imaging data pinpointed differential activity in the tools.
hippocampus in response to identical noxious stimuli de-
pending on the anxiety modulation. In other words, antici- Author Disclosure Statement
patory anxiety acts as a prime, recruiting the hippocampus to No competing financial interests exist.
amplify the aversive event and preparing the individual to
behave adaptively in case of the worst possible outcome. References
While sense of presence intervenes on the efficacy of VR as a
distraction tool, anxiety (and emotional responses in general) 1. Cioffi D. Beyond attentional strategies: cognitive-perceptual
can also directly operate on the experience of pain. model of somatic interpretation. Psychological Bulletin
Research on the influence of emotions on the experience 1991; 109:25–41.
of virtual environments (and vice versa) is broad80–82 (pro- 2. Shallice T, Burgess P. (1993) Supervisory control of action
vide some diverse examples), but recent approaches that and thought selection. In Berry D, ed. Attention, selection
analyze the entire emotional response, and not just a priori and performance: a tribute to Donald Broadbent. Oxford:
Oxford University Press, pp. 171–187.
emotional categories, have theoretical and methodological
3. Melzack R, Wall PD. Pain mechanisms: a new theory.
benefits.83 Specifically, dimensional conceptions of emo-
Science 1965; 150:971–979.
tions provide better recognition of ambiguous and complex 4. Melzack R. Gate control theory. On the evolution of pain
affects.84 Moreover, these models have been particularly concepts. Pain Forum 1996; 5:128–138.
useful for the research in applied cyberpsychology.85 Ac- 5. Li A, Montano Z, Chen VJ, Gold JI. Virtual reality and pain
cording to Russel’s model,86 an emotion is a modification of management: current trends and future directions. Pain
the ‘‘core affect,’’ a neurophysiological category corre- Management 2011; 1:147–157.
sponding to the combination of valence (positive/negative) 6. Katz J, Melzack R. Pain ‘‘memories’’ in phantom limbs:
and arousal (low/high intensity). Adaptive self-report meth- review and clinical observations. Pain 1990; 43:319–336.
ods such as the Self-Assessment Manikin,87 which provides 7. Melzack R. Phantom limbs, the self and the brain (the DO
participants with pictorial Likert scales to evaluate their own Hebb Memorial Lecture). Canadian Psychology/Psycholo-
experience on a variety of dimensions, are suitable to mea- gie Canadienne 1989; 30:1.
PSYCHOLOGICAL FACTORS AND VR-BASED ANALGESIA 343

8. Melzack R. From the gate to the neuromatrix. Pain 1999; 29. Shahrbanian S, Ma X, Korner-Bitensky N, Simmonds MJ.
Suppl 6:S121–S126. Scientific evidence for the effectiveness of virtual reality
9. Ploghaus A, Tracey I, Gati JS, et al. Dissociating pain from for pain reduction in adults with acute or chronic pain.
its anticipation in the human brain. Science 1999; 284: Studies in Health Technology and Informatics 2009;
1979–1981. 144:40–43.
10. Derbyshire SW. Exploring the pain ‘‘neuromatrix.’’ Cur- 30. Wismeijer AA, Vingerhoets AJ. The use of virtual reality
rent Review of Pain 2000; 4:467–477. and audiovisual eyeglass systems as adjunct analgesic
11. Moseley GL. A pain neuromatrix approach to patients with techniques: a review of the literature. Annals of Behavioral
chronic pain. Manual Therapy 2003; 8:130–140. Medicine 2005; 30:268–278.
12. Melzack R. Pain and the neuromatrix in the brain. Journal 31. Mahrer NE, Gold JI. The use of virtual reality for pain
of Dental Education 2001; 65:1378–1382. control: a review. Current Pain and Headache Reports
13. Melzack R. Evolution of the neuromatrix theory of pain. 2009; 13:100–109.
The Prithvi Raj Lecture: presented at the third World 32. Malloy KM, Milling LS. The effectiveness of virtual reality
Congress of World Institute of Pain, Barcelona, 2004. Pain distraction for pain reduction: a systematic review. Clinical
Practice 2005; 5:85–94. Psychology Review 2010; 30:1011–1018.
14. Iannetti GD, Mouraux A. From the neuromatrix to the pain 33. Gorini A, Capideville CS, De Leo G, et al. The role of
matrix (and back). Experimental Brain Research 2010; 205: immersion and narrative in mediated presence: the virtual
1–12. hospital experience. Cyberpsychology, Behavior and Social
15. Legrain V, Iannetti GD, Plaghki L, Mouraux A. The pain Networking 2011; 14:99–105.
matrix reloaded: a salience detection system for the body. 34. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA
Progress in Neurobiology 2011; 93:111–124. statement for reporting systematic reviews and meta-ana-
16. Flor H. Psychological pain interventions and neurophysi- lyses of studies that evaluate health care interventions:
ology: implications for a mechanism-based approach. explanation and elaboration. PLoS Med 2009; 6:e1000100.
American Psychologist 2014; 69:188–196. 35. Bohil CJ, Alicea B, Biocca FA. Virtual reality in neuro-
17. Jensen MP, Turk DC. Contributions of psychology to the science research and therapy. Nature Reviews Neuroscience
understanding and treatment of people with chronic pain: 2011; 12:752–762.
why it matters to ALL psychologists. American Psycholo- 36. Biocca F. (1997) The cyborg’s dilemma: embodiment in
gist 2014; 69:105–118. virtual environments. In Proceedings of the Second Inter-
18. Linton SJ, Shaw WS. Impact of psychological factors in the national Conference on Cognitive Technology: Humanizing
experience of pain. Physical Therapy 2011; 91:700–711. the Information Age. IEEE.
19. Craig A. A new view of pain as a homeostatic emotion. 37. Sanchez-Vives MV, Slater M. From presence to con-
Trends in Neurosciences 2003; 26:303–307. sciousness through virtual reality. Nature Reviews Neu-
20. Sullivan MJ, Stanish W, Waite H, et al. Catastrophizing, roscience 2005; 6:332–339.
pain, and disability in patients with soft-tissue injuries. Pain 38. Slater M, Wilbur S. A framework for immersive virtual
1998; 77:253–260. environments (FIVE): speculations on the role of presence
21. Lyons IM, Beilock SL. When math hurts: math anxiety in virtual environments. Presence: Teleoperators and Vir-
predicts pain network activation in anticipation of doing tual Environments 1997; 6:603–616.
math. PLoS One 2012; 7:e48076. 39. Coelho C, Tichon JG, Hine TJ, et al. (2006) Media
22. Eccleston C. Chronic pain and distraction: an experimental presence and inner presence: the sense of presence in
investigation into the role of sustained and shifting atten- virtual reality technologies. In Riva G, et al., eds. From
tion in the processing of chronic persistent pain. Behaviour communication to presence: cognition, emotions and
Research and Therapy 1995; 33:391–405. culture towards the ultimate communicative experience.
23. McCaul KD, Malott JM. Distraction and coping with pain. Festschrift in honor of Luigi Anoll. Amsterdam: IOS
Psychological Bulletin 1984; 95:516–533. Press, pp. 22–45.
24. Montgomery GH, DuHamel KN, Redd WH. A meta-anal- 40. Riva G. Is presence a technology issue? Some insights from
ysis of hypnotically induced analgesia: how effective is cognitive sciences. Virtual Reality 2009; 13:159–169.
hypnosis? International Journal of Clinical and Experi- 41. Riva G, Waterworth JA, Waterworth EL, Mantovani F.
mental Hypnosis 2000; 48:138–153. From intention to action: the role of presence. New Ideas in
25. Buhle JT, Stevens BL, Friedman JJ, Wager TD. Distraction Psychology 2011; 29:24–37.
and placebo: two separate routes to pain control. Psycho- 42. Slater M, Linakis V, Usoh M, Kooper R. (1996) Immer-
logical Science 2012; 23:246–253. sion, presence, and performance in virtual environments:
26. Valet M, Sprenger T, Boecker H, et al. Distraction modu- an experiment with tri-dimensional chess. In ACM virtual
lates connectivity of the cingulo-frontal cortex and the reality software and technology (VRST). Hong Kong,
midbrain during pain—an fMRI analysis. Pain 2004; 109: China: Citeseer.
399–408. 43. Baños RM, Botella C, Alcañiz M, et al. Immersion and
27. Verhoeven K, Van Damme S, Eccleston C, et al. Dis- emotion: their impact on the sense of presence. CyberP-
traction from pain and executive functioning: an experi- sychology & Behavior 2004; 7:734–741.
mental investigation of the role of inhibition, task switching 44. Bowman DA, McMahan RP. Virtual reality: how much
and working memory. European Journal of Pain 2011; 15: immersion is enough? Computer 2007; 40:36–43.
866–873. 45. Rigby S, Ryan R. (2011) Glued to games: how video
28. Cohen LL, Blount RL, Cohen RJ, et al. Comparative study games draw us in and hold us spellbound. New York:
of distraction versus topical anesthesia for pediatric pain ABC-CLIO.
management during immunizations. Health Psychology 46. Juan MC, Baños R, Botella C, et al. An augmented reality
1999; 18:591–598. system for the treatment of acrophobia: the sense of pres-
344 TRIBERTI ET AL.

ence using immersive photography. Presence: Tele- 64. Bouchard Sp, St-Jacques J, Robillard Gv, Renaud P. An-
operators and Virtual Environments 2006; 15:393–402. xiety increases the feeling of presence in virtual reality.
47. Insko BE. (2003) Measuring presence: subjective, behav- Presence: Teleoperators and Virtual Environments 2008;
ioral and physiological methods. In Riva G, Davide F, 17:376–391.
IJsselsteijn WA, eds. Being there: concepts, effects and 65. MacFarlane S, Sim G, Horton M. (2005) Assessing us-
measurements of user presence in synthetic environments. ability and fun in educational software. In The 2005 Con-
Amsterdam: Ios Press, pp. 109–119. ference on Interaction Design and Children. New York:
48. Meehan M, Razzaque S, Insko B, et al. Review of four ACM.
studies on the use of physiological reaction as a measure of 66. Shneiderman B. Designing for fun: how can we design user
presence in stressfulvirtual environments. Applied Psy- interfaces to be more fun? Interactions 2004; 11:48–50.
chophysiology and Biofeedback 2005; 30:239–258. 67. Carroll JM. Beyond fun. Interactions 2004; 11:38–40.
49. Slater M, Brogni A, Steed A. (2003) Physiological re- 68. Jacobsen PB, Bovbjerg DH, Redd WH. Anticipatory anx-
sponses to breaks in presence: a pilot study. In Presence iety in women receiving chemotherapy for breast cancer.
2003: The 6th Annual International Workshop on Presence. Health Psychology 1993; 12:469–475.
Citeseer. 69. Lim CC, Devi MK, Ang E. Anxiety in women with breast
50. Garau M, Friedman D, Widenfeld HR, et al. Temporal and cancer undergoing treatment: a systematic review. Inter-
spatial variations in presence: qualitative analysis of inter- national Journal of Evidence-Based Healthcare 2011;
views from an experiment on breaks in presence. Presence: 9:215–235.
Teleoperators and Virtual Environments 2008; 17:293–309. 70. Morris LD, Louw QA, Grimmer-Somers K. The effec-
51. Lessiter J, Freeman J, Keogh E, Davidoff J. A cross-media tiveness of virtual reality on reducing pain and anxiety in
presence questionnaire: the ITC-sense of presence inven- burn injury patients: a systematic review. The Clinical
tory. Presence: Teleoperators and Virtual Environments Journal of Pain 2009; 25:815–826.
2001; 10:282–297. 71. Choinière M, Melzack R, Girard N, et al. Comparisons
52. Witmer BG, Singer MJ. Measuring presence in virtual between patients’ and nurses’ assessment of pain and
environments: A presence questionnaire. Presence: Tele- medication efficacy in severe burn injuries. Pain 1990;
operators and Virtual Environments 1998; 7:225–240. 40:143–152.
53. Gold JI, Kim SH, Kant AJ, et al. Effectiveness of virtual 72. Van der Does AJ, Willem A. Patients’ and nurses’ ratings
reality for pediatric pain distraction during i.v. placement. of pain and anxiety during burn wound care. Pain 1989;
Cyberpsychology and Behavior 2006; 9:207–212. 39:95–101.
54. Gutierrez-Martinez O, Gutierrez-Maldonado J, Cabas- 73. Silverman WK, Fleisig W, Rabian B, Peterson RA.
Hoyos K, Loreto D. The illusion of presence influences VR Childhood anxiety sensitivity index. Journal of Clinical
distraction: effects on cold-pressor pain. Studies in Health Child and Adolescent Psychology 1991; 20:162–168.
Technology and Informatics 2010; 154:155–159. 74. Spielberger C, Gorsuch RL, Lushene PR, et al. (1983)
55. Maani CV, Hoffman HG, Morrow M, et al. Virtual reality Manual for the State-Trait Anxiety Inventory STAI (Form
pain control during burn wound debridement of combat- Y). Palo Alto, CA: Consulting Psychologists Press.
related burn injuries using robot-like arm mounted VR 75. van Twillert B, Bremer M, Faber AW. Computer-generated
goggles. Journal of Trauma 2011; 71:S125–S130. virtual reality to control pain and anxiety in pediatric and
56. Schmitt YS, Hoffman HG, Blough DK, et al. A random- adult burn patients during wound dressing changes. Journal
ized, controlled trial of immersive virtual reality analgesia, of Burn Care & Research 2007; 28:694–702.
during physical therapy for pediatric burns. Burns 2011; 76. Nordahl R, Korsgaard D. Distraction as a measure of
37:61–68. presence: using visual and tactile adjustable distraction
57. Sharar SR, Carrougher GJ, Nakamura D, et al. Factors as a measure to determine immersive presence of con-
influencing the efficacy of virtual reality distraction anal- tent in mediated environments. Virtual Reality 2010;
gesia during postburn physical therapy: preliminary results 14:27–42.
from 3 ongoing studies. Archives of Physical Medicine and 77. Kain ZN, Sevarino F, Alexander GM, et al. Preoperative
Rehabilitation 2007; 88:S43–S49. anxiety and postoperative pain in women undergoing hys-
58. Hoffman HG, Patterson DR, Seibel E, et al. Virtual reality terectomy. A repeated-measures design. Journal of Psy-
pain control during burn wound debridement in the hy- chosomatic Research 2000; 49:417–422.
drotank. Clinical Journal of Pain 2008; 24:299–304. 78. van den Hout JH, Vlaeyen JW, Houben RM, et al. The
59. Tse MM, Ng JK, Chung JW, Wong TK. The effect of visual effects of failure feedback and pain-related fear on pain
stimulation via the eyeglass display and the perception of report, pain tolerance, and pain avoidance in chronic low
pain. Cyberpsychology & Behavior 2002; 5:65–75. back pain patients. Pain 2001; 92:247–257.
60. Wender R, Hoffman HG, Hunner HH, et al. Interactivity 79. Ploghaus A, Narain C, Beckmann CF, et al. Exacerbation
influences the magnitude of virtual reality analgesia. Jour- of pain by anxiety is associated with activity in a hippo-
nal of CyberTherapy and Rehabilitation 2009; 2:27–33. campal network. Journal of Neuroscience 2001; 21:9896–
61. Hoffman HG, Sharar SR, Coda B, et al. Manipulating 9903.
presence influences the magnitude of virtual reality anal- 80. Han K, Ku J, Kim K, et al. Virtual reality prototype for
gesia. Pain 2004; 111:162–168. measurement of expression characteristics in emotional
62. Chan EA, Chung JW, Wong TK, et al. Application of a situations. Computers in Biology and Medicine 2009;
virtual reality prototype for pain relief of pediatric burn in 39:173–179.
Taiwan. Journal of Clinical Nursing 2007; 16:786–793. 81. Macedonio MF, Parsons TD, Digiuseppe RA, et al. Im-
63. Riva G, Mantovani F, Capideville CS, et al. Affective in- mersiveness and physiological arousal within panoramic
teractions using virtual reality: the link between presence and video-based virtual reality. CyberPsychology & Behavior
emotions. CyberPsychology & Behavior 2007; 10:45–56. 2007; 10:508–515.
PSYCHOLOGICAL FACTORS AND VR-BASED ANALGESIA 345

82. Miyahira SD, Folen RA, Stetz M, et al. Use of immersive 87. Bradley MM, Lang PJ. Measuring emotion: the self-
virtual reality for treating anger. Studies in Health Tech- assessment manikin and the semantic differential. Journal
nology and Informatics 2010; 154:82–86. of Behavior Therapy and Experimental Psychiatry 1994;
83. Barrett LF. Discrete emotions or dimensions? The role of 25:49–59.
valence focus and arousal focus. Cognition & Emotion
1998; 12:579–599.
84. Eerola T, Vuoskoski JK. A comparison of the discrete and Address correspondence to:
dimensional models of emotion in music. Psychology of Stefano Triberti
Music 2011; 39:18–49. Psychology Department
85. Riva G, Baños RM, Botella C, et al. Positive technology: Università Cattolica del Sacro Cuore
using interactive technologies to promote positive func- Largo Gemelli 1
tioning. Cyberpsychology, Behavior, and Social Network- 20123 Milan
ing 2012; 15:69–77. Italy
86. Russell JA. Core affect and the psychological construction
of emotion. Psychological Review 2003; 110:145–172. E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0207

Virtual Reality as a Distraction Technique

in Chronic Pain Patients

Brenda K. Wiederhold, PhD, MBA, BCB, BCN,1 Kenneth Gao, BS,2

Camelia Sulea, MD,1 and Mark D. Wiederhold, MD, PhD, FACP 2

Abstract

We explored the use of virtual reality distraction techniques for use as adjunctive therapy to treat chronic pain.
Virtual environments were specifically created to provide pleasant and engaging experiences where patients
navigated on their own through rich and varied simulated worlds. Real-time physiological monitoring was used
as a guide to determine the effectiveness and sustainability of this intervention. Human factors studies showed
that virtual navigation is a safe and effective method for use with chronic pain patients. Chronic pain patients
demonstrated significant relief in subjective ratings of pain that corresponded to objective measurements in
peripheral, noninvasive physiological measures.

Introduction Examples of these techniques include deep breathing,

viewing videotapes, listening to music, and playing video
games.4–6 The success of these psychologically based tech-
P ain medications are the third most written pre-
scription today, and few prescription pain drugs achieve
acceptable pain relief in more than 50% of treated patients.
niques has led to the innovative use of VR as a distraction
technique (see Table 1).
Many people deal with physical pain in their daily lives, and A study conducted by Sarig et al. explored the use of VR
the pain can range from mild to excruciating. The most in managing chronic neck disability and pain. Twenty-five
common causes of pain include chronic illness, accidents, symptomatic and 42 asymptomatic individuals reported pain
surgery, advanced cancer, lower back problems, arthritis, using conventional pain ratings as their cervical range of
shingles, headaches, and fibromyalgia. Additionally, many of motion was measured. The goal of the study was to deter-
these patients have problems obtaining adequate medication mine if range of motion correlates with pain management.
to control their pain.1 One way to help is by using virtual Results indicated significant limitations in range of motion
reality (VR) to draw attention away from the patients’ mental measurements, as they showed sensitivity but lacked speci-
processing, thereby decreasing the amount of pain con- ficity.22 In 2013, Sarig et al. conducted a similar study to
sciously experienced by the patient. explore the issue further. Out of 25 patients, a comparison of
VR has also been found to be effective in reducing re- self-reported outcomes and cervical range of motion showed
ported pain and distress in patients undergoing burn wound correlations of 0.4–0.6 between the two measurements. This
care, chemotherapy, dental procedures, venipuncture, and objective quotient indicates that subjective pain ratings can
prolonged hospital visits.2–16 It appears that VR may change be supplemented with range of motion measurements and
how the brain physically registers pain, not just the percep- fear of motion reports to measure pain for physical rehabil-
tion of pain stimuli.2 An interesting study showed that 86% itation studies. Moreover, VR was seen to not only reduce
of patients undergoing wound care from a burn injury re- pain but objectively increase function.16
ported severe to excruciating pain even with therapeutic A pilot study of VR to treat fibromyalgia in 2013 studied
levels of opioids.3 The challenges of treating severe pain the long-term effects of VR therapy. The six women in the
confront clinicians daily. The search for adjunctive tech- study who had undergone 10 sessions of therapy supported
niques has led to a number of studies where pharmacological by adaptive virtual environments (VEs) were assessed at
agents are combined with behavioral modification ap- pretreatment, post-treatment, and at 6 months follow-up.
proaches. More recently, distraction techniques have been Results show that both depression rates were significantly
used as an adjunct during unpleasant medical procedures. reduced and coping strategies reflected positive growth.19

1
Virtual Reality Medical Institute, Brussels, Belgium.
2
Virtual Reality Medical Center, San Diego, California.

346
VR AS A DISTRACTION FOR CHRONIC PAIN 347

Another fibromyalgia study considered the use of noninva-

sive mirror visual feedback using VR to treat chronic pain of
one fibromyalgia patient using ketamine as a pain reliever.
On a 15 trial experiment, patient pain was shown to have
decreased significantly, indicating the supplementary nature
of VR with other medications.20
In 2010, Patterson et al. combined VR with hypnosis. The
randomized, controlled study of 21 trauma patients com-
pared subjective pain ratings of patients that were induced
under VRH (virtual reality hypnosis) and standard VR. Po-
sitive results of VRH therapy indicate a synergistic and ad-
ditive effect of the analgesic efficacy of hypnosis and VR FIG. 2. The scales of sense of being in the VR—how real
distraction techniques.23 was VR versus the simulated environment, similarities be-
Other chronic conditions have been studied using VR as tween the simulated environment and the actual places pa-
an adjunctive treatment. The first dermatological study of tients visited, how focused on the tasks patients were during
pruritus was conducted in 2009. Exposure to a computer- the simulated environment, on a scale from 1 to 7, where 7
simulated game seemed to reduce the subjective pruritus represents the normal experience of being in a place. 1 = ‘‘not
intensity significantly among the 24 patients. Although pain at all,’’ 7 = ‘‘very much.’’ VR was immersive and real.
and itching are activated under different internal brain
mechanisms, a comparison of the commonalities of pain
receptors, activations, and neural pathways can lead to in- branches for example moved six to eight times per minute to
sights on how to use these tools for the treatment of a variety guide breathing regulation.
of conditions such as chronic itching and chronic pain.24 Self-report questionnaires were completed by participants
and scored on a scale of 1 to 7, where 1 = ‘‘no effect’’ and
Methods 7 = ‘‘highly effective.’’ Overall the pain distraction VE was
found easy to use, had good stereo sound effects, and was
Participating in this study to investigate the efficacy of an immersive and interactive (see Figs. 1–3).
interactive VE were 40 patients aged 22–68 years with av- Controls reported good levels of presence and immersion
erage daily pain for at least 3 months and a daily average pain when using the environments. The system was easy to use
intensity score of q4 (0 = no pain, 10 = worst possible pain). and understand. Evaluation of post-experience question-
naires showed that the sense of being in the VEs was high.
Results This sense of being in VR correlated well with levels of
Before we tested the pain distraction system on patients, immersion and interactivity on the presence questionnaires.
we wanted to validate usability and safety in controls. To Because we were concerned with potential adverse effects in
determine the human factors related to the use of our pain patients using the VR system, we administered the Simulator
distraction system, we conducted an initial study with 15 Sickness Questionnaire. This questionnaire showed very low
controls. The subjects were enrolled as per the approved IRB levels of fatigue, headache, eyestrain, and nausea when using
protocol and signed the consent form. All participants went the VR system. These low numbers indicate the VR system is
through a 15 minute VR exposure session while wearing a both safe and effective.
HMD. The VEs consisted of pleasant and relaxing scenes,
including natural areas such as forests, beaches, and moun-
tains. Relaxing music and soothing effects such as the
branches swaying and tall grass moving were added. Tree

FIG. 1. The scales of sense of being in the virtual reality FIG. 3. Sickness exploration questionnaire scores in terms
(VR) simulated environment—Ease of use, Immersive, and of general discomfort, fatigue, headache, eyestrain, and
Interactive effects on a scale from 1 to 7, where 7 represents nausea, their mean scales are all <1.5, where the scales
the normal experience of being in a place. 1 = ‘‘not at all,’’ range from 0 to 3. 0 = ‘‘Absent,’’ 3 = ‘‘Severe.’’ No serious
7 = ‘‘very much.’’ VR environment was easy to use, inter- side effects were observed. It was determined that VR was
active, immersive, and real. indeed safe to use with this population.
348 WIEDERHOLD ET AL.

FIG. 6. Comparison of reported pain intensity.

VR is an effective method of reducing pain and anxiety (see

FIG. 4. Comparison of subjective pain ratings.
Figs. 4 and 5).
As in the previous study, we compared a pain focus
condition to a VE exploration condition in 34 additional
In our first pilot study, six chronic pain patients, ranging in chronic pain patients. Data on heart rate and skin temper-
age from 22 to 68 years, tested the VE with a head-mounted ature were collected, as well as pain intensity ratings ob-
display and physiological sensors. All six participants re- tained from self-report questionnaires. All patients reported
ported a drop in pain while in the VE, and the magnitude of a decrease in pain while in the VE, with significance
pain reduction from the VR compared to the pain focus ranging from p < 0.05 to p < 0.001, depending upon which
condition was large (75.8%) and significant. A nonpara- of the three pain rating scales were used (see Fig. 6). The
metric Wilcoxon signed rank test indicated that the mean significant decrease in heart rate ( p < 0.05) while the pa-
pain rating during the VR condition was significantly lower tients were in the VE indicates a reduced level of pain and
than the session with no distraction (n = 6; p = 0.028). Each of anxiety, and suggests that VR is an effective method of
the six participants exhibited higher mean skin temperature reducing this distress (see Fig. 7).
when engaged in the VE than when in the pain focus con-
dition. A paired t test also indicated that the overall mean Discussion
temperature was significantly higher when participants were
using VR (df = 5; p = 0.004). A higher average temperature in Overall, the results of this study show VR is effective at
VR suggests a reduced level of discomfort and anxiety, reducing pain. Within the subjective outcomes, patients re-
substantiates the self-reported pain ratings, and suggests that ported significantly lower pain ratings while exploring the
VE than during the pain focus session. Several patients re-
ported encouraging feedback as well, such as ‘‘this is the first
pain relief I have had in 3 years,’’ ‘‘I was so busy playing the

FIG. 5. Comparison of objective pain ratings. FIG. 7. Comparison of heart rate.

 Table 1. Current Research of Virtual Reality (VR) Treatment of Chronic Pain
Title Method Result
Do Neck Kinematics Correlate Twenty-five patients (19 females, 6 males; mean age Results showed significant correlations of approximately
with Pain Intensity, Neck 39 – 12.7 years) with chronic neck pain participated 0.4–0.6 between ROM and fear of motion, pain intensity,
Disability or with Fear of Motion?16 in this cross-sectional study. A customized VR system and disability. All 12 kinematic measures were correlated
was employed to evaluate cervical range of motion (ROM) with fear of motion, but only a few were correlated with
and kinematics, using an interactive game controlled by pain intensity, and with disability. The results emphasize fear
cervical motion via electromagnetic tracking. Self-reported of motion as a subjective measure primarily correlated with
outcome measures included pain intensity (visual analog neck kinematics, including range, velocity, and smoothness
scale), disability (Neck Disability Index), and fear of motion of cervical motion. The level of neck disability was found to
(TAMPA scale of kinesiophobia). Kinematic measures be partly related to ROM or to other kinematic impairments.
included cervical ROM, mean and peak velocity, and number However, ROM by itself remains a valid measure related to
of velocity peaks (NVP) reflecting smoothness of motion. pain intensity and to fear of motion in patients with chronic
neck pain. All correlations demonstrated were moderate,
indicating that these measures involve other factors in
need of further research.
A Virtual Reality System Ten children attending an outpatient pediatric neurology clinic Nine patients completed the 10-session intervention. Ratings
Combined with Biofeedback were treated by the proposed system. Participants practiced of pain, daily functioning, and quality of life improved
for Treating Pediatric Chronic relaxation with biofeedback and learned to associate significantly at 1 and at 3 months post-treatment. Most
Headache—A Pilot Study17 successful relaxation with positive pain-free virtual patients reported applying their newly acquired relaxation
images of themselves. and imagery skills to relieve headache outside the lab.
Virtual Visual Effect of Hospital Sixteen CM and 16 controls underwent 62 channels LEPs CM patients showed a reduction of laser pain rating and vertex
Waiting Room on Pain from the right hand, during a fully immersive VR experience, LEPs during the IH vision. The sLORETA analysis

349
Modulation in Healthy where two types of waiting rooms were simulated. The RH confirmed that in CM patients the two VR simulations
Subjects and Patients with simulated a classical hospital waiting room while the IH induced a different modulation of bilateral parietal cortical
Chronic Migraine18 represented a room with sea viewing. areas (precuneus and superior parietal lobe), and superior
frontal and cingulate girus, in respect to controls.
Virtual Reality in the Treatment The sample comprised six women diagnosed with fibromyalgia The results showed the long-term benefits of significantly
of Fibromyalgia: A Pilot Study19 (FM) according to the American College of Rheumatology reduced pain and depression and an increased positive affect
guidelines (1990). The treatment program consisted of and use of healthy coping strategies.
10 sessions of group CBT with the support of an adaptive
virtual environment (VE) containing a specific content for
developing relaxation and mindfulness skills. Patients were
assessed at pretreatment, post-treatment, and at a 6 months
follow-up for the following outcome variables: functional
status related to pain, depression, a negative and positive
affect, and coping skills.
Using Mirror Visual Feedback We have previously used noninvasive mirror visual feedback On 15 trials, the patient’s lower limb pain rating (on a scale
and Virtual Reality to to treat subjects with chronic pain from phantom limbs and from 1 to 10) decreased significantly. These preliminary
Treat Fibromyalgia20 suggested its use for complex regional pain syndrome: once results suggest that noninvasive dissociative anesthetics such
considered intractable pain. We wondered whether such as VR goggles, ketamine, and mirror visual feedback could
methods would work to alleviate the chronic pain of FM. be used to alleviate chronic pain from FM.
We tested mirror visual feedback on one FM patient.

(continued)
 Table 1. (Continued)
Title Method Result
Nonimmersive Virtual Reality A small open-label case series. Five patients with complex Four of the five patients showed >50% reduction in pain
Mirror Visual Feedback Therapy and regional pain syndrome received VR mirror visual intensity. Two of these patients ended their visits to our
Its Application for the Treatment of feedback therapy once a week for five to eight sessions pain clinic after five sessions.
Complex Regional Pain Syndrome: on an outpatient basis. Patients were monitored for
An Open-Label Pilot Study21 continued medication use and pain intensity.
Neck Pain Assessment in a Cervical range of motion (CROM) measures were collected Results obtained by both methods demonstrated significant
Virtual Environment22 from 25 symptomatic and 42 asymptomatic individuals using CROM limitations in the symptomatic group. The VR
VR and conventional assessments. Analysis of variance measures showed greater CROM and sensitivity while
was used to determine differences between groups and conventional measures showed greater specificity. A single
assessment methods. Logistic regression analysis, using session exposure to VR resulted in a significant increase
a single predictor, compared the diagnostic ability in CROM.
of both methods.
Virtual Reality Hypnosis for The authors report a randomized, controlled study of 21 VRH patients reported less pain intensity and less pain
Pain Associated with Recovery hospitalized trauma patients to assess the analgesic efficacy unpleasantness compared to control groups.
from Physical Trauma23 of virtual reality hypnosis (VRH)-hypnotic induction
and analgesic suggestion delivered by customized VR
hardware/software. Subjective pain ratings were obtained

350
immediately and 8 hours after VRH (used as an adjunct
to standard analgesic care) and compared to both
adjunctive VR without hypnosis and standard care alone.
Effects of Virtual Reality Twenty-four patients suffering from chronic pruritus—16 Student’s t tests were significant for reduction of pruritus
Immersion and Audiovisual due to atopic dermatitis and eight due to psoriasis vulgaris— intensity before and during VRI and AVD ( p = 0.0002
Distraction Techniques for were randomly assigned to play an interactive computer and p = 0.01 respectively), and were significant only between
Patients with Pruritus24 game using a special visor or a computer screen. Pruritus ratings before and after VRI ( p = 0.017). Scratching was
intensity was self-rated before, during, and 10 minutes after mostly absent or mild during both programs.
exposure using a visual analog scale ranging from 0 to 10.
The interviewer rated observed scratching on a three-point
scale during each distraction program.
Exploratory Findings with A sample of subjects with ‘‘arm’’ (n = 7) and ‘‘leg’’ (n = 7) Five subjects in each group felt the virtual limb to be moved
Virtual Reality for Phantom amputations underwent trials of a VR system, controlled by them and felt sensations of movement within it. With this,
Limb Pain: From Stump Motion by motion captured from their stump, which was translated they also reported reductions in their phantom limb pain
to Agency and Analgesia25 into movements of a virtual limb within the VR environment. greater than expected from distraction alone. No carry
Measures of pain in the phantom limb were elicited from over effect was seen.
patients before and during this exercise as they attempted
to gain agency for the movement they saw, and feel
embodied within the limb. After this, each subject was
interviewed about their experiences.
VR AS A DISTRACTION FOR CHRONIC PAIN 351

game, I forgot about my pain,’’ and ‘‘even though the pro- 9. Wiederhold BK, Wiederhold MD. Managing pain in mili-
cedure was finished, I wanted to keep playing.’’ This shows tary populations with virtual reality. NATO Science for
that this technology is significant not only in reducing pain but Peace & Security Series—E: Human & Societal Dynamics
also in eliminating the interruptive nature of chronic pain. 2012; 91:75–93.
Moreover, objective measures further supported the re- 10. Mosso JL, Rizzo S, Wiederhold B, et al. Cybertherapy—
duction of pain with use of the VR system. Skin temperature new applications for discomfort reductions. Surgical care
was significantly higher and heart rate was lower during the unit of heart, neonatology care unit, transplant kidney care
VR session, which indicates greater relaxation. unit, delivery room-cesarean surgery and ambulatory sur-
In virtual technologies, a necessary factor to consider is the gery, 27 case reports. Studies in Health Information & In-
formatics 2007; 125:334–336.
presence felt by the user. In a study conducted by Hoffman
11. Hoffman HG, Doctor JN, Patterson DR, et al. (2000) Vir-
et al., the distractive properties of a virtual program were
tual reality as an adjunctive pain control during burn wound
greatly enhanced with higher immersion and presence of the care in adolescent patients. Pain 85: 305–309.
VE used to reduce pain and anxiety of burn patients.26 Si- 12. Hoffman HG, Garcia-Palacios A, Patterson DR, et al. The
milarly, a comprehensive review of immersiveness on phys- effectiveness of virtual reality for dental pain control: a
iology reported that greater immersion has relaxing effects on case study. CyberPsychology & Behavior 2001; 4:527–535.
physiological factors such as heart rate, respiration rate, skin 13. Hoffman HG, Patterson DR, Carrougher GJ, et al. Effec-
temperature, and skin resistance.27 Due to the high presence tiveness of virtual reality-based pain control with multiple
and realism scores of the self-report surveys, the virtual treatments. The Clinical Journal of Pain 2001; 17:229–235.
program used in this study can be considered as effective in 14. Hoffman HG, Coda BA, Sharar SR, et al. (2003). Virtual
engaging patients, and thus distracting from pain. reality analgesia during thermal and electrical pain for
Additional studies can further determine the correlation longer durations, and multiple treatments. CyberTherapy.
between presence and pain management, as well as the as- San Diego, CA: Interactive Media Institute.
sociation of pain distracting qualities of VR and various 15. Tse MMY, Ng JKF, Chung JWY. (2003) Visual stimulation
types of pain. as pain relief for Hong Kong Chinese patients with leg
ulcers. CyberTherapy. San Diego, CA: Interactive Media
Acknowledgments Institute.
16. Sarig Bahat H, Wiess PL, Sprecher E, et al. Do neck ki-
We thank the National Institute on Drug Abuse, National nematics correlate with pain intensity, neck disability or
Institutes of Health for partial funding of this project. We with fear of motion? Manual Therapy 2013 Nov 9; doi:
also thank the participants who were willing to spend time 10.1016/j.math.2013.10.006. [Epub ahead of print].
with our clinical team. 17. Shiri S, Feintuch U, Weiss N, Pustilnik A, Geffen T, Kay B,
Meiner Z, Berger I. A virtual reality system combined with
Author Disclosure Statement biofeedback for treating pediatric chronic headache—a
pilot study. Pain Medicine 2013; 14:621–627.
No competing financial interests exist. 18. De Tommaso M, Ricci K, Laneve L, et al. Virtual visual
effect of hospital waiting room on pain modulation in
References healthy subjects and patients with chronic migraine. Pain
1. Brody JE. (2006) Let’s get serious about relieving chronic Research & Treatment 2013;515730.
pain. The New York Times, Jan. 6, 2006. www.nytimes 19. Botella C, Garcia-Palacios A, Vizcaino Y, et al. Virtual
.com/2006/01/10/health/10brod.html?pagewanted = all&_ reality in the treatment of fibromyalgia: a pilot study.
r = 0. (accessed Mar. 23, 2014). Cyberpsychology, Behavior, & Social Networking 2013;
2. Hoffman HG. (2004) Virtual-reality therapy. Scientific 16:215–223.
American. www.hitl.washington.edu/projects/vrpain/index_ 20. Ramachandran VS, Seckel EL. Using mirror visual feed-
files/SCIAMFin.pdf (accessed Mar. 22, 2014). back and virtual reality to treat fibromyalgia. Medical
3. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual Hypotheses 2013; 75:495–496.
reality for adjunctive treatment of adult burn pain during 21. Sato K, Fukumori S, Matsusaki T, et al. Nonimmersive
physical therapy. Clinical Journal of Pain 2000; 17:229–235. virtual reality mirror visual feedback therapy and its appli-
4. Schneider SM, Workman ML. Effects of virtual reality on cation for the treatment of complex regional pain syndrome:
symptom distress in children receiving chemotherapy. an open-label pilot study. Pain Medicine 2010; 11:622–629.
CyberPsychology & Behavior 1999; 2:125–134. 22. Sarig-Bahat H, Weiss PL, Laufer Y. Neck pain assessment
5. Schneider SM. (2003) Virtual reality for the treatment of in a virtual environment. Spine 2010; 35:E105–112.
breast cancer. CyberTherapy. San Diego, CA: Interactive 23. Patterson DR, Jensen MP, Wiechman SA, et al. Virtual
Media Institute. reality hypnosis for pain associated with recovery from
6. Schneider SM, Ellis M, Coombs WT, et al. Virtual reality physical trauma. The International Journal of Clinical &
intervention for older women with breast cancer. Cyber- Experimental Hypnosis 2010; 58:288–300.
Psychology & Behavior 2003; 6:301–307. 24. Leibovici V, Magora F, Cohen S, Ingber A. Effects of
7. Vazquez JLM, Santander A, Gao K, et al. Using cyber- virtual reality immersion and audiovisual distraction tech-
therapy to reduce postoperative anxiety in cardiac recovery niques for patients with pruritus. Pain Research & Man-
intensive care units. Journal of Anesthesia & Clinical Re- agement 2009; 14:283–286.
search 2013; 4:363. 25. Cole J, Crowle S, Austwick G, et al. Exploratory findings
8. Mühlberger A, Wieser MJ, Kenntner-Mabiala R, et al. Pain with virtual reality for phantom limb pain; from stump
modulation during drives through cold and hot virtual envi- motion to agency and analgesia. Disability & Rehabilita-
ronments. CyberPsychology & Behavior 2007; 10:516–522. tion 2009; 31:846–854.
352 WIEDERHOLD ET AL.

26. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual Address correspondence to:
reality for adjunctive treatment of adult burn pain during Prof. Brenda K. Wiederhold
physical therapy: a controlled study. Clinical Journal of Virtual Reality Medical Institute
Pain 2000; 16:244–250. 30 Clos Chapelle aux Champs, Box 1.3030
27. Wiederhold BK, Davis R, Wiederhold MD. The ef- 1200 Brussels
fects of immersiveness on physiology. Virtual Environ- Belgium
ments in Clinical Psychology & Neuroscience 1998; 58:
52–60. E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0057

Differential Effects of Two Virtual Reality Interventions:

Distraction Versus Pain Control

Desirée Loreto-Quijada, PhD,1 José Gutiérrez-Maldonado, PhD,1 Rubén Nieto, PhD,2

Olga Gutiérrez-Martı́nez, PhD,1 Marta Ferrer-Garcı́a, PhD,1 Carmina Saldaña, PhD,1
Adela Fusté-Escolano, PhD,1 and Liudmila Liutsko, PhD1

Abstract

There is evidence that virtual reality (VR) pain distraction is effective at improving pain-related outcomes.
However, more research is needed to investigate VR environments with other pain-related goals. The main aim of
this study was to compare the differential effects of two VR environments on a set of pain-related and cognitive
variables during a cold pressor experiment. One of these environments aimed to distract attention away from pain
(VRD), whereas the other was designed to enhance pain control (VRC). Participants were 77 psychology students,
who were randomly assigned to one of the following three conditions during the cold pressor experiment: (a)
VRD, (b) VRC, or (c) Non-VR (control condition). Data were collected regarding both pain-related variables
(intensity, tolerance, threshold, time perception, and pain sensitivity range) and cognitive variables (self-efficacy
and catastrophizing). Results showed that in comparison with the control condition, the VRC intervention sig-
nificantly increased pain tolerance, the pain sensitivity range, and the degree of time underestimation. It also
increased self-efficacy in tolerating pain and led to a reduction in reported helplessness. The VRD intervention
significantly increased the pain threshold and pain tolerance in comparison with the control condition, but it did
not affect any of the cognitive variables. Overall, the intervention designed to enhance control seems to have a
greater effect on the cognitive variables assessed. Although these results need to be replicated in further studies,
the findings suggest that the VRC intervention has considerable potential in terms of increasing self-efficacy and
modifying the negative thoughts that commonly accompany pain problems.

Introduction What is not completely clear is whether VR works solely by

drawing attention away from pain. For example, it has been

R esearch over the last decade has shown that virtual

reality (VR) is a useful tool for pain management. In
general terms, VR reduces pain levels, anxiety, unpleasant-
hypothesized that VR may also work by changing the way in
which people think and perceive reality.6 Being able to identify
mechanisms of action other than pain distraction, or designing
ness, and the need for analgesia, at the same time as in- interventions to act specifically on other mechanisms, could
creasing the pain threshold, pain tolerance, and procedural have enormous potential in terms of extending the application
cooperation. Moreover, people enjoy using VR and are keen of VR beyond the clinical setting of acute procedural pain
to use it again during other painful medical procedures.1–3 (where most applications have so far been applied7–9). Ap-
The effects of VR have been mainly explained in terms of plying the strategy of pain distraction in a situation of nonacute
pain distraction. Since attentional resources are limited, di- pain outside the clinic is difficult due to the amount of
verting attention away from pain by means of VR leaves equipment that is needed. However, if VR has other mecha-
fewer resources available for pain processing.1 This mech- nisms of action (such as changing the way in which people
anism is not new, as distraction is a traditional psychological think), the resulting effects could more easily be extrapolated
intervention for pain that has been shown to possess con- outside the healthcare setting, thereby raising the possibility of
siderable efficacy.4 However, VR distraction is thought to be developing useful strategies for persistent pain or long-term
more effective because it is immersive and engaging, inte- pain problems.
grating many sensory experiences and, therefore, demanding Some recent studies have used VR applications for pur-
a greater amount of attention.5 poses other than pain distraction. For example, Shiri et al.10

1
Department of Personality, Assessment, and Psychological Treatments, University of Barcelona, Spain.
2
PSiNET Research Group, Internet Interdisciplinary Institute, Universitat Oberta de Catalunya, Barcelona, Spain.

353
354 LORETO-QUIJADA ET AL.

designed a VR system that aimed to reinforce patients with Software. The VR environments were modeled and ani-
pain-free virtual images once they achieved an adequate state mated with 3D Studio Max 8. Adobe Photoshop 7 was used to
of relaxation (as measured by a biofeedback procedure). Re- create the different textures. Virtools 3.5 (Educational Ver-
sults showed that the VR system improved daily functioning sion) was used to program physical and visual effects, such
and quality of life and decreased pain ratings in a sample of that the participant could interact with the VR environment.
children with chronic headache. In another recent example,
Botella et al.11 combined cognitive behavioral therapy with a Measures
VR environment that sought to develop relaxation and mind-
fulness skills in fibromyalgia patients. Results showed a sig- There were five pain-related measures:
nificant reduction in pain and depression, as well as an increase
in positive affect and the use of healthy coping strategies. Pain threshold. Pain threshold was defined as the number
In order to explore whether VR might have a mechanism of seconds of immersion in the cold pressor tank until the
of action other than pain distraction, we developed and tested participant reported that the cold sensation first began to feel
a VR intervention whose aim was to increase pain control. painful.
The intervention involved presenting subjects with a figure
that represented pain and which could be converted into a Pain tolerance. Pain tolerance was defined as the total
figure representing no pain. It was hypothesized that con- number of seconds that each participant kept his/her hand
trolling the virtual figure could help people to increase their immersed in the cold water.
sense of pain control. The specific aim of the present study
was to test the effects of this intervention on a set of pain- Pain sensitivity range. Pain sensitivity range (PSR) was
related and cognitive variables, comparing the results with defined as the total number of seconds that passed between
those obtained when using an environment designed for pain the participant first reporting that the cold sensation had
distraction. begun to feel painful (pain threshold) and the point at which his/
her hand was withdrawn from the cold water (pain tolerance).
Method
Strongest pain intensity. The strongest pain intensity was
Participants assessed with a visual analog scale (VAS) that consisted of a
Participants were 77 psychology students at the University of line with two anchors: ‘‘no pain’’ and ‘‘the most intense pain.’’
Barcelona (70 female). They were aged between 20 and 56 years Immediately after withdrawal, participants were asked to rate
(M = 24.06; SD = 5.22), and received course credits for taking the strength of the most intense pain they had felt during the
part. They were all instructed to refrain from consuming alcohol procedure by making a vertical mark on the point of the line
or using other drugs on the day prior to the study. The exclusion that they considered representative of their pain. The distance
criteria were cardiovascular disease, hypertension, metabolic from the left anchor to the vertical mark served as the pain
dysfunctions, pregnancy, Raynaud’s disease, epilepsy, mental rating for the strongest pain intensity.
disorder, chronic pain conditions, diseases producing neuro-
pathic pain, or having taken pain/anti-inflammatory medication Estimation of time. Participants were asked to estimate
during the 4 hours prior to the study. how long they thought they had had their hand in the water
by the time of withdrawal. The difference between the esti-
mated and real time was calculated.
Apparatus and equipment Two cognitive measures were used:
Cold pressor apparatus. A plastic tank (34 cm · 34 cm ·
16 cm) filled with iced water maintained at 6C ( – 1C) was In vivo pain catastrophizing. This was assessed using the
used for the cold pressor procedure. To ensure that the water 13-item Pain Catastrophizing Scale (PCS14). Subjects are
temperature remained constant before each trial, a waterproof asked to reflect on past episodes of pain and to rate using a
thermometer was attached to the inside of the tank. However, 5-point scale the frequency of the catastrophic cognitions de-
the temperature could not be seen by the participant. The scribed in each item. Scores can be computed for three sub-
range of tolerance achieved with this water temperature was scales: helplessness, rumination, and magnification. Standard
between 1 3 minutes,12,13 thereby giving participants assigned PCS instructions and items were modified slightly in order to
to the VR conditions enough time to interact with the VR assess catastrophizing cognitions in relation to the cold water
environments. immersion (e.g., by asking subjects to consider statements such
Before each cold water immersion, an additional tank with as ‘‘There was nothing I could do to reduce the intensity of the
warm water (32C) was used for stabilization of hand tem- pain’’ or ‘‘I worried all the time about whether the pain would
perature. A digital thermometer to measure hand temperature end’’). This was done because laboratory-based studies have
and an atmospheric thermometer to measure room temperature highlighted the importance of specifying the context in which
were used. The room temperature was maintained at 22C. catastrophizing is assessed.15–17 Results in our sample showed
that the internal consistency was high for the in vivo PCS total
Hardware. The VR environments were displayed with score (a = 0.90).
two BARCO ID R600 projectors controlled by a computer.
They were projected onto a 2.43 meter · 1.82 meter screen Pain self-efficacy. Based on the work of Bandura et al.,18
with a resolution of 1024 · 768 pixels. The distance be- pain self-efficacy was assessed through two scales: (a) per-
tween the screen and the participant, who was provided with ceived self-efficacy for tolerating pain, and (b) perceived
StereoGraphics Corp. polarized 3D glasses, was 2 meters. self-efficacy for reducing pain intensity. The first of these
VR DISTRACTION VS. VR CONTROL 355

aspects was assessed by asking participants to estimate how ‘‘Surreal World’’ was used. This was developed on the basis
much time they thought they would be able to keep their hand of surreal art images that were intended to surprise users with
submerged in the cold water if they had to repeat the immer- unreal objects that challenge the laws of physics. To improve
sion. They have to give their answer according to a series of the sense of presence in the surreal world, participants were
time categories corresponding to increasing durations of im- able to generate simple interactions with the objects (e.g.,
mersion; the categories covered a total range from 0 seconds clicking on certain objects will cause them to change or
to 8 minutes, at 30 second intervals. The second aspect— behave in another way). Participants were asked to navigate
self-efficacy for reducing pain intensity—was measured using through the environment with one hand while immersing
a scale that described four severities of pain (ranging from dull their other hand in the cold pressor.
to excruciating). For each severity, participants were required
to rate their perceived ability to reduce pain using a 3-point VR control enhancement condition (VRC). For this con-
scale, ranging from 0 = ‘‘limited ability’’ to 2 = ‘‘good ability.’’ dition, we designed a stereoscopic VR figure as a represen-
A total score (ranging from 0 to 8) was then computed, with tation of pain. The figure, which appeared in the center of the
higher scores indicating greater perceived self-efficacy in re- screen against a black background, was an irregular sharp-
ducing pain. The internal consistency for this scale was ade- edged polygon that was modelled according to certain sen-
quate in the present sample (a = 0.78). sory descriptors (e.g., burning, cutting, sharp, stabbing, and
stinging) from the McGill Pain Questionnaire.19 The figure
Procedure was presented together with an unpleasant sound (a tone of
600 Hz at 80 dB). As was explained to participants, the initial
The study was approved by the ethics committee of the figure and the sound represented an unpleasant pain sensa-
University of Barcelona. A between-subjects experimental tion, but they could be gradually manipulated to achieve a
design was used. Subjects participated individually and were pleasant and calm state (analogous to a situation of no pain).
randomly assigned to one of the following experimental This pleasant state was represented by a spherical figure,
conditions: (a) Non-VR intervention (control condition), (b) with a certain resemblance to natural scenery, combined with
VR distraction intervention, or (c) VR control enhancement an audio track produced by a generative music engine, cre-
intervention. ating a complex series of quiet environmental sounds.
Common instructions were initially given to all partici- Participants were asked to try to ameliorate their pain
pants regarding the cold pressor experiment. The experi- sensation (caused by the cold pressor) by modifying the vir-
menter explained to participants that they had to immerse tual figure. To modify the initial stereoscopic figure, subjects
their nondominant hand in the cold water up to the wrist, simply had to click on the right button of the mouse. Three
palm-side down, and to leave their hand open (nonfisted). slider controls then appeared on the screen, and these enabled
Participants were instructed to say ‘‘It hurts now’’ when their participants to change the shape and color of the figure, as
hand began to feel uncomfortable or hurt, and ‘‘End’’ when well as the sound. They could also rotate the figure and move
they decided to withdraw their hand from the water. All it nearer or farther away by clicking and dragging the mouse.
participants were asked to repeat the instructions to confirm
that they had understood them.
Data analysis
Following these common instructions, participants as-
signed to the VR conditions (VR distraction and VR control All the analyses were conducted using SPSS v20. Descriptive
enhancement intervention) were provided with stereoscopic statistics were computed for the different pain-related measures
glasses and spent 2–3 minutes learning the possible inter- and the cognitive measures. Between-subjects univariate ana-
actions with the virtual environment. This was done using lyses of variance (ANOVA) were conducted to test the effects
their dominant hand to operate the mouse. Subsequently, and of the three different conditions (i.e., Non-VR, VRD, and VRC)
for all participants regardless of their experimental group, the on each of the pain-related and cognitive measures. Post hoc
lights in the room were turned off, with the experimenters comparisons were carried out to determine the specific differ-
remaining out of sight behind the participant in order to ences between conditions.
minimize any influence their presence might have on per-
formance. The cold pressor trial was then immediately Results
started. For safety reasons, the maximum permitted duration
of immersion was 5 minutes, although participants were Pain-related measures
unaware of this. At the end of the trial, participants were One-way between-subjects ANOVAs revealed significant
asked to rest their hand on a towel placed on the table. They differences between the three conditions for the following
were then immediately asked to complete the VAS, the in variables: pain threshold, F(2, 74) = 3.56, p < 0.05; pain toler-
vivo PCS, and the pain self-efficacy scales based solely on ance, F(2, 74) = 9.59, p < 0.0001; pain sensitivity range, F(2,
their experience during the cold pressor task. The specific 74) = 4.11, p < 0.05, and estimation of time, F(2, 74) = 3.17,
features of each condition were as follows. p < 0.05. There were no statistically significant differences in
relation to pain intensity, F(2, 74) = 0.88, p = 0.41.
Non-VR condition (Non-VR). Participants assigned to the Post hoc comparisons (see Table 1) for pain threshold
Non-VR condition were told that during the immersion, they showed that it was significantly higher in the VRD condition
had to look at a static blank screen in front of them. compared with the Non-VR condition. None of the other
comparisons showed significant differences in terms of pain
VR distraction condition (VRD). To divert the attention of threshold. As regards pain tolerance, this was significantly
participants in this condition, a virtual environment called lower in the Non-VR condition as compared with both the
356 LORETO-QUIJADA ET AL.

Table 1. Effects of Interventions on Pain-Related Measures

Non-VR VRD VRC Pairs comparisons [95% CI]
Pain threshold 19.97 (8.94) 70.10 (83.05) 62.12 (84.23) No-VR < VRD* [ - 97.83, - 2.43]
VRD > VRC [ - 37.77, 53.73]
VRC > No-VR ( - 5.54O89.85)
Pain tolerance 47.44 (20.76) 145.38 (101.81) 148.74 (114.13) No-VR < VRD** [ - 159.95, - 35.93]
VRD < VRC ( - 62.83O56.12)
VRC > No-VR **(39.29O163.30)
Pain sensitivity 27.46 (19.50) 75.28 (78.64) 86.61 (100.31) No-VR < VRD [ - 99.59, 3.97]
VRD < VRC [ - 61.00, 38.33]
VRC > No-VR* (7.36O110.93)
Pain intensity 99.08 (24.36) 95.57 (35.02) 113.25 (75.23) No-VR > VRD [ - 31.31, 38.34]
VRD < VRC [ - 38.34, 31.31]
VRC > No-VR ( - 20.65O49.00)
Time estimation -4.80 (24.01) -21.92 (110.53) -61.66 (72.70) No-VR > VRD [ - 39.42, 72.40]
VRD > VRC [ - 14.91, 95.66]
VRC < No-VR * ( - 112.78O - 0.95)
Data are mean (SD).
*p < 0.05; **p < 0.001.

VRD and VRC conditions, although there was no significant ducing pain, F(2, 74) = 0.63, p = 0.53; PCS total scores, F(2,
difference between the latter two conditions. The pain sensi- 74) = 1.25, p = 0.29; the Rumination subscale, F(2, 74) = 0.353,
tivity range was significantly broader in the VRC condition in p = 0.70; or the Magnification subscale, F(2, 74) = 0.20,
comparison with the Non-VR condition, but no significant p = 0.81.
differences were found for the other comparisons. Similarly, Post hoc comparisons revealed that self-efficacy for tol-
the underestimation of time was significantly greater in the erating pain was significantly higher and helplessness ratings
VRC condition as compared with the Non-VR condition, but significantly lower during the VRC condition, as compared
there were no significant differences for the other comparisons. with the Non-VR condition. No significant differences
emerged in any of the other comparisons (see Table 2).
Cognitive measures
Discussion
Statistically significant differences were observed in relation
to self-efficacy for tolerating pain, F(2, 74) = 3.15, p < 0.05, and The aim of the present study was to test whether two
on the Helplessness subscale of the PCS, F(2, 74) = 4.62, different VR interventions, designed for pain distraction
p < 0.05. No differences were found for self-efficacy in re- (VRD) and pain control (VRC), had differential effects on

Table 2. Effects of Interventions on Cognitive Measures Related to Pain

Non-VR VRD VRC Pairs comparisons [95% CI]
Self-efficacy tolerance 58.91 (48.63) 127.69 (175.25) 159.07 (160.07) No-VR < VRD [ - 166.49, 28.93]
VRD < VRC [ - 125.17, 62.41]
VRC > No-VR* (3.30O197.02)
Self-efficacy reduction 3.47 (1.44) 3.59 (1.30) 3.88 (1.31) No-VR < VRD [ - 1.03, 0.80]
VRD < VRC [ - 1.17, 0.58]
VRC > No-VR ( - 0.50O1.32)
Total catastrophism 18.90 (8.09) 15.68 (11.25) 14.52 (9.43) No-VR > VRD [ - 3.59, 10.05]
VRD < VRC [ - 5.44, 7.76]
VRC > No-VR ( - 11.21O2.43)
Helplessness 10.22 (4.53) 7.78 (5.96) 5.75 (4.30) No-VR > VRD [ - 1.12, 6.01]
VRD > VRC [ - 1.45, 5.52]
VRC > No-VR** ( - 8.00O - 0.94)
Rumination 7.45 (2.50) 6.86 (1.89) 7.04 (2.71) No-VR > VRD [ - 1.12, 2.29]
VRD < VRC [ - 2.29, 1.12]
VRC < No-VR ( - 2.10O1.28)
Magnification 2.77 (2.10) 2.43 (2.21) 2.83 (2.44) No-VR > VRD [ - 1.28, 1.96]
VRD < VRC [ - 1.98, 1.19]
VRC > No-VR ( - 1.61O1.73)
Data are mean (SD).
*p < 0.05; **p < 0.001.
VR DISTRACTION VS. VR CONTROL 357

pain-related and cognitive variables. With respect to pain- Acknowledgment

related variables, both interventions increased pain toler- This research was supported by Fundació La Marató de
ance. Additionally, the VRC intervention increased the pain TV3.
sensitivity range and the degree of time underestimation, as
compared with the control condition. The VRD condition Author Disclosure Statement
significantly increased the pain threshold in comparison with
the control condition. Overall, therefore, both interventions No competing financial interests exist.
have some effects on pain-related variables, a finding that is
consistent with previous studies1,4 and with our own results in References
earlier experiments involving the same interventions.20–22
1. Li A, Montaño Z, Chen VJ, et al. Virtual reality and pain
Notably, however, neither of the two interventions had any management: current trends and future directions. Pain
effect on pain intensity. This result might be expected for the Management 2011; 1:147–157.
VRC intervention, since its objective is to increase control over 2. Shahrbanian S, Ma X, Korner-Bitensky N, et al. Scientific
pain, and similar results were obtained when using this envi- evidence for the effectiveness of virtual reality for pain
ronment in previous experiments.21,22 However, such a result reduction in adults with acute or chronic pain. Studies in
is surprising in the case of the VRD intervention, since the Health Technology & Informatics 2009; 144:40–43.
available literature suggests that VR environments designed 3. Rutter CE, Dahlquist LM, Weiss KE. Sustained efficacy of
for pain distraction reduce pain intensity, this being the effect virtual reality distraction. Journal of Pain 2009; 10:391–397.
that we observed in a previous study that used this environ- 4. Malloy KM, Milling LS. The effectiveness of virtual reality
ment.20 These results are likely due, at least in part, to the distraction for pain reduction: a systematic review. Clinical
sample size used in the present study. However, the fact that Psychology Review 2010; 30:1011–1018.
participants were asked to indicate the strongest pain intensity 5. Mahrer NE, Gold JI. The use of virtual reality for pain
rather than give an overall rating of pain intensity during the control: a review. Current Pain & Headache Reports 2009;
procedure may also have a bearing on these findings.22 13:100–109.
As regards the cognitive variables, an effect on some of 6. Keefe FJ, Huling DA, Coggins MJ, et al. Virtual reality for
them was only observed for the VRC condition. This sup- persistent pain: a new direction for behavioral pain man-
ports our hypotheses as well as the design of the intervention agement. Pain 2012; 153:2163–2166.
that aimed to enhance pain control. However, although these 7. Hoffman HG, Chambers GT, Meyer WJ, et al. Virtual re-
results are quite innovative and interesting, they now need to ality as an adjunctive non-pharmacologic analgesic for
acute burn pain during medical procedures. Annals of Be-
be replicated in larger samples, and especially in clinical
havioral Medicine 2011; 41:183–191.
contexts.
8. Kipping B, Rodger S, Miller K, et al. Virtual reality for
Assuming that our findings are replicated, an intervention acute pain reduction in adolescents undergoing burn wound
such as the one presented here would have considerable care: a prospective randomized controlled trial. Burns
potential in terms of extending the benefits of VR beyond the 2012; 38:650–657.
clinic. Patients would be able to use this VR intervention at 9. Wohlheiter KA, Dahlquist LM. Interactive versus passive
the clinic to gain control over pain and change their cogni- distraction for acute pain management in young children:
tions, and this would then help them in their daily life outside the role of selective attention and development. Journal of
the clinic. A number of reports along these lines have already Pediatric Psychology 2013; 38:202–212.
been published, one example being experiments involving 10. Shiri S, Feintuch U, Weiss N, et al. A virtual reality system
VR hypnosis.23,24 In the introduction to this paper, we combined with biofeedback for treating pediatric chronic
mentioned other examples10,11 in which VR has been used headache—a pilot study. Pain Medicine 2013; 14:621–627.
for purposes other than pain distraction, and these could be 11. Botella C, Garcia-Palacios A, Vizcaino Y, et al. Virtual
particularly useful in the clinical context. What makes the reality in the treatment of fibromyalgia: a pilot study.
intervention described here especially interesting and inno- Cyberpsychology, Behavior, & Social Networking 2013;
vative is that it is designed to change cognitive variables (i.e., 16:215–223.
self-efficacy and catastrophizing) that have been shown to be 12. Mitchell LA, MacDonald RA, Brodie EE. Temperature and
very important in the context of chronic pain problems.25,26 the cold pressor test. Journal of Pain 2004; 5:233–237.
The main weakness of this study is the use of an unbal- 13. Piira T, Hayes B, Goodenough B, et al. Effects of atten-
anced sample regarding gender, since males and females tional direction, age, and coping style on cold-pressor pain
have different responses to pain,27 and this may influence the in children. Behavior Research Therapy 2006; 44:835–848.
14. Sullivan MJL, Bishop SR, Pivik J. The Pain Catastrophiz-
final results. Replications of this study with a more bal-
ing Scale: development and validation. Psychological As-
anced distribution of males and females are needed. Also, in sessment 1995;7:524–532.
contrast to previous studies on VRD, this study used non- 15. Dixon KE, Thorn BE, Ward LC. An evaluation of sex
immersive VR. The link between immersion and presence differences in psychological and physiological responses to
and between pain distraction and presence is well estab- experimentally-induced pain: a path analytic description.
lished, so this difference may explain the limited efficacy of Pain 2004; 112:188–196.
VRD in our study. The results obtained in this study showing 16. Edwards RR, Campbell CM, Fillingim RB. Catastrophizing
that the intervention designed to enhance control (VRC) has and experimental pain sensitivity: only in vivo reports of
a greater effect on the cognitive variables assessed than the catastrophic cognitions correlate with pain responses.
intervention designed to increase distraction (VRD) can be Journal of Pain 2005; 6: 338–339.
applied, at this moment, only to nonimmersive VR systems. 17. Edwards RR, Smith MT, Stonerock G, et al. Pain-related
Replications of this study with immersive VR are needed. catastrophizing in healthy women is associated with greater
358 LORETO-QUIJADA ET AL.

temporal summation of and reduced habituation to thermal 24. Teeley AM, Soltani M, Wiechman SA, et al. Virtual reality
pain. The Clinical Journal of Pain 2006; 22:730–737. hypnosis pain control in the treatment of multiple fractures:
18. Bandura A, O’Leary A, Taylor CB, et al. Perceived self- a case series. American Journal of Clinical Hypnosis 2012;
efficacy and pain control: opioid and nonopioid mecha- 54:184–194.
nisms. Journal of Personality & Social Psychology 1987; 25. Gatchel RJ, Okifuji A. Evidence-based scientific data
53:563–571. documenting the treatment and cost-effectiveness of com-
19. Melzack R. The McGill Pain Questionnaire: major prop- prehensive pain programs for chronic nonmalignant pain.
erties and scoring methods. Pain 1975; 1:277–299. The Journal of Pain 2006; 7:779–793.
20. Gutierrez-Maldonado J, Gutierrez-Martinez O, Cabas- 26. Keefe FJ, Rumble ME, Scipio CD, et al. Psychological
Hoyos K. Interactive and passive virtual reality distraction: aspects of persistent pain: current state of the science. The
effects on presence and pain intensity. Studies in Health Journal of Pain 2004; 5:195–211.
Technology & Informatics 2011; 167:69–73. 27. Wiesenfeld-Hallin Z. Sex differences in pain perception.
21. Gutiérrez-Maldonado J, Gutiérrez-Martı́nez O, Loreto- Gender Medicine 2005; 2:137–145.
Quijada D, et al. The use of virtual reality for coping with
pain with healthy participants. Psicothema 2012; 24:516– Address correspondence to:
522. Dr. José Gutiérrez-Maldonado
22. Loreto-Quijada D, Gutiérrez-Maldonado J, Gutiérrez- Department of Personality, Assessment,
Martı́nez O, Nieto R. Testing a virtual reality intervention and Psychological Treatments
for pain control. European Journal of Pain 2013; 17:1403– University of Barcelona
1410. Passeig Vall d’Hebrón, 171
23. Soltani M, Teeley AM, Wiechman SA, et al. Virtual reality 08035 Barcelona
hypnosis for pain control in a patient with gluteal hi- Spain
dradenitis: a case report. Contemporary Hypnosis & In-
tegrative Therapy 2011; 28:142–147. E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0203

Clinical Use of Virtual Reality Distraction System

to Reduce Anxiety and Pain in Dental Procedures

Mark D. Wiederhold, MD, PhD, FACP,1 Kenneth Gao, BS,1 and Brenda K. Wiederhold, PhD, MBA, BCB, BCN 2,3

Abstract

Virtual reality (VR) has been used by clinicians to manage pain in clinical populations. This study examines the
use of VR as a form of distraction for dental patients using both subjective and objective measures to determine
how a VR system affects patients’ reported anxiety level, pain level, and physiological factors. As predicted,
results of self-evaluation questionnaires showed that patients experienced less anxiety and pain after undergoing
VR treatment. Physiological data reported similar trends in decreased anxiety. Overall, the favorable subjective
and objective responses suggest that VR distraction systems can reduce discomfort and pain for patients with
mild to moderate fear and anxiety.

Introduction where children either played video games or navigated through

a VE while receiving wound care for their burns, exposure

O ne of the most challenging aspects of dental care

that medical practitioners face today is the treatment of
patient pain.1 Despite advances in dental technologies and
to VR lessened their reported pain ratings as compared with
playing video games.12 In another controlled study, adult burn
patients undergoing physical therapy reported less pain while
treatment, many people still avoid or delay dental care involved in VR than those that only participated in standard
because of the fear and anxiety of pain.2 Analgesics have physical therapy.13 Evidence shows that VR is effective in re-
been the mainstream solution for alleviating pain in the ducing pain in children with cancer, as chemotherapy-related
past. However, medications are often not effective. More symptom distress was reduced significantly immediately after
recently, advanced technologies have integrated both the using VR during treatment.14 Specifically for dental work,
knowledge of the mechanisms of pain medications and another clinical study observed that dental patients undergoing
techniques in behavioral medicine. These advances have plaque removal below their gum line experienced considerable
moved toward using distraction and hypnosis techniques to reduction in pain when using VR compared to participants that
treat pain.3 watched a movie and to participants that did not have any type
Pain perception has a strong psychological component. In of distraction.15
order to experience pain, conscious attention is required.2 Research involving the concept of distraction has shown
Distraction has been found to take a patient’s attention away that techniques used in the past such as concentrating on
from pain. Attention given to pain often determines not only deep breathing or watching a movie are less effective than
the level of pain being reported, but also the distress levels. using VR. This study examines the efficacy of using VR to
By encouraging a patient to focus his/her attention on other control dental pain using both patient reported surveys and
thoughts, less attention is available for the pain.4,5 Virtual physiological measurements to evaluate fear and pain before
reality (VR) utilizes advanced technologies to create virtual and after dental treatment. Dental fear has been measured
environments (VE) that allow patients to be immersed in an with questionnaires such as the Dental Anxiety Scale and
interactive, simulated world.6 These advanced systems in- Dental Fear Survey, as well as the Dental Fear Interview.
teract at many levels with the VE, stimulating sights, sounds, While there are numerous self-report instruments that mea-
and motion to encourage immersion in the virtual world to sure various aspects of the sensory, affective, and evaluative
enhance distraction from pain.7 components of pain, only a few tools have been developed
Other studies have also shown that involving the patient in that directly assess fear and anxiety associated with pain.
a VE reduced their reported levels of pain during medical This study will integrate both subjective and objective var-
procedures such as chemotherapy, physical therapy, burn iables to determine a more effective way of measuring and
wound changes, and surgery (see Table 1).8–11 In one study reducing both pain and distress.

1
Virtual Reality Medical Center, San Diego, California.
2
Interactive Media Institute, San Diego, California.
3
Virtual Reality Medical Institute, Brussels, Belgium.

359
360 WIEDERHOLD ET AL.

FIG. 1. Patient in treatment room. FIG. 3. Measurement without the virtual reality (VR)
distraction system.
Methods
Setting and patients temperature, galvanic skin response (GSH), electroenceph-
alogram (EEG), heart rate variability, heart rate, and respi-
We recruited five adult patients for the study on a volun- ration rate (see Fig. 2).
tary basis as they came for their dental treatments at the
Scripps Center for Dental Care in La Jolla, CA (Dr. John F. Procedures
Weston, D.D.S.) (see Fig. 1).
Before we began treatment, the patients completed the
Outcome measures questionnaires. We also recorded demographic information,
the date of last treatment, and the details about the dental
Patients first completed the Dental Anxiety Scale and procedure. We attached seven sensors to the patients’ fingers,
Amount of Fear Scale. The Dental Anxiety Scale is a 4-item abdomens, and arms to gather physiological information.
questionnaire that asks about fear of dental treatment. The The clinician performed the dental treatment without the use
Amount of Fear Scale is a 45-item, Likert-type (1–5 scale) of the VR distraction system for 5 minutes (see Figs. 3 and 4)
verbal report instrument used to assess dental fear. The and then performed it with use of the VR distraction system
survey provides a total dental fear score. for 5 minutes (see Fig. 5).
A post-experience questionnaire was created by the inves- The VEs included relaxing nature worlds where the pa-
tigators to assess patient treatment preference and effects of tients could navigate through beaches, forest, mountains, and
the VR distraction system. This questionnaire includes the other pleasant areas. The patients self-navigated to provide a
presence questionnaire (from Usoh et al. ‘‘Using Presence further sense of control.
Questionnaires in Reality,’’ Witmer & Singer, Vs. 3.0), and
STAIP-AD Test form Y (from Consulting Psychologists Press). Results
The Procomp+ biofeedback device by Thought Technol-
ogy was used to assess physiological measures. This device Standardized questionnaires
is an advanced biofeedback and psychophysiological data Scores for the pre/post questionnaires, including their sub-
acquisition system. It measures electromyogram (EMG), scales, are shown in Table 2.

FIG. 2. Psychophysiological monitoring and biofeedback

equipment. FIG. 4. Biofeedback sensors and wireless trackball.
 Table 1. Previous Research of Virtual Reality (VR) Distraction for Dental Procedures
Title Method Results
Improving Dental Experiences Using Participants (n = 69) were randomly assigned to one of three VR VR distraction affected on concurrent experiences, such as
Virtual Reality Distractions: A Simu- conditions: active, passive, or control. Each participant was labeled as perceived control, as well as memories after the dental
lations Study16 high or low dentally anxious prior to dental treatment with the VR experience had ended. Participants with higher anxiety
application. experienced greater reduction in memory vividness.
The Impact of Virtual Reality Distraction 120 healthy children aged 4–6 years with no previous anxiety disorder were There was a significant decrease in pain perception ( p < 0.001)
on Pain and Anxiety during Dental randomly divided into two even groups. The study consisted of three and state anxiety scores ( p < 0.001) with the use of VR
Treatment in 4–6 Year Old Children: consecutive treatment sessions. The first visit consisted of fluoride eyeglasses during dental treatment.
A Randomized Controlled Clinical therapy. In the next sessions, the groups received restorative treatment
Trial17 with and without VR eyeglasses in a randomized single blind controlled
crossover fashion. Then at the end of each session, the subjects’ pain
severity was assessed using Wong Baker FACES Pain Rating Scale, and
state anxiety was measured by Faces version of the Modified Child
Dental Anxiety Scale [MCDAS (f )].
Virtual Reality Distraction for Pain The authors recruited 38 patients. They used a within-patient/split-mouth The mean ( – standard deviation) VAS scores for five questions
Control During Periodontal Scaling design. Patients received scaling and root planing procedures (SRP) pertaining to control, movie, and VR were 3.95 – 2.1,
and Root Planing Procedures18 under three treatment conditions in three quadrants. The three 2.57 – 1.8, and 1.76 – 1.4 respectively. Paired t tests revealed
conditions were control, watching a movie, and VR. After each SRP that VAS scores were significantly lower during VR
procedure, patients responded to questions about their discomfort and/ compared with the movie ( p < 0.001) and control ( p < 0.001)
or pain by using a visual analog scale (VAS) (range = 0 to 10 in which conditions. Similarly, BP and PR were lowest during VR,
lower numbers indicate less pain or discomfort). The authors also followed by the movie and control conditions. Patients
recorded patients’ blood pressure (BP) and pulse rate (PR). Patients reported that they preferred the VR condition.

361
were asked which of the three treatment modalities they preferred.
The Effect of Virtual Reality During The behavior, anxiety, and heart rate of 26 children aged 5–7 years were Differences (ANOVA) in behavior ( pp0.50) and anxiety
Dental Treatment on Child Anxiety evaluated for the first 5 minutes of two restorative treatment visits. ( pp0.65) were not significant. The overall pulse rate was
and Behavior19 Thirteen children viewed VR at their first restorative visit and not the significantly lower (ANOVA; pp0.001) when the child was
second, and 13 children viewed VR at the second restorative visit and wearing glasses and viewing VR.
not the first. Before and immediately following the restorative visits,
each child was instructed to draw a human figure. The restorative
appointments were video recorded and heart rate monitored. The
Koppitz method of evaluating drawings was used to measure anxiety.
The Frankl behavior rating scale was used to evaluate behavior.
The Effectiveness of Virtual Reality for Two patients (aged 51 and 56 years old) with adult periodontitis—a For patient 1, mean pain ratings were in the severe range while
Dental Pain Control: A Case Study15 chronic, progressive inflammatory disease that affects gums, ligaments, watching a movie (7.2) or no distraction (7.2), but in the mild
and bones around the teeth—were studied in the treatment room of a pain range (1.2) during the VR condition. Patient 2 reported
periodontist. Each patient received periodontal scaling and root planing mild to moderate pain with no distraction (M = 4.4), mild
(scraping off/removing plaque deposits below the gum line, hereafter pain while watching the movie (M = 3.3), and essentially no
referred to as scaling) under three treatment conditions: (1) VR pain while in VR (M = 0.6) during his periodontal scaling.
distraction, (2) movie distraction, and (3) a no-distraction control
condition. Condition order was randomized and counterbalanced. For
each of the three treatment conditions, five visual analog pain scores for
each treatment condition served as the dependent variables. On 0–10
labeled scales, both patients provided sensory and affective pain ratings,
and subjective estimates of time spent thinking about his pain during the
procedure.
362 WIEDERHOLD ET AL.

Table 2. Patient Scores Between

Pre- and Post- Questionnaire
Pre questionnaire
Patient Amount of fear Self-Eval1 Self-Eval2 Absorption
P1 83 39 10 16
P2 113 22 27 16
P3 136 25 16 18
P4 144 30 19 12
P5 111 21 17 16
Mean 117.4 27.4 17.8 15.6
Post questionnaire
Patient Post_Exp Self-Eval1 Self-Eval2 Presence
P1 37.5 40 9 166 FIG. 5. Measurement with VR distraction system.
P2 55 23 29 127
P3 40 31 11 179
P4 56 31 17 136 Within the EKG data, LFN increased an average of 14.968
P5 45 17 25 138 for four of the five patients after VR distraction. The average
Mean 46.7 28.4 18.2 149.2 increase of the LF frequency band most likely indicates ef-
Difference in scores between pre and post questionnaires fectiveness of the VR distraction in reducing anxiety.
HRV is characterized by three main components: the high
Patient Part I Part II frequency (HF) component (0.15–0.40 Hz) measures the
influence of the vagus nerve in modulating the sinoatrial
P1 1 -1 node. The low frequency (LF) component (0.04–0.15 Hz)
P2 1 2 provides an index of sympathetic effects on the heart, par-
P3 6 -5 ticularly when measured in normalized units. The very low
P4 1 -2
P5 -4 8 frequency (VLF) component (0.003–0.04 HZ) reflects the
Mean 1 0.4 ( - 1.5)* influence of several factors on the heart, including chemo-
receptors, thermoreceptors, the renin-angiotensin system,
*0.4 for all patients; - 1.5 for patients 1–4. and other nonregular factors. Almost all of the variability
from a short-term spectral analysis of HRV is captured in
these three components. An example of one of the patient’s
We evaluated the differences between pre/post self-
EKG data is shown in Figure 8 to visualize the comparative
evaluation scores (post - pre score = changes) with the t test
features.
(see Table 3).
For part I of the self-evaluation questionnaire (Ho:u = 0,
Ha:u < 0), the p value is 0.56. This is strong evidence to Discussion
support that the true mean of the change is >0, that is,
An inexpensive, commercially available VE could have a
treatment increased the scores for patients. Data from part II
significant impact in reducing perceived pain involved in a
has a p value of 0.1875 (except patient 5 data; it is obvious
variety of medical procedures.
that the value 8 is an outlier), supporting that using the VR
The physiological results of this research suggest that the
distraction system decreased the anxiety for patients.
use of the VR distraction system may be a beneficial option
for patients with mild to moderate fear and anxiety associ-
Physiology
ated with dental treatments. This system may be a useful
We analyzed physiological measures (such as the heart adjunct in dental offices to help reduce anxiety, discomfort,
rate and respiration rate) along with order and condition boredom, and the time required to perform routine dental
(after use of the VR distraction system and after nonuse of procedures. It allows them to relax by allowing them to
the system). In these analyses, several significant effects navigate to another location while still physically remaining
were shown (see Figs. 6 and 7; Tables 4–6). in the dental office.

Table 3. Statistical Analysis of Pre and Post Questionnaires

Standard Standard
Mean deviation n error Reference t Value df p
Pre questionnaire 1.000000 3.535534 5 1.581139 0.00 0.632456 4 0.280719
Post questionnaire 0.400000 4.929503 5 2.204541 0.00 0.181444 4 0.864843
Post questionnaire - 1.500000 2.886751 4 1.443376 0.00 - 1.03923 3 0.187548
(without patient 5)
VR TO REDUCE PAIN IN DENTAL PROCEDURES 363

Table 4. Statistical Variable Definitions

and Abbreviations
SDNN Standard deviation on the NN intervals
(NN = normalized R to R = normalized IBI)
VLF Power in the VLF bandwidth (0.0033–0.04 Hz)
LFN Power in the LF bandwidth (0.04–0.15 Hz),
in normalized unit
HFN Power in the HF bandwidth (0.15–0.4 Hz),
in normalized unit
LF/HF Ratio LF/HF
Total Total power in the 0.0033–0.4 Hz bandwidth
Power
AvgMM Average HR Max–HR Min value
FIG. 6. Results show a trend of factors related to fear and AvgHR Average heart rate
anxiety reduction with VR distraction. AvgBR Average respiration (breathing) rate
AvgTM Average temperature

Additional research exploring the mechanism by which

VR distraction is achieved will be needed. There is much from the enormous improvements in more conventional
room for improving ‘‘presence and realism’’ in future computer technology (e.g., cheaper memory, cheap and fast
VR applications specifically designed for treating pain. graphics accelerators, higher information processing cap-
New virtual worlds, custom built to be more immersive, abilities of the hardware, and a dramatic maturation in
could produce even larger reductions in pain. Such new the quality of VR world building software commercially
worlds can take advantage of the versatility of VR soft- available).
ware. On a clinical level, several observations were noted To summarize, the present study provides encouraging
by the clinical staff and from the survey results to improve initial support for the use of VR as a technique for controlling
on existing problems with the design of the study (see fear and anxiety during dental procedures. Additional em-
Table 7). pirical research will be needed to determine whether VR can
The cost of an immersive VR system has dropped become a viable form of fear and anxiety control during
dramatically since the mid-1990s, and additional price re- dental treatments. Techniques that prove effective for treat-
ductions are inevitable. At the same time, the quality and ing dental pain will likely prove effective for other painful
portability of VR has increased dramatically, benefiting procedures.

FIG. 7. Evaluation outcome chart (heart rate, respiration rate) example.

364 WIEDERHOLD ET AL.

Table 5. EKG Statistical Data Without VR Distraction

SDNN VLF LFN HFN LF/HF POWER
Patient 1 322.91 12,726.91 56.46 43.54 1.3 32,431.2
Patient 2 119.85 905.51 36.18 63.82 0.57 3,069.24
Patient 3 194.59 1,514.26 49.41 50.59 0.98 6,206.21
Patient 4 149 508.68 33.17 66.83 0.5 1,885.13
Patient 5 116.04 1,613.61 44.59 55.41 0.8 5,730.46
Mean 180.478 3,453.794 43.962 56.038 0.83 9,864.448

Table 6. EKG Statistical Data With VR Distraction

SDNN VLF LFN HFN LF/HF POWER
Patient 1 350.46 7,080.83 54.97 45.03 1.22 34,153.53
Patient 2 54.07 385.69 73.41 26.59 2.76 947.02
Patient 3 71.6 394.2 59.78 40.22 1.49 1,518.05
Patient 4 116.61 2,095.33 60.1 39.9 1.51 2,525.88
Patient 5 81.59 739.1 46.39 53.61 0.87 1,166.04
Mean 134.866 2,139.03 58.93 41.07 1.57 8,062.104

FIG. 8. EKG of patient 5 with and without VR distraction.

Table 7. Observed and Reported Clinical Improvements

1 Set up virtual equipment in a spacious area to allow room to operate freely
2 Ensure the patient is familiarized with the virtual environment (VE) before beginning operations
3 Head-mounted display size and compatibility are essential for a smooth operation, as it may be difficult
to adjust mid-operation
4 Offer a wide range of VE to accommodate the varying tastes of patients
5 Use disposable covers between patients to maintain aseptic technique while saving time
VR TO REDUCE PAIN IN DENTAL PROCEDURES 365

Acknowledgments Peace & Security Series—E: Human & Societal Dynamics

2012; 91:75–93.
We thank the National Institute on Drug Abuse, National
11. Mühlberger A, Wieser MJ, Kenntner-Mabiala R, et al. Pain
Institutes of Health for partial funding of this project. We modulation during drives through cold and hot virtual
also thank the participants who were willing to spend time environments. CyberPsychology & Behavior 2007; 10:
with our clinical team. 516–522.
12. Hoffman HG, Doctor JN, Peterson DR, et al. Virtual reality
Author Disclosure Statement as an adjunctive pain control during burn wound care in
adolescent patients. Pain 2000; 85:305–309.
No competing financial interests exist.
13. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual
reality for adjunctive treatment of adult burn pain during
References physical therapy: a controlled study. Clinical Journal of
Pain 2000; 16:244–250.
1. Cohen LA, Harris SL, Bonito AJ, et al. Coping with 14. Schneider SM, Workman ML. Virtual reality as a distrac-
toothache pain: a qualitative study of low-income persons tion intervention for older children receiving chemother-
and minorities. Journal of Public Health Dentistry 2007; apy. Journal of Pediatric Nursing 2000; 26:593–597.
67:28–35. 15. Hoffman HG, Garcia-Palacios A, Patterson DR, et al. The
2. Locker D. Psychosocial consequences of dental fear and anxi- effectiveness of virtual reality for dental pain control: a
ety. Community Dental Oral Epidemiology 2003; 31:144–151. case study. CyberPsychology & Behavior 2001; 4:527–535.
3. Schmitt YS, Hoffman HG, Sharar SR. A randomized, con- 16. Tanja-Dijkstra K, Pahl S, White MP, et al. Improving
trolled trial of immersive virtual reality analgesia during phys- dental experiences by using virtual reality distraction: a
ical therapy for pediatric burn injuries. Burns 2011; 37:61–68. simulation study. PLoS One 2014; 9:e91276.
4. Hodes RL, Howland EW, Lightfoot N, et al. The effects of 17. Asl Aminabadi N, Erfanparast L, Sohrabi A, et al. The
distraction on responses to cold pressor pain. Pain 1990; impact of virtual reality distraction on pain and anxi-
41:109–114. ety during dental treatment in 4–6 year-old children: a
5. Miron D, Duncan GH, Bushnell MC. Effects of attention on randomized controlled clinical trial. Journal of Dental
the intensity and unpleasantness of thermal pain. Pain 1989; Research, Dental Clinics, Dental Prospects 2012; 6:117–
39: 345–352. 124.
6. Sharar SR, Miller W, Patterson DR. Applications of virtual 18. Furman E, Jasinevicius TR, Bissada NF, et al. Virtual re-
reality for pain management in burn-injured patients. Ex- ality distraction for pain control during periodontal scaling
pert Review of Neurotherapeutics 2008; 8:1667–1674. and root planing procedures. Journal of American Dental
7. Wiederhold MD, Wiederhold BK. Virtual reality and in- Association 2009; 140;1508–1516.
teractive simulation for pain distraction. Pain Medicine 19. Sullivan C, Schneider PE, Musselman RJ, et al. The effect
2007; 8:S182–188. of virtual reality during dental treatment on child anxiety
8. Vazquez JLM, Santander A, Gao K, et al. Using cybertherapy and behavior. ASDC Journal of Dentistry for Children
to reduce postoperative anxiety in cardiac recovery intensive 2000; 67:193–196.
care units. Journal of Anesthesia & Clinical Research 2013;
4:363.
9. Mosso JL, Rizzo S, Wiederhold B, et al. Cybertherapy—
new applications for discomfort reductions. Surgical care Address correspondence to:
unit of heart, neonatology care unit, transplant kidney care Prof. Mark D. Wiederhold
unit, delivery room-cesarean surgery and ambulatory Virtual Reality Medical Center
surgery, 27 case reports. Studies in Health Information & 9565 Waples St., Suite 200
Informatics 2007; 125:334–336. San Diego, CA 92121
10. Wiederhold BK, Wiederhold MD. Managing pain in mili-
tary populations with virtual reality. NATO Science for E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0046

Application of Virtual Body Swapping

to Patients with Complex Regional Pain Syndrome:
A Pilot Study

Bomyi Jeon, BA,1 Sungkun Cho, PhD,2 and Jang-Han Lee, PhD1

Abstract

This study aimed to apply virtual body swapping through mental rehearsal for patients with complex regional
pain syndrome (CRPS) and to investigate whether it is applicable to them. Ten patients who met the diagnostic
criterion for CRPS type 1 were randomly assigned to either the treatment or control group. All participants were
asked to watch the virtual body swapping training video clip with a head mounted display. The treatment group
was additionally asked to assume a posture similar to the body on the screen and rehearse the movements
mentally, as if the body presented on the screen was their body. No difference between the groups was found for
pain intensity, however, the treatment group showed significantly more improvement in body perception
disturbance (BPD) after the treatment than the control group. Even if the presented study is a preliminary one,
the above results suggest that virtual body swapping through mental rehearsal is applicable for patients with
CRPS and may be useful for improving BPD. The limitations of the study and the future investigations needed
to provide clearer clinical suggestions are presented and discussed.

Introduction was originally used for phantom limb pain patients, has been
introduced to manage pain and body perception disturbance
(BPD) for patients with CRPS.12,13 In mirror therapy,
C omplex regional pain syndrome (CRPS) is a chronic
progressive disease of unknown etiology characterized
by a triad of severe pain; the threat of touch; abnormalities in
imaginary movement of the affected limb, which is actually a
reflection of the patient’s intact limb in a mirror, alleviates
temperature, color, and sweating; and disturbed body per- the patient’s pain by correcting conflicts between visual
ception.1,2 Due to its unknown etiology, conventional therapy feedback and proprioceptive representations of the affected
for CRPS is mainly empirical for pain management and limb.14 Concurrent with previous studies, some researchers
functional rehabilitation rather than mechanism-based treat- who have applied mirror therapy to patients with CRPS have
ment.3,4 The extent of empirical treatment varies from the found that mirror therapy is effective for relieving pain and
noninterventional to the interventional; however, both have restoring disturbed body perception.15–17 However, mirror
limitations. Noninterventional treatments such as pharma- therapy appears to have limitations in that to be adopted for
cological treatment and physical therapy are often transient patients with CRPS, at least one limb should be intact. Pa-
and usually end with the patient experiencing recurrent pain. tients with CRPS, however, may have an affected body part
In addition, there is controversy over the invasiveness and without a counterpart, such as the head, neck, or other body
reliability of interventional treatments.5,6 Recent brain stud- part, or the patient may have both limbs affected.
ies on CRPS have contributed to a shift in treatment para- Therefore, inducing an illusionary body perception for
digms from an empirical one to a mechanism-based arena,7 the body instead of a single counterpart may overcome
and accordingly, neural rehabilitation has recently been in- the limitations of mirror therapy. Body swapping is a
troduced as an alternative therapy for CRPS.8 Such rehabil- way of evoking the perceptual illusion that a virtual body is
itation is expected to treat CRPS by correcting maladaptive perceived as his/her own body.18,19 The illusion of body
cortical changes such as the disruption of the somatosensory swapping can be induced as body ownership is shifted from
cortical network,9 dysfunction of the motor cortex,10 and the actual body to a virtual body by watching the virtual body
disrupted body schema.11 moving or being touched while synchronous movement or
Mirror therapy is a representative treatment that reflects tactile stimulation is performed.20–22 Despite its potential
the principle of neural rehabilitation. Mirror therapy, which implications, body swapping in the clinical setting, to our

1
Department of Psychology, Chung-Ang University, Seoul, Korea.
2
Department of Psychology, Chungnam National University, Daejeon, Korea.

366
VIRTUAL BODY SWAPPING FOR CRPS 367

knowledge, has not been studied yet because even light score, the more intense the pain experienced by the patient at
tactile stimulation or movement can induce pain for patients that moment.
with CRPS. For a treatment program for patients with CRPS The modified Body Perception Disturbance Questionnaire
to be applicable, it should (a) be available for the whole body (BPDQ)27 was used, which consists of nine items, such as
part and limbs that are counterpart and (b) induce a low level sense of disownership, lack of attention to the limb, distorted
of pain so as not to make the treatment session by itself mental visualization, impaired limb position sense, dislike,
aversive. and different perception of size, shape, weight, pressure, or
Our previous study opened the possibility of applying the temperature of the impaired limb. Each item was rated on an
virtual body swapping for patients with CRPS by employ- 11-point scale ranging from 0 (not at all) to 10 (very likely).
ing mental rehearsal. Mentally rehearsing body move- A sum total score was used in the analysis (from 0 to 90),
ment without moving the actual body while watching virtual with a higher score indicating greater BPD. Cronbach’s
body moves in healthy participants has been found to evoke alpha for the modified BPDQ in the present study was 0.73.
the illusion of virtual body swapping as much as physical A single item of the virtual body swapping illusion asks to
rehearsal did.23 This finding can be explained by the psycho- what extent participants perceived the virtual body’s move-
neuromuscular theory, which postulates that mental re- ment as being their own body’s movement was created for
hearsal activates a network of neural pathways required for this study and measured on a 7-point Likert scale ranging
movements so that imagining movements means actually from 1 (not at all) to 7 (very much). The higher the score was,
strengthening neural pathways of physical skill.24,25 Given the more successful the virtual body swapping experienced.
this, two clinical psychologists specializing in pain con-
firmed that virtual body swapping through mental rehearsal Material and training program
would be an appropriate way to evoke a body swapping
The virtual body swapping training video for patients with
illusion for patients with CRPS as it does not require any
CRPS was developed and has been found to successfully
touches or gross muscular movements inducing pain.
evoke virtual body swapping illusion in healthy partici-
This study aimed to apply virtual body swapping to pa-
pants.25 The 3 minute and 20 second long video clip was
tients with CRPS and to investigate whether it is applicable
filmed from the first person perspective and consisted of four
to them. As the first study to apply virtual body swapping
physical movements. The first person perspective would help
to patients with CRPS, it is necessary to ascertain that the
patients to feel as if they observed their body when they
virtual body swapping is applicable in a small sample of
watch video, and four physical movements were ergonomi-
patients with various pain sites. Given the findings of prior
cally natural from the view (making fists and opening up the
studies, we applied virtual body swapping to patients with
fingers, bending and unbending the elbows, bending the
CRPS and expected that the virtual body swapping illusion
ankles forward and backward, and bending and unbending
through mental rehearsal would reduce pain intensity and
the legs). The video was presented using a head mounted
BPD in patients with CRPS (Hypothesis; H1).
display (HMD, VR2000; Virtual Realities, Ltd.; Fig. 1) in a
dim light to help patients with CRPS be immersed in the
Methods training session by blocking other sensory information. Total
training sessions was designed not to exceed 10 minutes as it
Participants
has been known that training longer than 10 minutes may
Ten patients with CRPS type 1 were recruited from a cause fatigue and difficulty in concentration.27 The training
tertiary university pain center in Seoul, Korea. The inclusion program was delivered by one specialist in pain and two
criteria for the present study fulfilled the diagnostic criteria assistants (trained graduate students).
for CRPS type 1 according to the International Association
for the Study of Pain and pain doctors confirmed that the Procedure
participants meet the criteria. Accordingly, the criteria in-
Participants were asked to complete informed consent
cluded the presence of a noxious event unaccompanied by
form and demographic information questionnaires. Partici-
nerve lesion; continued pain, allodynia, or hyperalgesia; the
pants also responded to a pain intensity question and com-
region of pain suffers from edema, changes in skin blood
pleted the modified BPDQ to be used as baseline data.
flow, or pseudo motor activity; and the exclusion of other
Subsequently, all participants were asked to lie down on the
diagnoses.26(p330) Pain sites of each patients were various for
sofa and watch the experimental video clip with HMD.
the purpose of this study (entire body = 4, more than two
Participants in the treatment group were additionally asked
limbs = 4, lower limb = 1, upper limb = 1). Patients were
to assume a posture similar to that of the body on the screen
randomly assigned to either the treatment or control group.
and rehearse the movements mentally, as if the body pre-
All participants were male and had at least high school ed-
sented on the display was their own body. In contrast, par-
ucation. The mean age of the sample was 39.30 years
ticipants in the control group were not asked to perform these
(SD = 10.99) and the median duration of pain was 52 months
last two tasks while watching the video clip, to rule out an
(range 33–120 months). The two groups were not signifi-
alternative explanation of the experimental results (i.e.,
cantly different in age [t(8) = - 1.59, p = 0.15] or duration of
watching the video clip itself may influence pain intensity
pain [t(8) = - 0.98, p = 0.55].
and BPD). The experimental video clip was played twice
with a 1-minute break given between viewings. The partic-
Measurements
ipants were then asked to respond to the pain intensity
Pain intensity was measured on an 11-point Likert scale question and the virtual body swapping question and to
ranging from 0 (no pain) to 10 (severe pain). The higher the complete the BPDQ. As a final step, all participants were
368 JEON ET AL.

FIG. 1. Experimental pro-

cedure. The video was pre-
sented twice with one minute
of short break.

debriefed on the experiment and compensated for their par- significant difference in virtual body swapping scores between
ticipation. The procedure is described in Figure 1. the treatment and control group was found, t(8) = 2.40, p = 0.04,
indicating that the treatment group experienced greater virtual
Statistical analysis body swapping illusion than did the control group.
One-way analysis of covariance (ANCOVA) using pre-
treatment condition (pain intensity and BPD) as covariates was Discussion
conducted to analyze differences between the groups in post- The present study aimed to apply virtual body swapping to
treatment pain intensity and BPD scores. Pretreatment pain in- patients with CRPS and to investigate its treatment effects on
tensity and BPD were controlled in each analysis to reduce the pain intensity and BPD. Patients with CRPS seemed to ac-
variance of the baseline, respectively. The bootstrapping commodate themselves in the treatment session well and
method was used to increase the robustness of small-sample they reported that the training program did not induce
analyses.28 In the present set of analyses, parameter estimates aversive pain. In addition, the training program evoked il-
were based on 1,000 bootstrap samples with 95% confidence lusionary body perception. As a consequence, the treatment
intervals. An independent t test was used to investigate the group showed more significant improvement in BPD after
difference in virtual body swapping scores between the two the treatment than the control group. However, no difference
groups. SPSS 17.0 for windows was used for these analyses. between the groups was found for pain intensity.
The technique of virtual body swapping therapy on BPD is
Results consistent with novel therapies such as mirror therapy and
Pain intensity and BPD motor imagery with respect to normalizing sensory-motor
cortical representation by manipulating corrective visual
One-way ANCOVA for post-treatment pain intensity and information input.29,30 Functional brain imaging studies have
BPD, using pretreatment pain intensity and BPD as covari- demonstrated that representation of the affected limb is en-
ates was conducted. Bootstrapped descriptive statistics are larged or reduced on sensory-motor cortices, and a correla-
described in Table 1. There was no significant difference tion between corrective cortical reorganization and pain
between the groups in pain intensity, F(1, 7) = 0.05, p = 0.81.
For BPD, the result showed a significant difference between
the groups, F(1, 8) = 16.22, p = 0.01, gp2 = 0.70. These results
indicate that the treatment group reported less BPD after
treatment than did the control group (Fig. 2).
Virtual body swapping illusion
An independent t test was conducted to compare virtual body
swapping illusion between the treatment and control group. A

Table 1. Bootstrapped Statistics on Body

Perception Disturbance [Mean (SD)]
95% confidence interval
Condition Statistics Upper Lower
Treatment 52.60 (24.43) 31.83 (6.87) 75.00 (32.53)
Control 61.80 (21.95) 55.74 (2.29) 84.50 (20.98) FIG. 2. Body perception disturbance scores for treatment
and control groups with time *p < 0.05.
VIRTUAL BODY SWAPPING FOR CRPS 369

reduction has been found.31,32 These results imply that BPD in further research, a larger sample size with a balanced
correlates with the abnormal change in body schema and that gender ratio is required to confirm the results of this study.
restoring body schema can benefit BPD. Body schema can be Second, we relied on a single item to measure the virtual
altered because our body representation is a complex com- body swapping illusion, which may not accurately reflect it.
bination of vision, somesthesis, and motor feedback rather Thus, further research needs to employ more reliable mea-
than a simple registration of body location.33,34 Therefore, surements such as a multiple-item measure and brain imag-
BPD can be induced when appropriate visual, somesthetic, ing. Third, the treatment was conducted only once without
or motor feedback is not given when moving the body.35 any preparatory stage. Although there was improvement in
In the present study, normal body and normal movement BPD in one treatment session, this does not constitute con-
are projected onto the patients with CRPS as corrective vi- clusive evidence that one session is enough. In addition to
sual information, while the patients mentally rehearse the this limitation, the baseline was measured only once and this
movement to provide cognitive and motor input. As mental occurred just before the treatment. Additionally, a followup
rehearsal has been used to enhance functional recovery of to determine any long-lasting effects was not conducted. In
patients with physical disabilities,36 it seems promising that further research, the baseline should be measured several
virtual body swapping through mental rehearsal could im- times before the initial treatment session to obtain a stable
prove physical function of patients with CRPS. baseline, and a followup is necessary to determine the sus-
Despite the fact that the virtual body swapping through tainability of the effect after the treatment is terminated.
mental rehearsal was helpful in improving BPD, there was no The result of the present study has demonstrated that the
significant group difference in post-treatment pain intensity. virtual body swapping through mental rehearsal can be
This finding may reflect that single-session treatment is not useful for improving BPD in patients with CRPS. This
sufficient to relieve pain intensity. There are incoherent re- finding can be especially beneficial for patients who have
sults regarding how many sessions are necessary for treat- difficult body conditions and have been unable to benefit
ment using corrective visual feedback, such as mirror visual from previous visual feedback therapies because either both
feedback and augmented reality, to achieve effective pain limbs are affected or the affected body part has no counter-
reduction. Sato et al.37 reported that even single-session part. Further studies in a larger and various samples are
treatment could reduce pain intensity in some patients, but necessary to establish the virtual body swapping through
most researchers preferred multiple-session treatment, from mental rehearsal as a clinical training program for CRPS.
one session per week for several weeks to daily basic intense
training.13,32,37 Otherwise, our treatment requires prepara- Acknowledgments
tory staging before actual virtual body swapping is applied. This research was supported by Basic Science Research
Because a mismatch between motor intention and proprio- Program through the National Research Foundation of Korea
ceptive feedback causes pain in many pathological chronic (NRF) funded by the Ministry of Education, Science and
pain conditions including CRPS,38,39 even inducing move- Technology (2012R1A1A2008624) and the Chung-Ang
ment intention by virtual body swapping could elicit pain. In University Excellent Student Scholarship in 2014.
this regard, Moseley8,32 suggested and proved the efficiency
of an additional training phase before mirror visual feedback Author Disclosure Statement
to restore body scheme with laterality training and to accli-
mate to following movement using motor imagery. No competing financial interests exist.
The results of this study have important clinical implica-
References
tions for patients with CRPS. Above all, to our knowledge,
this study is the first attempt to apply virtual body swapping 1. Förderreuther S, Sailer U, Straube A. Impaired self-
through mental rehearsal for patients with CRPS. Other perception of the hand in complex regional pain syndrome
treatments using illusionary body perception have been lim- (CRPS). Pain 2004; 110:756–761.
ited because traditional techniques require at least one intact 2. Lewis JS, Kersten P, McCabe CS, et al. Body perception
limb or accompanying pain, while virtual body swapping disturbance: a contribution to pain in complex regional pain
through mental rehearsal extended the clinical venue of CRPS syndrome. Pain 2007; 133:111–119.
beyond these limitations. Second, most clinical approaches to 3. Rho RH, Brewer RP, Lamer TJ, et al. Complex regional pain
CRPS have focused on pain reduction. However, this re- syndrome. Mayo Clinic Proceedings 2002; 77:174–180.
search targeted BPD and pain as one of the main symptom of 4. Stanton-Hicks MD, Burton AW, Bruehl SP, et al. An up-
CRPS and suggested a promising treatment. Moreover, the dated interdisciplinary clinical pathway for CRPS: report of
an expert panel. Pain Practice 2002; 2:1–16.
virtual body swapping is a mechanism-based treatment that
5. Burton AW, Hassenbusch SJ, Warneke C, et al. Complex
aims to normalize a distorted body scheme and resolve regional pain syndrome (CRPS): survey of current prac-
conflict between neural networks rather than to transiently tices. Pain Practice 2004; 4:74–83.
relieve pain. 6. Birkleinm F. Complex regional pain syndrome. Journal of
Notwithstanding the above implications, some limitations Neurology 2005; 252:131–138.
remain. First of all, the small male-specific sample was uti- 7. Burton AW, Bruel S, Harden RN. Current diagnosis and
lized as a preliminary study to explore the applicability of a therapy of complex regional pain syndrome: refining di-
novel treatment program; thus alternatively, bootstrapping agnostic criteria and therapeutic options. Expert Review of
method was used in the present study. Bootstrapping method Neurotherapeutics 2005; 5:643–651.
has been known to be useful in solving distribution problem 8. Moseley GL. Is successful rehabilitation of complex regional
and small sample size analysis as it estimates statistics in pain syndrome due to sustained attention to the affected
prospective big sample from observed data.28 Nevertheless limb? A randomised clinical trial. Pain 2005; 114:54–61.
370 JEON ET AL.

9. Juottonen K, Gockel M, Silen T, et al. Altered central orthodox jews. Journal of Social and Clinical Psychology
sensorimotor processing in patients with complex regional 2010; 29:930–944.
pain syndrome. Pain 2002; 98:315–323. 29. Regenbrecht H, Franz E, McGregor G, et al. (2010) From
10. Schwenkreis P, Janssen F, Rommel O, et al. Bilateral mirror therapy to augmented reality. http://ohmynerves
motor cortex disinhibition in complex regional pain syn- .wordpress.com/2010/10/14/from-mirror-therapy-to-augmented-
drome (CRPS) type I of the hand. Neurology 2003; reality/ (accessed Jan. 28, 2014).
61:515–519. 30. Moseley GL. Graded motor imagery is effective for long-
11. Schwoebel J, Friedman R, Duda N, et al. Pain and the body standing complex regional pain syndrome: a randomised
schema: evidence for peripheral effects on mental repre- controlled trial. Pain 2004; 108:192–198.
sentations of movement. Brain 2001; 124:2098–2104. 31. Malihofter C, Handwerker HO, Neundorfer B, et al. Pat-
12. Ramachandran V, Hirstein W. The perception of phantom terns of cortical reorganization in complex regional pain
limbs. Brain 1998; 121:1603–1630. syndrome. Neurology 2003; 61:1707–1715.
13. McCabe CS, Haigh RC, Ring EF, et al. A controlled pilot 32. Pleger B, Tegenthoff M, Ragert P, et al. Sensorimotor re-
study of the utility of mirror visual feedback in the treat- turning in complex regional pain syndrome parallels pain
ment of complex regional pain syndrome (type 1). Rheu- reduction. Annals of Neurology 2005; 57:425–429.
matology (Oxford) 2003; 42:97–101. 33. Graziano MS, Botvinick MM. (2002) How the brain rep-
14. Chan BL, Witt R, Charrow AP, et al. Mirror therapy for resents the body: insights from neurophysiology and psy-
phantom limb pain. New England Journal of Medicine chology. In: Wolfgang P, Benhard H, eds. Common
2007; 357:2206–2207. Mechanisms in Perception and Action: Attention and Per-
15. Karmarkar A, Lieberman I. Mirror box therapy for complex formance XIX. New York, NY: Oxford University Press,
regional pain syndrome. Anaesthesia 2006; 61:412–413. pp. 136–157.
16. Tichelaar YV, Geertzen JH, Keizer D, et al. Mirror box 34. Botvinick M. Probing the neural basis of body ownership.
therapy added to cognitive behavioural therapy in three Science 2004; 305:782–783.
chronic complex regional pain syndrome type I patients: a 35. McCabe C. Mirror visual feedback therapy. A practical
pilot study. International Journal of Rehabilitation Research approach. Journal of Hand Therapy 2011; 24:170–
2007; 30:181–188. 179.
17. Cacchio A, De Blasis E, De Blasis V, et al. Mirror therapy 36. Francine M, Philip LJ, Carol LR. Towards the integration
in complex regional pain syndrome type 1 of the upper limb of mental practice in rehabilitation programs. A critical
in stroke patients. Neurorehabilitation and Neural Repair review. Frontiers in Human Neuroscience 2013; 7:576.
2009; 23:792–799. 37. Sato K, Fukumori S, Matsusaki T, et al. Nonimmersive
18. Petkova VI, Ehrsson HH. If I were you: perceptual illusion virtual reality mirror visual feedback therapy and its ap-
of body swapping. PLoS One 2008; 3:e3832. plication for the treatment of complex regional pain syn-
19. Slater M, Perez-Marcos D, Ehrsson HH, et al. Inducing drome: an open-label pilot study. Pain Medicine 2010;
illusory ownership of a virtual body. Frontiers in Neu- 11:622–629.
roscience 2009; 3:214–220. 38. Harris AJ. Cortical origin of pathological pain. The Lancet
20. Ehrsson HH, Spence C, Passingham RE. That’s my hand! 1999; 354:1464–1466.
Activity in premotor cortex reflects feeling of ownership of 39. Swart CMAK, Stins JF, Beek PJ. Cortical changes in
a limb. Science 2004; 305:875–877. complex regional pain syndrome (CRPS). European Journal
21. Ehrsson HH, Holmes NP, Passingham RE. Touching a of Pain 2009; 13:902–907.
rubber hand: feeling of body ownership is associated with
activity in multisensory brain areas. The Journal of Neu-
roscience 2005; 25:10564–10573. Address correspondence to:
22. Dummer T, Picot-Annand A, Neal T, et al. Movement and Prof. Jang-Han Lee
the rubber hand illusion. Perception 2009; 38:271–280. Department of Psychology
23. Hwang H, Cho S, Lee JH. The effect of mental rehearsal
Chung-Ang University
on the generation of body swapping illusion. Post Ses-
84 Heukseok-ro, Dongjak-gu
sion Presented at the 17th Annual CyberPsychology &
CyberTherapy Conference, Brussel, Belgium. Seoul 156-756
24. Richardson A. Mental practice: a review and discussion, Korea
Part 1. Research Quarterly 1967; 38:95–107.
25. Linden CA, Uhley JE, Smith D, et al. The effects of mental E-mail: [email protected]
practice on walking balance in an elderly population. The
Occupational Therapy Journal of Research 1989; 9:155–169. Prof. Sungkun Cho
26. Harden RN, Bruehl SP, Stanton-Hicks M, et al. Proposed Department of Psychology
new diagnostic criteria for complex regional pain syn- Chungnam National University
drome. Pain Medicine 2007; 8:326–331. 99 Daehak-ro, Yuseong-gu
27. Lewis J, McCabe CS. Body perception disturbance (BPD) Daejeon 305-764
in CRPS. Practical Pain Management 2010; 10:60–66. Korea
28. Rosmarin DH, Pirutinsky S, Siev J. Recognition of scru-
pulosity and non-religious OCD by orthodox and non- E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0198

Virtual Reality for Pain Management in Cardiac Surgery

José Luis Mosso-Vázquez, MD,1 Kenneth Gao, BS,2 Brenda K. Wiederhold, PhD, MBA, BCB, BCN,3
and Mark D. Wiederhold, MD, PhD, FACP 2

Abstract

Surgical anxiety creates psychological and physiological stress, causes complications in surgical procedures,
and prolongs recovery. Relaxation of patients in postoperative intensive care units can moderate patient vital
signs and reduce discomfort. This experiment explores the use of virtual reality (VR) cybertherapy to reduce
postoperative distress in patients that have recently undergone cardiac surgery. Sixty-seven patients were
monitored at IMSS La Raza National Medical Center within 24 hours of cardiac surgery. Patients navigated
through a 30 minute VR simulation designed for pain management. Results were analyzed through comparison
of pre- and postoperative vital signs and Likert scale survey data. A connection was found in several physio-
logical factors with subjective responses from the Likert scale survey. Heavy positive correlation existed
between breathing rate and Likert ratings, and a moderate correlation was found between mean arterial pressure
and Likert ratings and heart rate and Likert ratings, all of which indicated lower pain and stress within patients.
Further study of these factors resulted in the categorization of patients based upon their vital signs and
subjective response, providing a context for the effectiveness of the therapy to specific groups of patients.

Introduction Virtual reality (VR) methods have been previously ex-

plored for postoperative cases, most of which have fo-

W hen faced with upcoming surgeries, patients often

claim a psychological fear of surgical failure, anes-
thesia, or the ‘‘unknown.’’1 A widely accepted cause of
cused on two cases: burn victims and children (see Table 1).
Burn victims have shown to be a popular application of VR
therapy due to the painful nature of postburn physical ther-
surgical anxiety is the recently increasing demands for effi- apy. Past studies have explored pain management of burn
ciency in hospital operations, leading to less time spent by injuries by measuring pain scores, as well as maximal joint
healthcare professionals to assure patients of their well- range of motion immediately and after therapy. Results in-
being. Patients also suggest personal reasons for experiencing dicate that post-therapy pain ratings dropped, patients spent
surgery-related anxiety, including sociodemographic or less time thinking about the pain, and a vast majority enjoyed
psychological variables, or past surgical experiences.2 Pa- the simulation. Similarly, distraction techniques have shown
tients under surgical distress can experience adverse effects promise in use with pediatric operations. While some stud-
on their mental and physiological states, and slowed post- ies show subjective pain measurements decreased under VR
operative recovery.3 Even patients who report rare accounts conditions, others show that no measureable differences
of anxiety are susceptible to physiological changes, including were found in either pain or distress, but the simulations were
increased respiratory rate, heart rate, blood pressure, vaso- qualified as distracting.
constriction, and gastric stasis.4 Intense forms of surgical In this study, we aim to address postoperative anxiety
distress can activate the sympathetic nervous system and through the application of VR distraction therapy. Ad-
downregulate immune functions.5 vancements in technology have allowed the use of VR in
By addressing this issue, hospitals would improve surgery intensive care units (ICUs) to complement standard pain man-
outcomes, patient recovery, and patient psychological and agement techniques. A report by Kho et al. concluded that
physical well-being. Efforts are currently centered on pre- VR techniques are promising in their study of the efficacy of
operative anxiety. Medical interventions, such as mid- video games as an additional tool in physical therapy ICU
azolam, and therapeutic attempts, such as music in waiting patients.7 Another study at the Virtual Reality Medical
rooms, have shown mixed results.6 Center correlates immersion in a virtual world with patients’

1
Hospital General y Regional No. 25 IMSS, Mexico City, Mexico.
2
Virtual Reality Medical Center, San Diego, California.
3
Virtual Reality Medical Institute, Brussels, Belgium.

371
 Table 1. Previous Research of Virtual Reality (VR) Distraction for Surgical Procedures
Title/authors Method Results
The Use of the Virtual Reality as Patients were randomized into two groups: VR (VRG, n = 30) On the first day after surgery, patients in both groups showed
Intervention Tool in the Postoperative and control (CG, n = 30). The response to treatment was decreased functional performance. However, the VRG
of Cardiac Surgery10 assessed through the functional independence measure showed lower reduction (45.712.3) when compared to CG
Cacau Lde A, Oliveira GU, Maynard LG, (FIM), by the 6-minute walk test (6MWT) and the (35.0612.09, p < 0.05) on the first postoperative day, and no
Araújo Filho AA, Silva WM Jr, Nottingham Health Profile (NHP). Evaluations were significant difference in performance on discharge day
Cerqueria Neto ML, Antoniolli AR, performed preoperatively and postoperatively. ( p > 0.05). In evaluating the NHP field, we observed a
Santana-Filho VJ significant decrease in pain score at third assessment
( p < 0.05). These patients also had a higher energy level in
the first evaluation ( p < 0.05). There were no differences
with statistical significance for emotional reactions, physical
ability, and social interaction. The length of stay was
significantly shorter in patients of VRG (9.410.5 days vs.
12.2 1 0.9 days, p < 0.05), which also had a higher 6MWD
(319.9119.3 meters vs. 263.5115.4 meters, p < 0.02).
Managing Pain in Military Populations By constantly being exposed to combat and living in war zones, A multifactorial approach is necessary, and the introduction
with Virtual Reality11 servicemen and women face increased risk of complicated of new approaches and technology can increase the numbers
Wiederhold BK, Wiederhold MD injuries, including amputations, penetrating wounds, spinal of tools available to combat this significant health issue
cord injuries, and traumatic brain injuries (TBIs). In in troops.
addition, many service members may undergo multiple
surgical procedures as a result of serious injury. The
incidence of pain syndromes is significantly higher when

372
present with posttraumatic stress disorder (PTSD) and other
psychiatric disorders such as depression. The combination of
these ‘‘poly-trauma’’ events makes the management of both
acute and chronic pain in military populations challenging.
Comparing Distraction/Relaxation At the present time, most providers treat chronic pain patients Results suggest that there was a greater reduction in self-rated
Modalities with Chronic Pain Patients12 with a combination of analgesics and nondrug approaches. pain when participating in the relaxation imagery session
Stetz MC, Brown KS, Folen RA, Nelson KL, That said, many of these professionals are also starting to enhanced with technology.
Wiederhold BK incorporate the use of technology (e.g., VR and biofeedback)
into their practice. The purpose of this study was to compare
standard chronic pain treatment (i.e., assisted relaxation with
a clinician) with technology-assisted relaxation without a
clinician.
Virtual Reality Pain Control During Burn Patients were U.S. soldiers burned in combat attacks involving Patients reported significantly less pain when distracted with
Wound Debridement of Combat- explosive devices in Iraq or Afghanistan. During the same VR. ‘‘Worst pain’’ (pain intensity) dropped from 6.25 out of
Rrelated Burn Injuries Using Robot- wound care session using a within-subject experimental 10 to 4.50 out of 10. ‘‘Pain unpleasantness’’ ratings dropped
Like Arm Mounted VR Goggles13 design, 12 patients received half of their severe burn wound from ‘‘moderate’’ (6.25 out of 10) to ‘‘mild’’ (2.83 out of
Maani CV, Hoffman HG, Morrow M, cleaning procedure (*6 minutes) with standard of care 10). ‘‘Time spent thinking about pain’’ dropped from 76%
Maiers A, Gaylord K, McGhee LL, pharmacologies and half while in VR (treatment order during no VR to 22% during VR. Patients rated ‘‘no VR’’ as
DeSocio PA randomized). Three 0 to 10 Graphic Rating Scale pain scores ‘‘no fun at all’’ ( < 1 out of 10) and rated VR as ‘‘pretty fun’’
for each of the treatment conditions served as the primary (7.5 out of 10). Follow-up analyses showed VR was
variables. especially effective for the six patients who scored 7 out of
10 or higher (severe to excruciating) on the ‘‘worst pain’’
(pain intensity) ratings.

(continued)
 Table 1. (Continued)
Title/authors Method Results
Virtual Reality and Interactive Simulation Current advances are being made to control pain by integrating When immersion is high, much of the user’s attention is
for Pain Distraction8 both the science of pain medications and the science of the focused on the virtual environment (VE), leaving little
Wiederhold MD, Wiederhold BK human mind. Various psychological techniques, including attention left to focus on other things, such as pain. In this
distraction by VR environments and the playing of video way, VR provides an effective medium for reproducing
games, are being employed to treat pain. In VR environ- and/or enhancing the distractive qualities of guided imagery
ments, an image is provided for the patient in a realistic, for the majority of the population who cannot visualize
immersive manner devoid of distractions. This technology successfully.
allows users to interact at many levels with the VE, using
many of their senses, and encourages them to become
immersed in the virtual world they are experiencing.
The Effect of Virtual Reality on Pain and Thirty-nine inpatients, aged 21 to 57 years (mean 35 years), Because of nonsignificant carryover and order effects, the data
Range of Motion in Adults with Burn with a mean TBSA burn of 18% (range = 3–60%) were were analyzed using simple paired t tests. VR reduced all
Injuries14 studied using a within-subject, crossover design. All patients Graphic Rating Scale pain scores (worst pain, time spent
Carrougher GJ, Hoffman HG, Nakamura D, received their regular pretherapy pharmacologic analgesia thinking about the pain, and pain unpleasantness by 27%,
Lezotte D, Soltani M, Leahy L, Engrav regimen. During physical therapy sessions on two 37%, and 31% respectively), relative to the no VR condition.
LH, Patterson DR consecutive days (VR one day and no VR the other day; Average ROM improvement was slightly greater with the
order randomized), each patient participated in active- VR condition. However, this difference failed to reach
assisted ROM exercises with an occupational or physical clinical or statistical significance ( p = 0.243). Ninety-seven
therapist. At the conclusion of each session, patients percent of patients reported zero to mild nausea after the VR
provided 0 to 100 Graphic Rating Scale measurements of session.
pain after each 10 minute treatment condition. On the day

373
with VR, patients wore a head-position-tracked, medical care
environment excluding VR helmet with stereophonic sound
and interacted in a VE conducive to burn care. ROM
measurements for each joint exercised were recorded before
and after each therapy session.
Virtual Reality on Mobile Phones to With the present randomized controlled study, we intended to A significant reduction of anxiety was obtained after 45
Reduce Anxiety in Outpatient Surgery15 verify the effectiveness of VR in reducing anxiety in patients minutes of operation in the VR group, but not in the
Mosso JL, Gorini A, De La Cerda G, undergoing ambulatory operations under local or regional control group. After 90 minutes, the reduction was
Obrador T, Almazan A, Mosso D, Nieto anesthesia. In particular, we measured the degree to which larger in the experimental group than in the control group.
JJ, Riva G anxiety associated with surgical intervention was reduced by
distracting patients with immersive VR provided through a
cell phone connected to an HMD compared to a no-
distraction control condition.
The Use of Virtual Reality for Needle- Twenty-one children and adolescents were included in an Self-reported and observed pain and distress scores were low,
Related Procedural Pain and Distress in intervention group with nonimmersive VR and another 21 and few significant differences of quantitative data between
Children and Adolescents in a children and adolescents in a control group where they the groups were found. Two themes emerged in the analysis
Paediatric Oncology Unit16 underwent either venous punctures or subcutaneous venous of the interviews; the VR game should correspond to the
Nilsson S, Finnström B, Kokinsky E, port devices. Self-reported pain and distress, heart rate, and child and the medical procedure and children enjoyed the
Enskär K observational pain scores were collected before, during, and VR game and found that it did distract them during the
after the procedures. Semi-structured qualitative interviews procedure.
were conducted in conjunction with the completed
intervention.

(continued)
 Table 1. (Continued)
Title/authors Method Results
Using Cybertherapy to Reduce Twenty-two patients were monitored at IMSS La Raza Likert test data showed that 21 of 22 subjects reported less
Postoperative Anxiety in Cardiac National Medical Center within 24 hours of cardiac surgery. discomfort after navigating through the VE. Physiological
Recovery Intensive Care Units17 Patients navigated through a 30 minute VR simulation data generally supported the Likert data, with 64% of
Vazquez JLM, Santander A, Gao K, designed for pain management. Results were analyzed patients lowering respiratory rate, moderated blood carbon
Wiederhold MD, Wiederhold BK through comparison of pre- and postoperative vital signs and dioxide levels, and decreased diastolic blood pressures in
Likert scale survey data. another 64% of patients.
Virtual Reality as a Pediatric Pain This case study explored the use of VR analgesia with a Using a subjective pain scale (5 faces denoting levels
Modulation Technique: A Case Study18 16-year-old patient with cerebral palsy participating in a of pain), the patient’s overall pain ratings while in the
Steele E, Grimmer K, Thomas B, twice daily physiotherapy program following Single Event VR (experimental) condition were 41.2% less than those
Mulley B, Fulton I, Hoffman H Multi-Level Surgery. Over 6 days, the patient spent half of in the no-VR (control) condition.

374
his physiotherapy sessions using VR and the other half
without (order randomized). Traditional pharmacological
pain management was administered throughout the trial.
Cybertherapy—New Applications for 27 patients have been participated in this preliminary report The majority of patients demonstrated comfort with virtual
Discomfort Reductions. Surgical Care from 3 public hospitals from Mexico city in 2006. The VR scenarios during surgical procedures or hospitalization.
Unit of Heart, Neonatology Care Unit, scenarios were developed in the Virtual Reality Medical
Transplant Kidney Care Unit, Delivery Center of San Diego CA, and the HMD is from the Southern
Room-Cesarean Surgery and University of los Angeles, CA.
Ambulatory Surgery, 27 Case Reports19
Mosso JL, Rizzo S, Wiederhold B, Lara V,
Flores J, Espiritusanto E, Minor A,
Santander A, Avila O, Balice O,
Benavides B
VR FOR PAIN MANAGEMENT IN CARDIAC SURGERY 375

attention to the virtual environment (VE) as opposed to physician installed the head-mounted display on the patient’s
pain.8 Immersiveness also has been shown to have beneficial head to display a VR simulation. Meanwhile, a projector
effects on various physiological factors that link to anxiety, emitted the same simulation on the unit wall so the clinical
such as heart rate, respiratory rate, skin temperature, and skin team could follow along. The simulation consisted of a set of
resistance.9 five cybertherapy environments (developed by the Virtual
Reality Medical Center in San Diego, CA): Cliff, Dream
Methodology Castle, Enchanted Forest, Icy Cool World, and Drive, Walk,
Bike. The patient was allowed to explore the VE for
Patients (n = 67; 25 female, 42 male) in the cardiac surgery
30 minutes. Throughout the simulations, all patients were
department of IMSS La Raza National Medical Center were
conscious, had normal vision, free movement of limbs, and
asked to participate in the study. Each patient was moni-
did not have airway cannulation or hemodynamic disorders.
tored in hyperacute units within 24 hours of their cardiac
Postsimulation data were collected through a questionnaire
surgery, which included mitral valve replacement, aortic valve
and vital signs.
replacement, tricuspid valve replacement, coronary stent in-
sertion, coronary revascularization, tricuspid plasty, ventric-
Results
ular communication repair, and bridge tricuspid resection.
The clinical team consisted of four physicians, nurses, and Data analysis is composed of comparisons between pre
technicians. Procedural instructions were given to the pa- and post cybertherapy vital signs and subjective scale re-
tients after their admission to the ICU. Consent to participate sults using a Likert scale design. Complications included
and basic demographic information were collected. A clini- a 68 year old female patient who experienced cardiac ar-
cal professional recorded relevant vital signs and adminis- rhythmia during treatment, and three patients who presented
tered the presimulation questionnaire to measure patient signs of nausea and vertigo that interrupted the cyberther-
discomfort. Once all preliminary data were collected, the apy session.

FIG. 1. Correlation of physiological factors with change in subjective pain measurements. (A) Patients’ initial respiratory
rates and change in subjective responses were measured against each other. Upwards trend line indicates that patients with
higher respiratory rates experienced a larger decrease in their reported pain. (B) Subjects with higher initial heart rates
generally reported a larger decrease in pain post-therapy, while other subjects with lower to normal heart rates indicated
little to no change in pain. (C) Initial mean arterial pressure and change in subjective ratings showed slight positive
correlation. (D) Initial oxygen saturation and change in subjective pain responses showed slight correlation, possibly
explained by the small range of possible oxygen saturation within healthy subjects.
376 MOSSO-VÁZQUEZ ET AL.

FIG. 2. Correlation of change in physiological factors with change in subjective pain measurements. (A) Significant
correlation existed between change in Likert scale responses and respiratory rate. (B) A positive sloping trend line for
change in heart rate and change in subjective responses positively supports the calming effect of the simulation. (C) As
opposed to heart rate, a decreasing trend for change in mean arterial pressure and change in Likert ratings indicates the same
pain reducing effect. (D) Change in oxygen saturation and Likert responses showed little correlation, again, most likely due
to the small range of oxygen saturation.

Overall, the results of the therapy were positive (see using Boolean values based upon their change in responses
Fig. 1). Of the 67 patients, 59 patients (88%) reported a (see Fig. 3). For each physiological factor, for example heart
decreased level of pain experienced post-therapy. The mean rate, patients were identified with ‘‘improvements in heart
change in the Likert scale was 3.75, which corresponds to a rate and reported survey response,’’ ‘‘improvement in heart
decrease from ‘‘severe’’ to ‘‘moderate’’ or ‘‘moderate’’ to rate, but not survey response,’’ ‘‘improvement in survey
‘‘light.’’ Physiologically, 25 patients (37.3%) experienced response, but not in heart rate,’’ and ‘‘improvement in neither
reduced heart rates, 35 (52.2%) experienced reduced mean heart rate nor survey response.’’ By categorizing patients
arterial pressure, and 14 (64%) of 22 patients tested for re- into these groups, a visual representation of the type of pa-
spiratory rate experienced a reduction. tients that should undergo this therapy can be seen. Re-
Respiratory rate measurements were plotted against the spiratory rate was not taken into consideration for this
change in subjective responses before and after the therapy analysis due to the small sample size.
treatment. The correlation had a linear fit, with an R2 value of
0.925. Similarly, heart rate and mean arterial pressure were
Discussion
plotted against the survey responses, showing positive cor-
relation but with much higher variation (R2 = 0.025 and After cardiac surgery, it is common for patients to show
R2 = 0.02 respectively). Oxygen saturation showed similar symptoms of worry, apprehension, and depression. The mel-
trends. However, they were not as substantial as respiratory ancholic state can last many weeks and disrupt recovery, both
rate, heart rate, or mean arterial pressure. psychologically and physiologically. Patient relaxation can
Interestingly, when the changes in the physiological factors reduce postsurgical pain, improve overall well-being, and
were analyzed against the change in Likert scales, similar prevent hematomas and other complications. This experiment
correlations existed (see Fig. 2). Thus, not only is there a trend has shown that navigating through a VE can reduce psycho-
in the match between objective and subjective pain mea- logical stress. Improvements could be made to the therapy
surements, but the level of pain reduction matches as well. content or procedure to benefit those who did not report pos-
To provide further context to the patients who were pos- itive changes in vital signs or discomfort, although we recog-
itively affected by the therapy, patients were categorized nize that cybertherapy may not be suitable for some patients.
VR FOR PAIN MANAGEMENT IN CARDIAC SURGERY 377

FIG. 3. Categorization of patients using Boolean values. (A) Four distinct groups are seen using heart rate and subjective
responses. Notably, those who improved in neither category had initially low heart rates and pain responses, whereas those
who improved in both started with higher values. (B) Three groups are visualized, with patients that improved in MAP and
Likert categories having a wide range of MAP but high pain ratings. (C) As expected, oxygen saturation values were evenly
distributed across the healthy range.

It is evident from past studies to date that presence is an Acknowledgments

important factor in delivering pain distraction. Hoffman et al. We thank the National Institutes of Health, National Institute
describes how immersion and presence enhances distractive on Drug Abuse for funding of the virtual world development.
properties of the VE.20 Wiederhold et al. presented com- We also thank the participants who were willing to spend
parisons of subjects that experienced varying levels of VR time with our clinical team to answer questions and surveys.
immersion, noting significant differences in not only sub-
jective responses but also physiology.9 Considering the in-
fluence of immersion on the efficacy of pain distraction, a Author Disclosure Statement
future improvement to this study could correlate the change No competing financial interests exist.
in reported Likert pain ratings to a presence rating.
This is an uncontrolled study, possibly leading to over- References
estimation of effectiveness. While not as extensive as a
controlled trial, it is conclusive that there are changes in 1. Pritchard MJ. Identifying and assessing anxiety in pre-
physiology before and after the virtual simulation, especially operative patients. Nursing Standard 2009; 51:35–40.
in the patient-reported discomfort scale. As this study was 2. Dirik G, Karanci AN. Predictors of pre- and postoperational
performed under real-world clinical conditions, the validity anxiety in emergency surgery patients. Journal of Psycho-
somatic Research 2003; 4:363–369.
and clinical utility of the observed data are significant.
3. Kiecolt-Glaser JK, Page GG, Marucha PT, et al. Psycho-
VR has shown to be a noninvasive and innocuous pro-
logical influences on surgical recovery. American Psy-
cedure to improve postsurgical distress in ICUs. Using this chologist 1998; 11:1209–1218.
technology allows patients to interact at many levels with 4. Bailey L. Strategies for decreasing patient anxiety in the
the VE, using multiple senses, and encourages them to perioperative setting. Association of Perioperative Regis-
become immersed in the virtual world they are experi- tered Nurses Journal 2010; 4:445–457.
encing. In this way, VR provides an effective medium for 5. Moon JS, Cho KS. The effects of handholding on anxiety in
reproducing and/or enhancing the distractive qualities of a cataract surgery patients under local anesthesia. Journal of
pain treatment. VR in ICUs represent a tremendous social Advanced Nursing 2001; 3:407–415.
impact in patients that are in critical condition by acting as 6. Ni CH, Tsai WH, Lee LM, et al. Minimising preoperative
additional support mechanism to avoid and reduce post- anxiety with music for day surgery patients—a randomised
surgical distress. clinical trial. Journal of Clinical Nursing 2012; 21:620–625.
378 MOSSO-VÁZQUEZ ET AL.

7. Kho ME, Damluji A, Zanni JM, et al. Feasibility and ob- Studies in Health Technology & Informatics 2009; 142:
served safety of interactive video games for physical re- 195–200.
habilitation in the intensive care unit: a case series. Journal 16. Nilsson S, Finnström B, Kokinsky E, et al. The use of
of Critical Care 2011; 2:219.e1–e219.e6. virtual reality for needle-related procedural pain and dis-
8. Wiederhold MD, Wiederhold BK. Virtual reality and in- tress in children and adolescents in a paediatric oncology
teractive simulation for pain distraction. Pain Medicine unit. European Journal of Oncology Nursing 2009; 13:102–
2007; S3:S182–188. 109.
9. Wiederhold BK, Davis R, Wiederhold MD. The effects of 17. Vazquez JLM, Santander A, Gao K, et al. Using cyber-
immersiveness on physiology. Virtual Environments in therapy to reduce postoperative anxiety in cardiac recovery
Clinical Psychology & Neuroscience 1998; 58:52–60. intensive care units. Journal of Anesthesia & Clinical
10. Cacau Lde A, Oliveira GU, Maynard LG, et al. The use of Research 2013; 4:363.
virtual reality as intervention tool in the postoperative of 18. Steele E, Grimmer K, Thomas B, et al. Virtual reality as a
cardiac surgery. Revista brasileira de cirurgia cardiovas- pediatric pain modulation technique: a case study. Cy-
cular 2013; 28:281–289. berPsychology &Behavior 2003; 6:633–638.
11. Wiederhold BK, Wiederhold MD. Managing pain in mili- 19. Mosso JL, Rizzo S, Wiederhold B, et al. Cybertherapy—
tary populations with virtual reality. NATO Science for new applications for discomfort reductions. Surgical care
Peace & Security Series—E: Human & Societal Dynamics unit of heart, neonatology care unit, transplant kidney care
2012; 91:75–93. unit, delivery room-cesarean surgery and ambulatory sur-
12. Stetz MC, Brown KS, Folen RA, et al. Comparing gery, 27 case reports. Studies in Health Information &
distraction/relaxation modalities with chronic pain patients. Informatics 2007; 125:334–336.
NATO Science for Peace & Security Series—E: Human & 20. Hoffman HG, Richards T, Coda B, et al. The illusion of
Societal Dynamics 2012; 91:171–177. presence in immersive virtual reality during an fMRI brain
13. Maani CV, Hoffman HG, Morrow M, et al. Virtual reality scan. CyberPsychology & Behavior 2003; 6:127–131.
pain control during burn wound debridement of combat-
related burn injuries using robot-like arm mounted VR
goggles. The Journal of Trauma 2011; 71:S125–130. Address correspondence to:
14. Carrougher GJ, Hoffman HG, Nakamura D, et al. The ef- Prof. Mark D. Wiederhold
fect of virtual reality on pain and range of motion in adults Virtual Reality Medical Center
with burn injuries. Journal of Burn Care & Research 2009; 9565 Waples St., Suite 200
30:785–791. San Diego, CA 92121
15. Mosso JL, Gorini A, De La Cerda G, et al. Virtual reality
on mobile phones to reduce anxiety in outpatient surgery. E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0052

Virtual Reality for the Induction of Positive Emotions

in the Treatment of Fibromyalgia:
A Pilot Study over Acceptability, Satisfaction,
and the Effect of Virtual Reality on Mood

Rocio Herrero, PhD,1 Azucena Garcı́a-Palacios, PhD,1,2 Diana Castilla, PhD,1,2

Guadalupe Molinari, BA,1 and Cristina Botella, PhD1,2

Abstract

One of the most important aspects of fibromyalgia syndrome (FMS) is its impact on quality of life, increasing
negative emotions and dysfunctional coping strategies. One of these strategies is to avoid activities, especially
meaningful activities, which reduces positive reinforcement. Commencing significant daily activities could enable
chronic patients to experience a more fulfilling life. However, the main difficulty found in FMS patients is their
willingness to start those activities. Promoting positive emotions could enhance activity management. The aim of
this paper is to present a description of a system along with data regarding the acceptability, satisfaction, and
preliminary efficacy of a virtual reality (VR) environment for the promotion of positive emotions. The VR
environment was especially designed for chronic pain patients. Results showed significant increases in general
mood state, positive emotions, motivation, and self-efficacy. These preliminary findings show the potential of VR
as an adjunct to the psychological treatment of such an important health problem as chronic pain.

Introduction tested the efficacy of psychological programs for FMS and

have revealed small yet robust effect sizes of short- and long-
term efficacy.8 The conclusion was that psychological pro-
F ibromyalgia syndrome (FMS) is a chronic musculo-
skeletal pain condition of unknown etiology, character-
ized by widespread pain and muscle tenderness, and often
grams are promising interventions for FMS, even though
there is still room for improvement. Further research is nee-
accompanied by fatigue, sleep disturbance, and depressed ded to respond more appropriately to patients with FMS.
mood.1 It is estimated that around 2–4% of the general The use of information and communication technologies
population suffer from FMS.2 FMS is a complex condition (ICTs) in the field of psychological treatments has developed
involving biological, psychological, and social factors, which at a fast pace in recent years. ICTs offer different methods
cause a negative impact on patients’ quality of life. This that can help to improve the effectiveness of some compo-
condition is becoming an important public health problem nents of treatment. One of these elements is virtual reality
because it is associated with an increased use of health ser- (VR), used for treating a range of psychological disor-
vices, emergency room visits, and medication, and increased ders.9,10 In the field of pain, VR has been used mainly in the
work disability.3,4 The treatment of FMS has a poor prog- treatment of acute pain associated with medical proce-
nosis for recovery,5 and it is considered a challenge for health dures.11,12 However, the use of VR in chronic pain is scarce.
professionals. Several studies support that FMS is better A recent systematic review about the use of VR found
addressed from a multidimensional perspective, being more promising results for the efficacy of distraction for pain
effective than management from single approaches.6 In this reduction.13 Some researchers have explored the use of a VR
sense, psychological aspects are among the best predictors of mirror in the treatment of complex regional pain syndrome
disability caused by chronic pain7 and constitute a promising and phantom limb pain.14,15 The literature on the applica-
component in the treatment for FMS. Such programs include tions of VR in the field of chronic pain is very scarce. Keefe
various components such as relaxation, mindfulness, cogni- et al.16 conducted a review of this issue and found some
tive therapy, and activity management. Several studies have preliminary studies where VR could be a good approach to

1
Department of Basic and Clinical Psychology and Psychobiology, Universitat Jaume I, Castelló de la Plana, Spain.
2
Ciber Fisiopatologı́a de la Obesidad y la Nutrición (CIBEROBN) Hospital Clı́nico Universitario Santiago de Compostela Choupana,
Santiago de Compostela, Spain.

379
380 HERRERO ET AL.

expose patients to movements that they may fear or avoid Measures

due to pain. It has been suggested that mirrors and VR could Screening and psychological diagnostic assessment was
be potential new treatments for this condition. Our research conducted using the Structured Clinical Interview for DSM-IV
team realized a pilot study showing the utility of VR to Axis I Disorder (SCID-I)24 and the Structured Clinical Inter-
induce relaxation in FMS.17 Our aim is to contribute to the view for DSM-IV Axis II Personality Disorder (SCID-II).25
exploration of the use of VR in the treatment of chronic pain. The outcome measures chosen to determine if the VR pro-
Chronic pain is characterized by a loss of valued activities, cedure could produce changes from pretest to posttest were:
which has an effect on the mood of the sufferer. The task of
making FMS patients become more active is challenging. As  Mood state (MS): Patients were asked to assess their
a chronic condition, it leads to a dysfunctional pattern of general mood state, using a pictorial scale with seven
activity that is very difficult to reverse. The activity man- facial expressions ranging from ‘‘very sad’’ to ‘‘very
agement component of the program consists of setting goals happy.’’
related to activities that are significant for the patients and  Pain and fatigue intensity: Patients were asked to assess
getting patients to perform those activities progressively, their pain and fatigue intensity, using a numeric rating
balancing the period of rest and activity. Feelings such as low scale (NRS) comprising 11 points, ranging from 0 = ‘‘no
mood and fear and symptoms of the condition—pain and, pain or fatigue’’ to 10 = ‘‘worst pain or fatigue.’’
more importantly, fatigue—get in the way of the willingness  Motivation and self-efficacy: Patients were asked to
to perform the activities, causing low motivation and a poor assess their motivation and sense of self-efficacy re-
sense of self-efficacy. Positive emotions can help to coun- garding specific activities that they chose in a previous
teract the effect of these aspects. The influence of positive session, using a NRS comprising 7 points, ranging from
emotions influences cognitive processes, well-being, and 1 = ‘‘none’’ to 7 = ‘‘very much.’’
health,18,19 promoting flexible and creative thinking and  Intensity of several emotions: Participants were asked
playing an important role in building of psychological to rate the intensity of different emotions (joy, sadness,
strength and intellectual and social resources.20 The pro- anger, surprise, anxiety, relaxation, and vigor/energy),
motion of positive emotions may help in the regulation of from 1 = ‘‘not at all’’ to 7 = ‘‘completely.’’
negative emotions or, in promoting the increase of available Following induction, an opinion questionnaire was admin-
resources, to maintain long-term gains and to provide people istered to assess the participants’ acceptability and satisfaction
with the strength to become more resilient. Our research regarding the VR. Participants rated four topics using a scale
team is currently working on the study of the effect of pos- from 1 to 10: ‘‘To what extent are you satisfied with the VR
itive emotions in the treatment of mental and health prob- component that you received?’’; ‘‘To what extent do you feel
lems, and in the use of technology to promote well-being.21 that VR was useful for you?’’; ‘‘To what extent do you feel
To achieve this goal, we rely on the potential of VR. We that VR annoyed you?’’; ‘‘To what extent would you rec-
have developed a VR component using an adaptive display ommend VR to others with the same problem as you?’’
for the delivery of an adjunct to the activity management In addition, five more questions were administered in order
component.22 The use of multiple sensory multimedia cues to compare before induction with after induction. Participants
(music, images, and videos) that VR offers prompted us to were asked to rate on a scale where 1 = ‘‘much worse’’ to
use this technology for inducing positive emotions in FMS 7 = ‘‘much better’’ the change from before induction to after
patients. Before carrying out a controlled study to analyze induction in pain, fatigue, general mood state, motivation,
the effectiveness of the VR, a pilot study was designed to and self-efficacy.
explore users’ opinions and acceptance, and to collect some
initial data about its utility to increase positive emotions and
Virtual environment
promote motivation and self-efficacy.
The configuration used a range of devices: two PC com-
Materials and Method puters, a 3 · 4 meter screen made of reflective material, two
projectors, and a Dolby 7.1 surround sound audio system.
Participants
The first PC had the graphical outputs from its graphic card
The sample comprised 40 patients, all women ranging in connected to the projector, which were used to project the
age from 27 to 66 years (M = 48.8; SD = 9.3) and diagnosed environment onto a metacrilate screen. The second PC hos-
with FMS according to ACR criteria.23 Of these, 52.5% had ted the therapist’s application and controlled the features of
an additional diagnosis of anxiety disorder, and 65% of de- the virtual environment that were shown to the patient.
pressive disorder. They have suffered chronic pain for a Participants were placed in front of the screen in groups of
range of 1–30 years (M = 10; SD = 7.1). Most of the sample six people. One of the therapists was in charge of operating
(55%) had an elementary level of education, 12.5% had not the VR system during the 20 minute session.
finished elementary studies, 15% finished high school, and The VR environment was an adaptive display named
17.5% had a university degree. Regarding work status, EMMA, developed in the framework of EU funded Project
47.5% were active workers, 32.5% were housewives, and (IST-2001-39192-EMMA, Engaging Media for Mental
20% did not work. Of those who were not working, 12.5% Health Applications). EMMA is a flexible VR environment
were on sick leave. that includes five predefined scenarios aimed to induce
Exclusion criteria included severe mental illness, mental emotions (desert, beach, forest, snowy landscape, and a
retardation, or being involved in the process of obtaining dis- meadow). It is possible to change the weather or the time
ability compensation. All participants agreed to participate and (day and night), and to include sounds, images, and videos.
signed an informed consent form before starting the study. This VR environment has demonstrated its capacity to
VR FOR THE TREATMENT OF FIBROMYALGIA 381

Table 1. Fragment of the Narrative

Included in the VR Procedure
Pain is an important challenge, but with perseverance,
courage, optimism and determination you can get
what you want to achieve your goals. Don’t let pain
prevent you from doing what you want to do. Begin
with small and short-term goals, and, little by little,
progress to bigger and long-term goals. Remember
that there is something in you that is bigger than any
obstacle.
Now, write your goal on this board, a little goal for this
week. Write: I will. . Read it out loud. Your strength
is your determination and courage, courage that is
inside you, courage that you demonstrate every day,
facing pain.
Now, let’s walk around the room showing off your goals
[walk with the board].
Start doing this activity today; include it in your routine
FIG. 1. Treatment setting for the delivery of virtual reality because it is something you want to do. When your energy
(VR) sessions. goes down, remember this session.
If you believe you are tired, you are tired.
If you believe you won’t be able to do it, you won’t
induce several emotions26 and its efficacy in the treatment of do it.
stress-related disorders.27 If you believe that you would like to win, but you won’t
In this study, the scenario chosen was the beach, including be able to, you will lose.
music, sounds, narratives, and images selected especially If you believe you will lose, you have already lost.
to induce positive emotions and promote motivation, self- Because life teaches us
efficacy, and behavior activation. Figures 1, 2 and 3 show That success begins with the willingness to succeed.
images of the setting and the VR environment. Everything is in our minds.
Melodies with positive valence and high arousal were Think big and your facts will grow.
included from the International Affective Digitized Think small and you will be left behind.
Sounds.28,29 Besides, other melodies were selected, follow- Believe you can, and you will.
Everything is in your mind.
ing two rules: tempo and mode.30 Research suggests that a If you believe you are advanced, you really are.
fast tempo evokes energy and activation, and a major mode is Positive thoughts bring positive energy.
related to positive mood.31 Only when you think positively
Images were selected from the International Affective Can you start to change your world.
Picture System,32 meeting the criteria of positive valence and You make the change possible.
high arousal. Other images were also included, selected ac- The battle of life is not won by the strongest or fastest
cording to three dimensions: color, brightness, and satura- man,
tion. Research indicates to evoke positive emotions, it is Because, sooner or later, the man who wins is the one who
important to use images with bright and high saturated col- believes he can win.
ors, with a prevalence of green and blue colors.

FIG. 2. An example of narratives and images offered to FIG. 3. Another example of narratives and images offered
the participants during the induction. to the participants during the induction.
382 HERRERO ET AL.

third session included information about how to program an

activity management plan and looked at choosing the activ-
ities for each patient. At the end of the third session, patients
chose the activities to be performed on the following week
and went through the VR component as an adjunct to increase
motivation related to the performance of the chosen activities.
The induction lasted approximately 20 minutes. Before and
after going through the VR environment, participants filled
out the outcome measures. Participants received three more
therapeutic sessions to progress in the activity management
program.

Results
Figure 4 displays the mean and standard deviation of the
opinion and acceptability of the VR system. Results showed a
FIG. 4. Mean and standard deviation of the opinion and
acceptability of the system. high level of satisfaction with the VR (M = 8.84; SD = 1.365),
and participants recommended the use of the VR to others
(M = 9.22; SD = 1.058). Regarding the usefulness, participants
considered the VR to be highly useful (M = 9.00; SD = 1.592).
In addition, we included narratives designed by a team of
In addition, participants considered that the VR was not an-
therapists with expertise in CBT treatment for chronic pain in
noying (M = 0.49; SD = 1.465).
order to induce motivation and positive emotions in FMS
Table 2 summarizes the results of the t test for related
sufferers (see Table 1).
samples and the Cohen’s d calculated to examine the before
The characteristics of this VR environment allow VR
and after induction results. Regarding pain and fatigue in-
sessions to be performed in a group. This is important in the
tensity, there was a decrement from pretest to posttest, but it
case of FMS, given that group therapy is recommended for
was not statistically significant. However, there was a sig-
chronic pain sufferers.33
nificant improvement in mood state from pre- to post-session
with a moderate effect size. Regarding self-efficacy and
Procedure
motivation related to meaningful activities, there was a sig-
Participants were recruited from the rheumatology unit of nificant increase in both variables with small effect sizes.
the Hospital General de Castellon. The rheumatologist gave Finally, for intensity of emotions, results showed significant
general information about the study and referred FMS increases in joy, surprise, calmness, and vigor. In addition,
patients to LabPsitec at Jaume I University. All subjects at- significant decreases in sadness and anxiety were observed.
tended voluntarily. Once the participants gave written in- The biggest effect sizes were found in calmness and joy. No
formed consent, the SCID-I and SCID-II were administered differences were found in anger.
to determine if the patients met the inclusion criteria. The Table 3 summarizes the percentage results for the com-
group therapy sessions lasted 2 hours and were attended by parison questions before and after induction. The results
six patients and two therapists in each session. After this, all show that 52.63% of participants felt somewhat better after
participants received two sessions of psycho-education about induction regarding their pain, 21.05% felt the same, 15.79%
FMS and about the activity management component. The felt better, and 10.52% felt much better. Only 7.5% reported

Table 2. Results of the Efficacy of the VR Induction Procedure

Pretest Posttest
n Mean (SD) Mean (SD) t p Cohen’s da
Pain 40 5.07 (2.03) 4.82 (2.24) 1.759 0.086 0.12
Fatigue 40 4.36 (2.49) 4.18 (2.49) 0.764 0.449 0.07
Mood State 39 4.69 (1.26) 5.21 (1.17) - 4.687 0.000 - 0.43
Activities
Self-efficacy 36 4.66 (1.70) 5.11 (1.52) - 2.394 0.022 - 0.30
Motivation 32 4.55 (1.65) 4.96 (1.65) - 2.652 0.012 - 0.25
Emotion
Joy 40 4.25 (1.53) 4.80 (1.44) - 3.626 0.001 - 0.37
Sadness 40 2.43 (1.52) 2.07 (1.44) 2.211 0.033 0.24
Anger 39 1.44 (1.02) 1.28 (0.76) 1.030 0.310 0.18
Surprise 40 2.40 (1.82) 3.05 (2.01) - 2962 0.005 - 0.34
Anxiety 39 2.26 (1.52) 2.10 (1.54) 1.098 0.279 0.10
Calmness 40 3.60 (1.95) 4.73 (1.60) - 3.984 0.000 - 0.63
Vigor/Energy 40 3.73 (1.65) 4.35 (1.63) - 3.007 0.005 - 0.38
a
What Cohen (1988) defines as d = 0.2 are regarded as a ‘‘small’’ effect size, d = 0.5 as ‘‘medium,’’ and d = 0.8 as ‘‘large.’’
VR FOR THE TREATMENT OF FIBROMYALGIA 383

Table 3. Results in Percentage for the Comparison This work contributes to the use of ICT and, specifically, VR
Questions Before and After Induction in a field where research is still very scarce—chronic pain.16
in Pain, Fatigue, Mood State, This is the first study testing a VR procedure for induction of
Self-Efficacy, and Motivation positive emotions, and could be an important step for the im-
Mood provement of psychological treatments in chronic pain pa-
Pain Fatigue state Self-efficacy Motivation tients, given the importance of positive emotions to promote
significant activities as an essential component of well-being.
Much worse 0 0 0 2.5 2.5 These findings encourage us to continue with this line of re-
Worse 0 0 0 2.5 0 search, to explore concretely the efficacy of this procedure in a
Somewhat 7.5 2.5 0 0 2.5 controlled study in order to improve patients’ quality of life.
worse Our work also contributes to a different way of delivering
Same 27.5 33.3 21.1 17.9 12.5 VR. We used a large screen and not a head mounted display,
Somewhat 42.5 41.7 44.7 33.3 35.9 as it is usual in VR therapy. Our study demonstrated that it is
better
Better 12.5 11.1 15.8 30.8 33.3 possible to deliver a VR therapeutic component in a group
Much better 10.0 11.1 18.4 12.8 12.8 setting. This is important in the case of FMS, given that
group therapy is recommended for chronic pain sufferers.33
The main limitation of this study is that our data are from a
feeling a little worse. Regarding fatigue, 50% of participants single VR induction, without an evaluation of a long-term
felt the same, 37.5% felt somewhat better, and 12.5% felt effect. Our main aim was to explore if it was feasible to use
better. Only one participant reported feeling somewhat the VR procedure in this population. Given their dysfunc-
worse. Regarding general mood state, 33.33% of participants tional and chronic condition, we wanted to examine if pa-
felt somewhat better after induction, 27.78% felt the same, tients felt comfortable with the use of VR in a usual CBT
27.78% felt better, and 11.11% felt much better. In the same group session. This aim was achieved in a significant number
way, 57.9% of participants felt better after induction in terms of participants, where not only was not only feasible, it also
of their sense of self-efficacy regarding the activities chosen had positive effects. Further research is needed to explore the
in the activity management plan, 15.79% felt the same, efficacy of the repeated use of this VR procedure within a
15.79% felt somewhat better, and 10.52% felt much better. CBT program. Another limitation of this study is the absence
Only two participants reported feeling worse or much worse. of a control group, but our aim was to develop a VR procedure
With regard to motivation, 57.9% of participants felt better designed for a specific population and test it in the context of
after induction, 21.05% felt somewhat better, 10.52% felt the real treatment. Our next step will consist of designing a control
same, and 10.52% felt much better. Only two participants study in order to compare the VR procedure with other VR
reported feeling somewhat worse or much worse. environments validated as mood induction procedures.
Discussion
Acknowledgments
This study presents data of the opinion, acceptance, and
The research presented in this paper was funded in
preliminary efficacy of a VR procedure for the induction of
part by Fundació La Marató de TV3 (Ajuts de la Marató
positive emotions and motivation as an adjunct to an activity
de TV3 2006), Ministerio de Educación y Ciencia, Spain;
management component for the psychological treatment of
PROYECTOS CONSOLIDER-C (SEJ2006-14301/PSIC),
FMS.
by Fundació Caixa Castelló-Bancaixa (P11B2009-30);
Forty patients received this procedure within the content
and by Generalitat Valenciana, Redes de Excelencia ISIC
of a CBT group session. Most patients reported feeling better
(ISIC/2012/012). CIBER Fisiopatologia de la Obesidad y
after going through the VR procedure and being more mo-
Nutricion is an initiative of ISCIII CB06/03/0052 from
tivated to become involved in meaningful activities, showing
the Spanish Government.
that it is feasible to deliver a VR procedure for the induction
of positive emotions as an adjunct to the activity manage-
Author Disclosure Statement
ment component, and it had a positive effect on patients.
Furthermore, all patients highly recommend the use of VR No competing financial interests exist.
and considered it was a useful tool in their treatment.
This is an important result, given that the chronicity of References
the dysfunctional behavior pattern in FMS sufferers makes
1. Theadom A, Cropley M, Humphrey KL. Exploring the role
the task of becoming active very challenging. The activity
of sleep and coping in quality of life in fibromyalgia.
management component consists of setting goals related
Journal of Psychosomatic Research 2007; 62:145–151.
to activities that are meaningful for the patients and pro- 2. Mease P. Fibromyalgia syndrome: review of clinical pre-
gressively encouraged them to perform those activities in a sentation, pathogenesis, outcome measures and treatment.
balanced way. Negative emotions are a barrier to achieving Journal of Rheumatology 2005; 75:6–21.
therapeutic goals, causing low motivation and low self- 3. Langley PC. The prevalence, correlates and treatment of
efficacy. Our VR environment was designed to promote pain in the European Union. Current Medical Research &
positive emotions and motivation, and offers preliminary Opinion 2011; 27:463–480.
data on the possibility of using its positive effects in en- 4. Spaeth M. Epidemiology, costs, and the economic burden
couraging FMS sufferers to become involved in meaning- of fibromyalgia syndrome: efficacy of operant behavioral
ful activities to improve their mood, emotional well-being, and cognitive behavioral treatments. Arthritis Research &
and quality of life. Therapy 2009;11:2.
384 HERRERO ET AL.

5. Garcı́a-Campayo J, Magdalena J, Magallon R, et al. A Cyberpsychology, Behavior, and Social Networking 2012;
meta-analysis of the efficacy of fibromyalgia treatment 15:78–84.
according to level of care. Arthritis Research & Therapy 22. Herrero R, Castilla D, Vizcaı́no Y, Molinari G, Garcı́a-
2008; 10:15. Palacio A, Botella C. Avances en el tratamiento psicológico
6. Hauser W, Bernardy K, Arnold B, et al. Efficacy of multi- de la fibromialgia: el uso de la realidad virtual para la
component treatment in fibromyalgia syndrome: a meta- inducción de emociones positivas y la promoción de la
analysis of randomized controlled clinical trials. Arthritis & activación comportamental. Un estudio piloto. Revista
Rheumatology 2009; 61:216–224. Argentina de Clı́nica Psicológica, 2013; 22:111–120.
7. Van Houdenhove B, Egle UT. Fibromyalgia: a stress dis- 23. Wolfe F, Smythe H, Yunus MB, et al. The American Col-
order? Piecing the biopsychosocial puzzle together. Psy- lege of Rheumatology 1990 criteria for the classification of
chotherapy & Psychosomatics 2004; 73:267–275. fibromyalgia. Arthritis & Rheumatism 1990; 33:160–172.
8. Glombiewski JA, Sawyer AT, Gutermann J, et al. Psy- 24. First MB, Spitzer RL, Gibbon M, et al. (1996) Structured
chological treatments for fibromyalgia: a meta-analysis. clinical interview for DSM-IV axis I disorders, clinician
Pain 2010; 151:280–295. version (SCID-I). Washington, DC: American Psychiatric
9. Powers MB, Emmelkamp P. Virtual reality exposure ther- Press, Inc., 1996. (Spanish version published by Masson,
apy for anxiety disorders: a meta-analysis. Journal of An- 1999).
xiety Disorders 2008; 22:561–569. 25. First MB, Gibbon M, Spitzer RL, et al. (1997) Structured
10. Opris D, Pintea S, Garcı́a-Palacios A, et al. Virtual reality clinical interview for DSM-IV axis II personality disorders,
exposure therapy in anxiety disorders: a quantitative meta- (SCID-II). Washington, DC: American Psychiatric Press,
analysis. Depression & Anxiety 2012; 29:85–93. Inc., 1997. (Spanish version published by Masson, 1999).
11. Hoffman HG, Garcia-Palacios A, Patterson DR, et al. The 26. Baños RM, Liaño V, Botella C, et al., eds. Persuasive
effectiveness of virtual reality for dental pain control: a technology: lecture notes in computer science. Berlin/
case study. CyberPsychology & Behavior 2001; 4:527–535. Heidelberg: Springer-Verlag, pp. 7–15.
12. Hoffman HG, Patterson DR, Seibel E, et al. Virtual reality 27. Baños RM, Guillen V, Quero S, et al. A virtual reality
pain control during burn wound debridemant in the hy- system for the treatment of stress-related disorders: a pre-
drotank. Clinical Journal of Pain 2008; 24:299–304. liminary analysis of efficacy compared to a standard cog-
13. Malloy KM, Milling LS. The effectiveness of virtual reality nitive behavioural program. International Journal of Human
distraction for pain reduction: a systematic review. Clinical Computer Studies 2011; 69:602–613.
Psychology Review 2010; 30: 1011–1018. 28. Bradley MM, Lang PJ. (1999) International affective digitized
14. Cole J, Crowle S, Austwick G, et al. Exploratory findings sounds (IADS): Stimuli, instruction manual and affective
with virtual reality for phantom limb pain; from stump ratings. Technical report B-2. Gainesville, FL: The Center for
motion to agency and analgesia. Disability & Rehabilita- Research in Psychophysiology, University of Florida.
tion 2009; 31:846–854. 29. Yik MSM, Russell JA, Barrett LF. Structure of self-reported
15. Gaggioli A, Amoresano A, Gruppioni E, et al. A myoelectric- current affect: integration and beyond. Journal of Personality
controlled virtual hand for the assessment and treatment of & Social Psychology 1999; 77:600–619.
phantom limb pain in trans-radial upper extremity amputees: 30. Gabrielsson A, Lindstrom E. (2001) The influence of mu-
a research protocol. Studies in Health Technology & Infor- sical structure on emotional expression. In Juslin PN, Slo-
matics 2010; 154:220–222. boda JA, eds. Music and emotion: theory and research.
16. Keefe, FJ, Huling DA, Coggins MJ, et al. Virtual reality for Oxford: Oxford University Press, pp. 223–248.
persistent pain: a new direction for behavioral pain man- 31. Rigg MG. Speed as a determiner of musical mood. Journal
agement. Pain 2012; 153:2163–2166. of Experimental Psychology 1940; 27:566–571.
17. Botella C, Garcia-Palacios A, Vizcaı́no Y, Herrero R, 32. Lang PJ, Bradley MM, Cuthbert BN. (1995) International
Baños RM, Belmonte MA. Virtual reality in the treatment affective picture system (IAPS): technical manual and af-
of fibromyalgia: a pilot study. Cyberpsychology, Behavior, fective ratings. Gainesville, FL: The Center for Research in
and Social Networking 2013; 16:215–223. Psychophysiology, University of Florida.
18. Isen AM. (2002) a role for neuropsychology in understand- 33. Flor H, Turk DC. (2011) General principles in the treatment
ing the facilitating influence of positive affect on social be- of chronic pain. In Flor H, Turk DC, eds. Chronic pain. An
havior and cognitive processes. In Snyder CR, Lopez SJ, eds. integrated biobehavioral approach. Seattle, WA: IASP
Handbook of positive psychology. New York: Oxford Uni- Press. pp. 321–336.
versity Press, pp. 528–540.
19. Fredrickson BL. The role of positive emotion in positive Address correspondence to:
psychology: the broaden and build theory of positive Dr. Rocio Herrero
emotion. American Psychologist 2001; 56:218–226. Universitat Jaume I
20. Catalino LI, Fredrickson BL. Tuesdays in the lives of Av. Sos Baynat s/n; 1207
flourishers: the role of positive emotional reactivity in op- Castelló de la Plana 46022
timal mental health. Emotion 2011; 11:938–950. Spain
21. Botella C, Riva G, Gaggioli A, Wiederhold BK, Alcañiz M,
Baños RM. The present and future of positive technologies. E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0202

Mobile Devices as Adjunctive Pain Management Tools

Brenda K. Wiederhold, PhD, MBA, BCB, BCN,1 Kenneth Gao, BS,2 Lingjun Kong, MS,2
and Mark D. Wiederhold, MD, PhD, FACP 2

Abstract

Approximately 108 million people in North America and Europe suffer from chronic pain. Virtual reality (VR)
is a promising method for pain management in a clinical setting due to the distracting properties of an
immersive virtual environment. In this study, we demonstrated the potential use of mobile phones as a means of
delivering an easily accessible, immersive experience. Thirty-one patients tested VR pain distraction. Objective
measurements of heart rate correlated to decreased anxiety, while, subjectively, patients also reported reduced
levels of discomfort. The positive results of this study indicate that mobile phones can provide an immersive
experience sufficient to deliver pain management distraction. Because mobile devices are widely available, the
potential for developing pain management programs that are accessible has become a realistic possibility.

Introduction cisely the amount of physical relief being provided by this

innovative new modality.

T his project’s key technology objectives are devel-

oping virtual reality (VR) mobile phone software for the
management of chronic, neuropathic pain, and proving its
Advantages of using a mobile phone for pain management
include:
 The mobile phone is an appliance with which the pa-
effectiveness in a study compared to pain focus.
tient is familiar, thus requiring minimal instruction in
Evidence shows that there is a clear need for adjunctive
its use for a noncall purpose.
pain relief. Chronic pain is the most common reason for
 Graphics quality is improving continuously, and the
seeking medical care.1 Recent studies show prevalence
software is completely portable, allowing anytime/
ranging from 13% to 53% in countries throughout the
anywhere use by the patient.
world,2–5 and reaching up to nearly one-third of the adult
 No computer is required, because the software pur-
population in the United States.6 Chronic pain rises with
chase is added to the patient’s mobile phone bill, and
age and affects a higher proportion of women than men.2–4
the download to the mobile phone is accomplished via
Although the definition of chronic pain is pain that lasts for
Short Messaging Service (SMS).
3–4 months, long-term surveys show that 20% to 46% of
 Similarly, software upgrades can be performed auto-
chronic pain patients have experienced pain for 10 years or
matically.
more.3,7 Pain is of moderate to severe intensity for most
patients, and other than opioid analgesics, few prescription As more mobile phone subscribers opt for Internet service,
pain drugs achieve acceptable pain relief in more than 50% new versions of software can be developed that allow pa-
of treated patients.8 Even with the newer drugs, a 50% re- tients to transmit real-time physiological data (e.g., heart
duction in pain for 60% of patients is the best outcome rate, skin conductance) securely to their physicians while
achieved to date for patients with certain types of neuro- using the software. Along with that software, we can develop
pathic pain.9 and package a set of mini-sensors for patients who wish to
A review of the FDA’s 510(k) database for pain relief chart their physiological progress after using the pain man-
devices shows only five alternatives to drug therapy: three agement software over time. Physicians will be able to use
are transcutaneous electrical nerve stimulator (TENS) de- these data to support insurance reimbursements based on
vices, one uses infrared therapeutic heating, and another uses objective evidence-based patient progress.
neuromodulation (U.S. FDA, 2006). These devices, while Brain imaging shows that being distracted has a real effect
effective for various types of pain, are not inexpensive or in decreasing the intensity of pain signals in the brain, and that
easily portable. The inclusion of objective physiological VR actually changes how the brain physically registers pain,
measures during VR distraction will help to determine pre- not just patients’ perception of the incoming signals.10–12

1
Virtual Reality Medical Institute, Brussels, Belgium.
2
Virtual Reality Medical Center, San Diego, California.

385
386 WIEDERHOLD ET AL.

FIG. 1. Time of pain exposure comparison. HMD, head- FIG. 3. The numerical pain scale decreased when subjects
mounted display. were using the mobile phone (mean score decreased by 0.66,
p < 0.002), and it further decreased by 0.32 when patients
used the HMD.
Research on the effect of VR on pain shows a reduction of
30% in reports of ‘‘worst pain’’ (sensory component of pain),
44% in ‘‘time spent thinking about pain’’ (cognitive), and 45% Use of the mobile phone as a new platform for VR
in ‘‘pain unpleasantness’’ (emotional), as well as significant therapy has, however, now become an emerging research
reductions in pain-related brain activity in all five brain regions design (see Table 1).24,25
of interest: the anterior cingulate cortex, the insula, the thala-
mus, and the primary and secondary somatosensory cortices.13 Methods
VR systems are available with 3D images, motion capture, Procedure
and an 80 field of view. However, most systems today re-
quire headgear to stimulate the VR and are therefore found in Efficacy of mobile phone displays to deliver pain dis-
hospitals or clinics. Since chronic pain can exist for months traction VR was tested in comparison to two other methods
to years after patients are discharged from the hospital, VR of simulation delivery—the traditional head-mounted dis-
software on a mobile platform can provide easily accessible, play (HMD), and a standard flat-panel display used as a
transportable pain relief with little equipment required.14 baseline. Human factors testing was first done with con-
The challenge is proving that an easily portable pain trols, after which the VR was used with clinical chronic
management device with a small screen, such as that on a pain patients.
mobile phone, can be effective for pain relief in patients with
chronic, neuropathic pain. To be effective, we believe that the Controls
virtual environment must be subjectively immersive.15 Stu- The VR distraction was first tested on a group of 20 par-
dies to date show that VR is effective at lessening distress, ticipants with low daily pain intensity scores of <4 (0 = no
pain, and anxiety in burn wound care, chemotherapy, dental pain, 10 = worst possible pain) to ensure that the distraction
procedures, surgical procedures, phantom limb pain, physi- was of sufficient use to increase pain tolerance. In these
cal therapy procedures, ulcer care, and venipuncture.16–23 studies, participants were asked to submerge their hand into a

FIG. 2. Compared to baseline, the Simple Descriptive

Pain (SDP) intensity scale decreased when patients used the FIG. 4. The Visual Analog Pain Scale decreased when
mobile phone (mean score decreased by 0.3). The SDP scale subjects were using the mobile phone pain distraction (mean
decreased further when patients were using the HMD (mean score decreased by 0.58, p < 0.02), and it further decreased
score decreased by 0.355, p < 0.05). by 0.445 ( p < 0.04) when the HMD was used.
MOBILE DEVICES AS ADJUNCTIVE PAIN MANAGEMENT TOOLS 387

For example, in the cold bath exposure study, at baseline,

the mean length of time that participants tolerated the pain
stimuli was 156 seconds, while the mobile phone pain dis-
traction increased the mean length of time to 194 seconds, and
the HMD condition increased it to 206 seconds (see Fig. 1).
This initial study showed that pain distraction using these
worlds on a mobile platform was effective. There were no
adverse effects from using the simulation in controls. Speci-
fically, there was no cybersickness, and the human factors
analysis study revealed that the systems were easily operable.

Chronic pain patients

In this study, we wanted to ensure that patients could
express their pain ratings in a reliable manner. Therefore, we
FIG. 5. At baseline, the mean heart rate was 74 beats per used the Simple Descriptive Pain Intensity Scale (see Fig. 2),
minute (bpm). When subjects used the mobile phone pain the Numerical Pain Intensity Scale (see Fig. 3), and the Visual
distraction, the mean heart rate decreased to 72 bpm, and
then decreased to 70 bpm when subjects used the HMD. Analog Scale (see Fig. 4). All scales showed a subjective
decrease in pain experienced while using both the mobile
device and the HMD. While the HMD was more effective in
reducing subjective pain ratings, mobile devices also were
bath of cold water. We measured the amount of time they
able to achieve pain reduction effectively. Half the patients
were able to keep their hand submerged in the water during
experienced the HMD condition first, followed by the mobile
baseline, HMD, and mobile device measurements.
device condition. The other half experienced the mobile de-
vice first, followed by the HMD. During these studies, pa-
Chronic pain participants
tients’ physiology was monitored noninvasively. Both HMD
Thirty-one patients, aged 18–65 years, with current non- and mobile platform conditions were able to reduce the heart
cancer pain for at least 3 months and a daily average pain rate during exploration of virtual environments (see Fig. 5).
intensity score of q4 were exposed to virtual environments The reduction in subjective pain scores correlated well with
in a HMD or mobile device. These two conditions were reduction in heart rate, confirming a less anxious or aroused
compared to a baseline pain focus measurement. Data were state. In addition, patients often spontaneously reported feel-
collected during a 5 minute pain focus session, followed by ing more relaxed and less stressed when using the VR.
either a HMD or mobile device VR exposure session of 20
minutes. Half the patients received the HMD exposure, while Discussion
the other half was exposed to the mobile device first followed
This study demonstrated that significant reductions in pain
by the HMD exposure. During the exposure to the simula-
and anxiety can be achieved using the smaller screen of a
tion, patients were instructed to interact with the simulation
mobile device. These results were not as effective as those
graphics and explore the virtual worlds.
achieved with the full HMD immersion. From a clinical
protocol point of view, it may be useful to use the HMD
Measures
setting in the clinic or hospital and provide mobile devices
A pain intensity scale questionnaire was the subjective that patients can use outside the clinic or at home. To a
measurement, which composed of a Simple Descriptive Pain certain extent, there is probably a learning component that
Intensity Scale, Numerical Pain Intensity Scale, and Visual will be necessary when using the mobile device. We are
Analog Scale. During the exploration and during baseline, currently conducting studies where we are trying to deter-
patients’ physiological measures, including heart rate, pe- mine if initial HMD exposure results in more effective pain
ripheral skin temperature, respiration, and skin conductance, reduction on mobile devices. Patients who use VR for ther-
were continuously monitored. A paired t test was used to apy often demonstrate a positive learning effect over the
assess the differences in the pain intensity scale at baseline course of repeated sessions. The advantage of the in-clinic
and during the mobile phone and HMD pain distraction training is that patients are taught to recognize their levels of
treatments. physiological arousal and are then taught relaxation tech-
niques such as paced breathing and progressive muscle re-
Results laxation. We believe that the use of mobile devices should be
correlated with physiological intervention to achieve the
Controls
best results. In addition, the positive correlation between
Although VR has been successfully used for pain dis- reduction in subjective pain ratings and improvement in
traction for the past 15 years, we wanted to test the new physiological measures provides strong evidence that these
mobile platform with controls to assure both safety and ef- techniques can be adapted for wider clinical use.
fectiveness. We did a number of studies, which included We are exploring the use of other mobile devices such as iPads
length of time exposed to an inflated blood pressure cuff and and iPhones where real-time physiological measures are incor-
exposure to TENS unit (data not shown). In all these studies, porated into the design of the virtual environments. In this way,
the participants were able to withstand a greater degree of the patient’s own physiology will influence the visual simulation
discomfort in both the mobile and HMD platforms. so that a feedback loop reinforces the pain reduction strategy.
 Table 1. Published Studies Using Handheld Devices in Pain Management
Title/Author Description Methods Results
Multi-Modal Distraction. Using This easy to use, handheld interactive device A prospective randomized control trial was MMD distraction (MMD-D) and MMD
Technology to Combat Pain in uses customized programs designed to completed in a pediatric tertiary hospital, procedural preparation (MMD-PP) were
Young Children with Burn inform the child about the procedure he/ Burns Outpatient Clinic. Eighty participants both shown to relieve reported pain
Injuries26 she is about to experience and to distract were recruited and studied over their first significantly ( pp0.05) and reduce the
Miller K, Rodger S, Bucolo S, the child during dressing changes. three dressing changes. Pain was assessed time taken for dressings ( pp0.05) com-
Greer R, Kimble RM using validated child report, caregiver re- pared to SD and VG. The positive effects
port, nursing observation, and physiological of both MMD-D and MMD-PP were
measures. sustained with subsequent dressing
changes.
Development and Testing of a Our research group has developed a native We used both low and high fidelity qualitative Thematic analysis of usability interviews
Multidimensional iPhone Pain iPhone application (app) called Pain Squad usability testing with qualitative semi- showed the app to be appealing overall to
Assessment Application for to tackle the problem of poorly managed structured, audiotaped interviews and itera- adolescents. Analyses of both low and
Adolescents with Cancer27 pain in the adolescent with cancer group. tive cycles to design and refine the iPhone high fidelity testing resulted in minor
Stinson JN, Jibb LA, Nguyen C, The app functions as an electronic pain based Pain Squad app. Qualitative thematic revisions to the app to refine the theme
Nathan PC, Maloney AM, diary and is unique in its ability to collect analysis of interviews using constant com- and improve its usability. Adolescents
Dupuis LL, Gerstle JT, Alman data on pain intensity, duration, location, parative methodology captured emergent resoundingly endorsed the game-based
B, Hopyan S, Strahlendorf C, and the impact pain has on an adolescent’s themes related to app usability. Content nature of the app and its virtual reward
Portwine C, Johnston DL, life (i.e., relationships, school work, sleep, validity was assessed using question im- system. The importance of app pain diary
Orr M mood). It also evaluates medications and portance rating surveys completed by par- questions was established by content
other physical and psychological pain ticipants. Compliance and satisfaction data validity analysis. Compliance with the
management strategies used. Users are were collected following a 2 week feasibil- app, assessed during feasibility testing,

388
prompted twice daily at configurable times ity trial where users were alarmed to record was high (mean 81%, SD 22%), and
to complete 20 questions characterizing their pain twice daily on the app. adolescents from this phase of the study
their pain, and the app transmits results to found the app likeable, easy to use, and
a database for aggregate reporting through not bothersome to complete.
a Web interface.
Evaluating the Usability of a In this paper, we present an Android appli- Our evaluation with a group of wheelchair
Virtual Reality-Based Android cation (PainDroid) that has been enhanced users revealed that PainDroid demon-
Application in Managing the virtual reality (VR) technology for the strated high usability among this popu-
Pain Experience of Wheel- purpose of improving the management of lation, and is foreseen that it can make an
chair Users28 pain. important contribution in research on the
Spyridonis F, Gronli TM, assessment and management of pain.
Hansen J, Ghinea G
Virtual Reality on Mobile When undergoing ambulatory surgical oper- With the present randomized controlled study, A significant reduction of anxiety was
Phones to Reduce Anxiety in ations, the majority of patients experience we intended to verify the effectiveness of obtained after 45 minutes of operation in
Outpatient Surgery29 high levels of anxiety. Different experi- VR in reducing anxiety in patients under- the VR group but not in the control
Mosso JL, Gorini A, De La mental studies have shown that distraction going ambulatory operations under local or group, and, after 90 minutes, the reduc-
Cerda G, Obrador T, Almazan techniques are effective in reducing pain regional anesthesia. In particular, we mea- tion was larger in the experimental group
A, Mosso D, Nieto JJ, Riva G and related anxiety. Since VR has been sured the degree to which anxiety associated than in the control group.
demonstrated as a good distraction tech- with surgical intervention was reduced by
nique, it has been repeatedly used in distracting patients with immersive VR
hospital contexts for reducing pain in burn provided through a cell phone connected to
patients, but it has never been used during a HMD compared to a no-distraction control
surgical operations. condition.
MOBILE DEVICES AS ADJUNCTIVE PAIN MANAGEMENT TOOLS 389

In summary, we first validated the pain reduction techniques 15. Dixon MW, Wraga M, Proffitt DR, et al. Eye height scaling
in controls and then tested them in patients with chronic pain. of absolute size in immersive and nonimmersive displays.
The mobile devices were easy to use and were not associated Journal of Experimental Psychology 2000; 26:582–593.
with any adverse effects. There was no cybersickness, and 16. Vazquez JLM, Santander A, Gao K, et al. Using cyber-
patients with chronic pain enjoyed using the systems and ex- therapy to reduce postoperative anxiety in cardiac recovery
perienced pain relief. Larger-scale studies and longer-term fol- intensive care units. J of Anesthesia & Clinical Research
low-up are needed. These techniques, however, do appear to be 2013; 4:363.
both safe and effective when used in a chronic pain population. 17. Mosso JL, Rizzo S, Wiederhold B, et al. Cybertherapy—
new applications for discomfort reductions. Surgical care
unit of heart, neonatology care unit, transplant kidney care
Acknowledgments
unit, delivery room-cesarean surgery and ambulatory sur-
We thank the National Institutes of Health and National gery, 27 case reports. Studies in Health Information & In-
Institute on Drug Abuse for funding this project. We also formatics 2007; 125:334–336.
thank the participants who were willing to spend time with 18. Wiederhold BK, Wiederhold MD. Managing pain in mili-
our clinical team to answer questions and surveys. tary populations with virtual reality. NATO Science for
Peace & Security Series—E: Human & Societal Dynamics
Author Disclosure Statement 2012; 91:75–93.
19. Mühlberger A, Wieser MJ, Kenntner-Mabiala R, et al. Pain
No competing financial interests exist. modulation during drives through cold and hot virtual envi-
ronments. CyberPsychology & Behavior 2007; 10:516–522.
References 20. Corah NL. Dental anxiety. Assessment, reduction, and in-
creasing patient satisfaction. Dental Clinician North America
1. Porreca F, Schug SA, Bellamy N. (2006) Changing per-
1988; 32:779–790.
ceptions in chronic pain. The Postgraduate Institute of
21. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual
Medicine.
reality for adjunctive treatment of adult burn pain during
2. Elliott AM, Smith BH, Penny KI, et al. The epidemiology of
physical therapy: a controlled study. Clinical Journal of
chronic pain in the community. Lancet 1999; 354:1248–1252.
Pain 2000; 16:244–250.
3. Blyth FM, March LM, Brnabic AJ, et al. Chronic pain in
22. Hoffman HG, Patterson DR, Carrougher GJ, et al. Effec-
Australia: a prevalence study. Pain 2001; 89:127–134.
tiveness of virtual reality-based pain control with multiple
4. Gerdle B, Bjork J, Henriksson C, et al. Prevalence of cur-
treatments. Clinical Journal of Pain 2001; 17:229–235.
rent and chronic pain and their influences upon work and
23. Tse MMY, Ng JKF, Chung JWY. Visual stimulation as
healthcare-seeking: a population study. Journal of Rheu-
pain relief for Hong Kong Chinese patients with leg ulcers.
matology 2004; 31:1399–1406.
CyberPsychology & Behavior 2003; 6:315–320.
5. Hattori S. The prevalence of chronic pain in Japan. Nihon
24. Riva G, Preziosa A, Grassi A, et al. Stress management
Yakurigaku Zasshi 2006; 127:176–180.
using UMTS cellular phones: a controlled trial. Studies in
6. Stetz MC, Brown KS, Folen RA, et al. Comparing dis-
Health Technology & Informatics 2006; 119:461–463.
traction/relaxation modalities with chronic pain patients.
25. Preziosa A, Villani D, Grassi A, et al. Managing exam
NATO Science for Peace & Security Series—E: Human &
stress: the use of mobile phones for enhancing emotion
Societal Dynamics 2010; 91:171–177.
regulation. Poster presented at CyberTherapy 11 2006, June
7. Lazarus H, Neumann CJ. Assessing undertreatment of pain:
12–15, Gatineau, Canada.
the patients’ perspectives. Journal of Pharmaceutical Care
26. Miller K, Rodger S, Bucolo S, et al. Multi-modal distrac-
in Pain & Symptom Control 2001; 9:5–34.
tion. Using technology to combat pain in young children
8. Dolcos F, McCarthy G. Brain Systems Mediating Cognitive
with burn injuries. Burns 2010; 36:647–658.
Interference by Emotional Distraction. The Journal of
27. Stinson JN, Jibb LA, Nguyen C, et al. Development and
Neuroscience 2006; 26:2072–2079.
testing of a multidimensional iPhone pain assessment ap-
9. Parry G. (2006) Neuropathic pain treatment: pathophysiology
plication for adolescents with cancer. Journal of Medical
to next generation therapeutics. In Parry G, McCarberg B,
Internet Research 2013; 15:e51.
Hsu E, et al. Navigating decisions in neuropathic pain. www
28. Spyridonis F, Gronli TM, Hansen J, et al. Evaluating the
.medscape.org/viewarticle/530441_1 (accessed Mar. 23, 2014).
usability of a virtual reality-based Android application in
10. Brody JE. (2006) Let’s get serious about relieving chronic
managing the pain experience of wheelchair users. Con-
pain. The New York Times, Jan. 6, 2006. www.nytimes.com/
ference Proceedings: IEEE Engineering in Medicine &
2006/01/10/health/10brod.html?pagewanted=all&_r = 0. (ac-
Biology Society 2012; 2012:2460-3.
cessed Mar. 23, 2014).
29. Mosso JL, Gorini A, De La Cerda G, et al. Virtual reality on
11. Wiederhold MD, Wiederhold BK. Virtual reality and in-
mobile phones to reduce anxiety in outpatient surgery. Studies
teractive simulation for pain distraction. Pain Medicine
in Health Technology & Informatics 2009; 142:195–200.
2007; 8:S182–188.
12. Hoffman HG. (2004) Virtual-reality therapy. Scientific
American. Address correspondence to:
13. Hoffman HG, Richards TL, Bills AR, et al. Using fMRI to Prof. Brenda K. Wiederhold
study the neural correlates of virtual reality analgesia. CNS Virtual Reality Medical Institute
Spectrums 2006; 11:45–51. 30 Clos Chapelle aux Champs, Box 1.3030
14. Wiederhold MD, Wiederhold BK. Pain management with 1200 Brussels
cell phone technology. Proceedings of the CyberTherapy Belgium
13 Conference: Changing the Face of Healthcare June 23–
25, 2008, San Diego, CA. E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0061

Virtual Reality and Musculoskeletal Pain:

Manipulating Sensory Cues to Improve
Motor Performance During Walking

Wendy Powell, PhD,1 and Maureen J. Simmonds, PhD 2

Abstract

Musculoskeletal pain (MSP) is the most expensive nonmalignant health problem and the most common reason
for activity limitation. Treatment approaches to improve movement without aggravating pain are urgently
needed. Virtual reality (VR) can decrease acute pain, as well as influence movement speed. It is not clear
whether VR can improve movement speed in individuals with MSP without aggravating pain. This study in-
vestigated the extent to which different audio and optic flow cues in a VR environment influenced walking speed
in people with and without MSP. A total of 36 subjects participated, 19 with MSP and 17 controls. All walked on a
motorized self-paced treadmill interfaced with a three-dimensional virtual walkway. The audio tempo was scaled
(75%, 100%, and 125%) from baseline cadence, and optic flow was either absent, or scaled to 50% or 100% of
preferred walking speed. Gait speed was measured during each condition, and pain was measured before and after
the experiment. Repeated measures analysis of variance showed that audio tempo above baseline cadence
significantly increased walking speed in both groups, F(3, 99) = 10.41, p < 0.001. Walking speed increases of
more than 25% occurred in both groups in the 125% audio tempo condition, without any significant increase in
pain. There was also a trend toward increased walking speeds with the use of optic flow, but the results in this
study did not achieve significance at the p < 0.05 level, F(2, 66) = 2.01, p = 0.14. Further research is needed to
establish the generalizability of increasing movement speed across different physical performance tasks in VR.

Introduction individuals with pain and illness can move faster when chal-
lenged to but tend not to if unchallenged.5 Thus, therapeutic
P ain remains a pervasive, complex, and challenging
phenomenon associated with tremendous human and fi-
nancial costs. Musculoskeletal pain (MSP) is the most ex-
approaches that enhance movement speed without increasing
perceived pain or effort may help patients recalibrate their
expectations and subsequently resume optimal and efficient
pensive nonmalignant health problem affecting the working
movement speeds that decrease disability.
age population and is the most common reason for activity
The benefits of virtual reality (VR) for rehabilitation are
limitation. In the United States, chronic pain is estimated to
known to include increased engagement with therapy6–8 and
affect 100 million adults and costs $560–635 billion annu-
distraction from pain.9,10 If this ability of VR to distract from
ally.1 Although pain is frequently a symptom of tissue injury
pain can be leveraged while employing techniques to facil-
or illness, persistent pain is now also recognized as a disease
itate faster movement, it could offer significant potential for
per se.2 Regardless of its genesis, pain is associated with
locomotor rehabilitation for conditions associated with MSP.
compromised mood and movement across health conditions.
Generalized psychomotor slowing is commonly associated
VR and analgesia
with pain, as individuals appear to have difficulty generating
or withstanding the relatively higher forces associated with Evidence from a number of studies has demonstrated an
faster movements. Psychomotor slowing frequently persists analgesic effect of VR for acute pain, primarily with pain due
despite the apparent resolution of injury or illness. This failure to burns or medical procedures,9,10 but the effect on active
to resume usual movement speed leads to prolonged reduction movement was not assessed. Furthermore, a recent systematic
in activity and increased disability.3,4 Research has shown that review reported strong evidence for the analgesic effect of

1
University of Portsmouth, Portsmouth, United Kingdom.
2
University of Texas HSC, San Antonio, Texas.

390
VR AND PAIN: SENSORY CUES FOR MOTOR PERFORMANCE 391

immersive VR on acute pain in adults, but found insufficient In addition, there is a strong link between auditory rhythms
evidence supporting the effectiveness of VR for reducing and motor activity, and the motor system is physiologically
chronic pain.11 Thus, while it is clear that VR may be useful for sensitive to arousal by the auditory system.19 A number of
the amelioration of pain in some settings, it is not known how studies in non-VR settings indicate that the use of audio cues
patients with chronic MSP might respond, particularly during can facilitate improved walking speed and quality,20–23 and
active motion, which would normally elicit increased levels of more recently it has been demonstrated that this audio cue
perceived pain. facilitating effect can also be seen in treadmill-mediated VR.24
To date, the mechanisms that account for a potential an- Not only has this effect been seen in healthy populations, there
algesic effect of VR are not clear, but are probably due in part are also data to suggest that audio cues can improve walking
to VR affording a means of attracting an individual’s atten- speed and cadence in Parkinson’s disease19,23,25–27 and also in
tion toward an alternative visual and auditory stimulus and stroke patients.20,22 However, both Parkinson’s disease and
thereby reducing the magnitude of attention available to stroke are associated with neurological deficits resulting in
focus on pain. Moreover, given that attention to visual and motor dysfunction, and it cannot be assumed that similar fa-
auditory stimuli in VR limits attention to pain stimuli, it is cilitation would be observed in populations with MSP, where
plausible that the addition of movement during VR could slow movement has a less direct neurological etiology. Fur-
demand even more attention and thereby further enhance thermore, chronic pain demands a high level of attention,
analgesia—or at least not allow for an increase in pain re- which may distract attention from other tasks,3,28 and therefore
lated to movement. it may be the case that patients with chronic pain would be less
able to attend to the visual and auditory cues that would oth-
VR to improve walking speed erwise lead to faster walking speeds.
The purpose of this study was to examine the extent to
Applications to support walking in VR generally use a which audio and visual cues in treadmill-mediated VR can
treadmill or similar device interfaced to the VR software to increase gait speed for people with slowed movement due
create the illusion of moving through the virtual environ- to pain.
ment.12,13 However, the interactions between a user and a
VR system can be complex, and there is evidence that even Materials and Methods
small changes in factors within a VR system can have a
Previous work identified that presenting an optic flow
significant effect on movement and movement perception.14
speed of 0.5 times normal (non-VR) walking speed was as-
Fixed pace treadmills are known to disrupt the spatio-
sociated with a significant increase in walking speed,16 and
temporal control of gait,15 and self-paced treadmills inter-
so this was selected as a level for this experiment. To provide
faced to VR are increasingly widely used,12,13 as they sup-
a comparison and control, two other visual conditions were
port the natural walking ratio.15 However, they also tend to
also included: optic flow matched to baseline treadmill
be associated with a decrease in walking speed when users
walking speed,a and absent optic flow (static image). The
are free to self-select their own pace,13–16 and this is true both
experiment used a virtual environment that was designed to
for healthy adults and for patients with MSP.15 Thus, if the
provide high contrast peripheral visual cues to improve self-
analgesic effect of VR and the natural walking support of the
motion perception29 without any central visual clutter or
self-paced treadmill are to be leveraged for effective reha-
obstacles.30 The audio cue rates were scaled from the base-
bilitation protocols, they need to be combined with tech-
line cadence using the same scaling as in our previous work
niques to facilitate or encourage increased walking speeds.
(75%, 100%, and 125% of baseline cadence).24
Optic flow (the apparent motion of objects, surfaces, and
The experimental design was a mixed 3 · 4 · 2 factorial ex-
edges in a visual scene caused by the relative motion between
periment with two within-subjects factors (optic flow · audio)
an observer or virtual camera and the scene) is used as a
(Table 1), and one between subjects factor (pain). Audio cue
powerful cue to determine self-motion. It has previously been
tempo, optic flow rate, and presence of pain were the inde-
demonstrated that altering the rate of optic flow in a virtual
pendent variables. Walking speed was the dependent variable.
environment can influence walking speeds in a healthy pop-
In addition, the pre- and post-experiment pain intensity and pain
ulation, with lower flow rates being associated with faster
affect were recorded as dependent variables for the MSP group.
walking speeds,16–18 but this has not yet been demonstrated in
patients with pain. However, it is plausible that the slowing of
Apparatus
optic flow rate, and the associated reduction in perceived self-
motion, may reduce the fear of pain associated with increased The treadmill used in this study was a self-paced motor-
walking speeds in people with MSP, reducing the inhibitory ized treadmill.31 The treadmill responded dynamically to the
effect of anticipatory pain on walking. speed of the user in real time. The belt speed was recorded to

Table 1. The Combination of Audio and Visual Cues for the Experimental Conditions
for the Two Experimental Groups
Audio rate 75% Audio rate 100% Audio rate 125%
No audio baseline cadence baseline cadence baseline cadence
No optic flow Condition 1 Condition 4 Condition 7 Condition 10
Optic flow 50% baseline speed Condition 2 Condition 5 Condition 8 Condition 11
Optic flow 100% baseline speed Condition 3 Condition 6 Condition 9 Condition 12
392 POWELL AND SIMMONDS

Table 2. Demographic Details of Participants

Pain Pain
Age Sex intensity affect
No pain 22–68 8 female/ N/A N/A
(n = 17) (M = 46.9) 9 male
Pain 24–80 13 female/ M = 3.9 M = 2.8
(n = 19) (M = 54.8) 6 male (2.5) (2.8)
Pain intensity and pain affect scored on a 1–10 Numeric Rating
Scale on day of testing (standard deviation [SD] in parentheses).

Ethical approval was obtained from the Comité d’éthique

de la recherche des établissements du CRIR (Montreal,
Canada). All participants were able to converse fluently in
either English or French, and gave their informed consent
prior to inclusion in the study.
FIG. 1. The high contrast walkway with vertical periph-
eral cues used to generate the optic flow. Procedure
The participants walked in each of the experimental con-
ditions in a counterbalanced order. For the visual cues, the
a computer using an optical sensor at a resolution of 0.01
preferred walking speed was used to scale the optic flow by a
meters per second.
factor of 0, 0.5, or 1, and the rate of apparent motion through
The treadmill was placed 1.5 meters in front of a
the virtual environment was maintained at this speed for the
2.44 meters · 3.05 meters screen. A three-dimensional model
duration of the trial. For the audio cues, the baseline cadence
of a virtual walkway was created using SoftImage XSI
was used to scale the audio tempo by a factor of 0, 0.75, 1, or
software. The scene consisted of two parallel rows of vertical
1.25, and the footstep beat was played at this tempo for the
columns on either side of a walkway (Fig. 1).
duration of the trial.
The virtual camera was set to match the starting position
During pilot testing, it was found that 2 minutes of
of the participant, with a horizontal field of view of 80 and a
walking was sufficient to obtain consistent walking speed
height of 1.6 meters above the ground plane. The scene was
data, and therefore each of the trials was limited to a duration
back-projected onto the screen using a single (monoscopic)
of 2 minutes.
projector. To minimize visual distraction, the room was
For each of the trials, the participants were asked to walk at
darkened for the experiment, with the main light source
their preferred (baseline) speed on the treadmill. At the start
being the display screen itself.
of each trial, treadmill walking was initiated in the absence of
CAREN D-flow software (Computer Assisted Rehabilita-
optic flow or audio. When participants reached 75% of their
tion Environments, Motek BV) was used to control the
preferred walking speed, the visual/audio cues for the trial
hardware system and synchronize the instantaneous treadmill
condition were initiated automatically. The participants then
speed and scene progression via a software gearing module.
continued to walk on the treadmill for 2 minutes, while being
The audio component was also synchronized by the D-flow
presented with the combinations of audio and visual cues.
software. The audio was the sound of a footstep on a hard
The participants were able to rest between trials as required,
surface, loaded as a .wav file into the application. The sample
and completed a total of twelve 2 minute trials.
sound was 0.2 seconds long, sampled at 705 kbps. It was de-
Participants were instructed to walk at a self-selected pace
livered to the participant via Logitech ClearChat wireless
for the duration of each 2 minute trial. No instructions were
stereo headphones.
given regarding whether they should attempt to synchronize
with the audio beat.
Participants
Participants from the pain group were asked to notify the
A total of 36 volunteers participated in the experiment. experimenters of any significant change in pain, and to give a
Patients with MSP on walking were recruited from the verbal Numeric Rating Scale (NRS) rating of perceived pain
Jewish Rehabilitation Hospital (Laval, Quebec) and the Con- intensity and pain affect immediately after completing the
stance Lethbridge Rehabilitation Centre (Montreal, Quebec). experiment.
Healthy volunteers were recruited from the staff and student
body of the Jewish Rehabilitation Hospital, the Constance Results
Lethbridge Rehabilitation Centre, and McGill University
The effect of audio and visual cues on walking speed
(Montreal, Quebec).
The participants were assigned to one of two groups based The walking speed of the participants was automatically
on the presence (n = 19) or absence (n = 17) of MSP in the recorded to the treadmill control computer during each trial,
upper or lower limb that compromised walking (Table 2). All and the mean walking speed (m/s) was calculated from these
were able to walk independently and had no other medical data (Table 3). A repeated measures analysis of variance
condition that limited walking (e.g., stroke, Parkinson’s (ANOVA; optic flow · audio cue tempo · pain) demon-
disease, heart disease, etc.). strated a significant effect of audio tempo on walking speed,
VR AND PAIN: SENSORY CUES FOR MOTOR PERFORMANCE 393

Table 3. Overall Mean Walking Speeds in Each of the Experimental Conditions

Audio rate 75% Audio rate 100% Audio rate 125%
No audio baseline cadence baseline cadence baseline cadence
Pain No pain Pain No pain Pain No pain Pain No pain
No optic flow 0.88 (0.33) 1.08 (0.30) 1.10 (0.35) 1.47 (0.28) 1.07 (0.41) 1.37 (0.35) 1.12 (0.40) 1.40 (0.29)
Optic flow 50% 1.06 (0.36) 1.39 (0.24) 1.04 (0.38) 1.38 (0.33) 1.06 (0.34) 1.36 (0.30) 1.09 (0.34) 1.46 (0.28)
baseline speed
Optic flow 100% 1.06 (0.39) 1.37 (0.26) 1.08 (0.29) 1.33 (0.30) 1.03 (0.36) 1.22 (0.48) 1.09 (0.36) 1.36 (0.28)
baseline speed
SD in parentheses.

F(3, 99) = 10.41, p < 0.001, but no significant effect of optic p = 0.65, or the pain affect, t(16) = 2.12, p = 0.06, between the
flow on walking speed, F(2, 66) = 2.01, p = 0.14. beginning and end of the experiment (after 12 trials) for the
Although there was no statistically significant effect of pain group (Fig. 4). Pain intensity and affect were not mea-
optic flow, there was a trend toward increased walking speeds sured for the no pain group.
when the treadmill was linked to the virtual environment,
particularly in the no pain group and the slow optic flow Discussion
condition, with > 20% mean walking speed increases (Fig. 2).
Post hoc analysis revealed that the walking speed in the fast The effect of audio and visual cues on walking speed
audio condition was significantly faster than the no audio The use of audio cues above baseline cadence was asso-
condition ( p < 0.001) and faster than the 100% audio condition ciated with faster walking speeds in both the pain and no pain
( p < 0.05), but was not significantly different from the slow groups. There was no difference in the direction or magni-
audio condition ( p = 0.3). The walking speed in the slow audio tude of the effect between the group with pain and the group
condition was also significantly faster than in the no audio without pain. This supports and extends the findings of our
condition ( p < 0.001). There was no significant difference previous work24 and suggests that audio cues may be ef-
between any other pairs of audio conditions. Walking speed in fective in facilitating faster walking in patients with chronic
all audio conditions was faster than without audio cues (Fig. 3). pain as well as in healthy adults.
There was no significant interaction effect, F(1, 33) = 0.074, It was somewhat surprising to find that the speed increase
p = 0.79, between pain and audio, and no significant interac- was similar in both the slow and fast audio cue conditions.
tion, F(1, 33) = 0.29, p = 0.56, between pain and visual cues. However, previous studies have noted the ability to syn-
However, there was a significant interaction, F(6, 198) = chronize to twice the speed of a slow tempo (‘‘doubling’’ the
12.31, p < 0.001, between audio and visual cues. tempo),32 and this would be consistent with the speed in-
There was a significant difference between the no pain and crease seen with this cue frequency, where the response to
pain groups, F(1, 33) = 8.08, p < 0.01). The mean walking the 75% tempo is similar to the response to the 125% tempo.
speed of the pain group was lower than the no pain group Further work is underway to investigate a wider range of
across all conditions. audio tempos.
There was a significant interaction between the audio and
Comparison of pain at the start and end of the experiment visual cues, with slower walking speeds when optic flow was
Repeated measures analysis (paired t test) showed no present compared with audio alone (no optic flow). This
significant difference in the pain intensity, t(16) = 0.46, might be explained by the model of competing attentional
demands. Auditory and visual stimuli both require attention,
which can be considered to be a finite shared resource.28 In
the presence of audio cues alone, there is sufficient attention
to respond to the cues, but by adding the visual cues, the
attention is divided between two cues.21 Audio cues that are
in conflict with the preferred cadence may disrupt the auto-
matic synchronicity of walking, necessitating more con-
scious attention. The suppression of the effect of audio on
walking speed by the addition of optic flow may therefore be
attributable to a reduction of attention to the audio cues in the
presence of a competing attentional load. However, the data
in this experiment do not display a robust enough pattern to
be certain of the underlying mechanisms, and further in-
vestigation is necessary to establish whether other attentional
loads also reduce the influence of audio cues on walking.
In contrast to earlier studies,16–18 altering the optic flow
rate did not have a significant effect on walking in either the
FIG. 2. The percentage increase in mean walking speed pain or no pain populations (although there was a trend to-
from baseline with varying optic flow rates. ward faster walking speeds in the optic flow conditions
394 POWELL AND SIMMONDS

FIG. 3. The percentage in-

crease in mean walking
speed from baseline with
varying audio cue tempo.

compared to a static scene). If this had been noted in just the to the findings in our previous study with this patient group.15
pain group, it might have been concluded that the presence of However, when the 75% or 125% audio cues were present, in
pain was sufficient distraction to prevent a normal response to the absence of optic flow, the pain group showed speed in-
the optic flow. However, neither group demonstrated any creases of up to 27% above their preferred treadmill walking
significant effect of optic flow rate, and since this is in direct speed, achieving speeds higher than the baseline treadmill
contrast to most previous studies, it warrants some examina- walking speed of the no pain group (Table 3). This supports
tion of the experimental design. The virtual environment, previous observations that individuals with pain can move
screen size, treadmill type, and optic flow rate were all similar faster but don’t.4
to those used in our previous work.16 However, due to the In total, the participants in this study undertook around 30
equipment constraints in the clinical laboratory, the projection minutes walking, albeit in short blocks, and much of this
was monoscopic, whereas stereoscopic projection was used walking was at or above the preferred (baseline) treadmill
previously. It has been noted that depth judgments and self- walking speed. However, there was no significant increase in
speed perception in VR are influenced by the use of binocular reported pain intensity or pain affect. While it would be an-
disparity cues,33,34 and it may be that the lack of visual depth ticipated that in normal treadmill walking, patients with
cues altered the perception of the speed of optic flow, reducing chronic MSP would notice an increase in pain over time, this
the strength of its effect. A further study comparing the effect study did not have a control MSP group walking on the tread-
of optic flow in mono and stereo virtual environments is re- mill without any audio or visual cues. To answer the question
quired to establish if this is the cause of the unexpected result as to whether the treadmill-mediated VR suppressed the per-
in this study. If so, it may have significant implications for ception of increased pain, a study comparing a VR intervention
virtual environment design for rehabilitation applications. with non-VR treadmill walking would be necessary.
Patients with pain walked on average 21% slower (1.06 m/s) The ability to disengage from pain relates to the perceived
across all conditions than the no pain group (1.35 m/s), similar threat,35 and since patients systematically overestimate the
pain associated with fast movements, this may act as a barrier
to voluntary increases in speed.4 Pain demands attention, and
chronic pain involves continual switching between pain and
other attentional demands.28 Attending to visual or auditory
cues also requires attention, and if this provides a sufficient
distraction to enable some disengagement from the pain, then
this may reduce the hindrance to faster walking. Indeed, this
is supported by the finding that walking speed is higher in all
cueing conditions compared with preferred speed measured
at the start of the study. Previous studies have demonstrated
that immersive VR can reduce perceived pain during passive
procedures,36,37 and the results of this study suggest that it is
possible that the pain-reducing properties of VR may also be
effective during active rehabilitation procedures.
It is evident that with careful VR design, patients with pain
FIG. 4. Comparison of pain intensity and pain affect at the can improve walking speeds to a level commensurate with ef-
start and end of the experiment. fective rehabilitation, and this can be achieved without
VR AND PAIN: SENSORY CUES FOR MOTOR PERFORMANCE 395

concomitant increases in pain. This demonstrates the potential pain: part 1: vertical ground reaction force. Spine (Phila Pa
of VR in the rehabilitation of patients with MSP, and may offer 1976) 2007; 32:1329–1336.
some support in breaking the pain/reduced movement cycle. 6. Bryanton C, Bosse J, Brien M, et al. Feasibility, motivation,
and selective motor control: virtual reality compared to
Conclusion conventional home exercise in children with cerebral palsy.
CyberPsychology & Behavior 2006; 9:123–128.
Chronic pain ( > 6 months) can result in a cyclic disability- 7. Rizzo A, Kim GJ. A SWOT analysis of the field of virtual
enhancing pattern of further decreased activity and avoidance reality rehabilitation and therapy. Presence—Teleoperators
that prevents normal restoration of function and perpetuates & Virtual Environments 2005; 14:119–146.
painful experiences,3 and thus interventions are needed that 8. Thornton M, Marshall S, McComas J, et al. Benefits of ac-
can distract from or reduce the perceived pain while sup- tivity and virtual reality based balance exercise programmes
porting improved movement. for adults with traumatic brain injury: perceptions of partic-
VR offers recognized benefits of increased engagement and ipants and their caregivers. Brain Injury 2005; 19:989–1000.
decreased pain perception, and it is clear from this study that 9. Hoffman HG, Richards TL, Coda B, et al. Modulation of
the manipulation of audio and visual cues in VR can improve thermal pain-related brain activity with virtual reality: ev-
walking speed, even in patients with chronic MSP. Incorporating idence from fMRI. Neuroreport 2004; 15:1245–1248.
audio cues into a VR application that were presented at a tempo 10. Hoffman HG, Garcia-Palacios A, Kapa V, et al. Immersive
25% above the normal preferred cadence facilitates increased virtual reality for reducing experimental ischemic pain. In-
walking speeds by around 27%, and this was achieved without a ternational Journal of Human–Computer Interaction 2003;
significant increase in either pain intensity or pain affect. This 15:469–486.
improvement in walking also appeared to be influenced by the 11. Shahrbanian S, Ma X, Korner-Bitensky N, et al. Scientific
rate of optic flow, although further work with stereoscopic pro- evidence for the effectiveness of virtual reality for pain
jection is necessary to quantify this effect properly. reduction in adults with acute or chronic pain. Studies in
Since both auditory and visual sensory output is an inte- Health Technology & Informatics 2009; 144:40–43.
12. Fung J, Richards CL, Malouin F, et al. A treadmill and
gral component of most virtual rehabilitation systems, VR
motion coupled virtual reality system for gait training post-
designers should incorporate these factors in a systematic
stroke. CyberPsychology & Behavior 2006; 9:157–162.
manner to improve rehabilitation outcomes. 13. Lichtenstein L, Barabas J, Woods Russell L, et al. A
feedback-controlled interface for treadmill locomotion in
Acknowledgments
virtual environments. ACM Transactions on Applied Per-
We thank Tamar Derghazarian and Shahnaz Shahrbanian ception 2007; 4:7.
for their assistance in participant recruitment and data col- 14. Powell WA, Stevens B. (2013) The influence of virtual reality
lection, and Christian Beaudoin for technical support. systems on walking behaviour: a toolset to support application
design. In Proceedings of International Conference on Vir-
Author Disclosure Statement tual Rehabilitation (ICVR). Philadelphia, PA, pp. 270–276.
15. Powell W, Stevens B, Simmonds M. Treadmill Interface
No competing financial interests exist. for virtual reality vs. overground walking: a comparison of
gait in individuals with and without pain. Studies in Health
Notes Technology & Informatics 2009; 144:198–203.
a. Prior to conducting the experiments, all participants were 16. Powell W, Hand S, Stevens B, et al. Optic flow with a
familiarized with the self-paced treadmill, and when they stereoscopic display: sustained influence on speed of loco-
were able to maintain a steady speed and cadence, they motion. Annual Review of CyberTherapy & Telemedicine
completed a treadmill 3 minute walk test, with no audio 2006; 4:65–70.
or visual cues. Average walking speed and cadence were 17. Prokop T, Schubert M, Berger W. Visual influence on
recorded, and used as baseline measures for the experi- human locomotion. Modulation to changes in optic flow.
Experimental Brain Research 1997; 114:63–70.
mental cue conditions.
18. Schubert M, Prokop T, Brocke F, et al. Visual kinesthesia
and locomotion in Parkinson’s disease. Movement Dis-
References
orders 2005; 20:141–150.
1. Institute of Medicine. (2011) Relieving pain in America: a 19. Thaut MH, Kenyon GP, Schauer ML, et al. The connection
blueprint for transforming prevention, care, education, and between rhythmicity and brain function. Engineering in
research. Washington, DC: National Academies Press. Medicine & Biology Magazine, IEEE 1999; 18:101–108.
2. Tracey L, Bushnell MC. How neuroimaging studies have 20. Ford MP, Wagenaar RC, Newell KM. The effects of au-
challenged us to rethink: is chronic pain a disease? The ditory rhythms and instruction on walking patterns in in-
Journal of Pain 2009; 10:1113–1120. dividuals post stroke. Gait & Posture 2007; 26:150–155.
3. Hart RP, Martelli MF, Zasler ND. Chronic pain and neu- 21. Lim I, van Wegen E, de Goede C, et al. Effects of external
ropsychological functioning. Neuropsychology Review rhythmical cueing on gait in patients with Parkinson’s
2000; 10:131–149. disease: a systematic review. Clinical Rehabilitation 2005;
4. Simmonds MJ, Goubert L, Moseley GL, et al. (2006) 19:695–713.
Moving with pain. In Flor H, Kalso E, Dostrovsky JO, eds. 22. Roerdink M, Lamoth CJC, Kwakkel G, et al. Gait coordi-
Proceedings of the 11th World Congress on Pain. Seattle, nation after stroke: benefits of acoustically paced treadmill
WA: IASP Press. walking. Physical Therapy 2007; 87:1009–1022.
5. Lee CE, Simmonds MJ, Etnyre BR, et al. Influence of pain 23. Suteerawattananon M, Morris GS, Etnyre BR, et al. Ef-
distribution on gait characteristics in patients with low back fects of visual and auditory cues on gait in individuals with
396 POWELL AND SIMMONDS

Parkinson’s disease. Journal of the Neurological Sciences 32. Styns F, van Noorden L, Moelants D, et al. Walking on
2004; 219:63–69. music. Human Movement Science 2007; 26:769–785.
24. Powell W, Stevens B, Hand S, et al. The influence of audio 33. Durgin FH, Proffitt DR, Olson TJ, et al. Comparing depth
cue tempo on walking in treadmill-mediated virtual reha- from motion with depth from binocular disparity. Journal of
bilitation. Journal of CyberTherapy & Rehabilitation 2010; Experimental Psychology: Human Perception & Perfor-
3:164–165. mance 1995; 21:679–699.
25. del Olmo MF, Arias P, Furio MC, et al. Evaluation of the 34. Palmisano S. Perceiving self-motion in depth: the role of
effect of training using auditory stimulation on rhythmic stereoscopic motion and changing-size cues. Perception &
movement in Parkinsonian patients—a combined motor Psychophysics 1996; 58:1168–1176.
and [18F]-FDG PET study. Parkinsonism & Related Dis- 35. Van Damme S, Crombez G, Eccleston C. Disengagement
orders 2006; 12:155–164. from pain: the role of catastrophic thinking about pain. Pain
26. McIntosh GC, Brown SH, Rice RR, et al. Rhythmic auditory- 2004; 107(1–2):70–76.
motor facilitation of gait patterns in patients with Parkinson’s 36. Gershon J, Zimand E, Lemos R, et al. Use of virtual reality
disease. Journal of Neurology, Neurosurgery, & Psychiatry as a distractor for painful procedures in a patient with pe-
1997; 62:22–26. diatric cancer: a case study. CyberPsychology & Behavior
27. Thaut MH, McIntosh GC, Rice RR, et al. Rhythmic audi- 2003; 6:657–661.
tory stimulation in gait training for Parkinson’s disease 37. Hoffman HG, Doctor JN, Patterson DR, et al. Virtual re-
patients. Movement Disorders 1996; 11:193–200. ality as an adjunctive pain control during burn wound care
28. Eccleston C, Crombez G. Pain demands attention: a cog- in adolescent patients. Pain 2000; 85:305–309.
nitive-affective model of the interruptive function of pain.
Psychological Bulletin 1999; 125:356–366. Address correspondence to:
29. Stone LS, Thompson P. Human speed perception is contrast Dr. Wendy Powell
dependent. Vision Research 1992; 32:1535–1549. School of Creative Technologies
30. Durgin FH, Fox LF, Schaffer E, et al. (2005) The percep- Eldon Building
tion of linear self-motion. In Proceedings of SPIE. San Winston Churchill Avenue
Jose, CA, pp. 503–514. Portsmouth
31. Fung J, Malouin F, McFadyen BJ, et al. Locomotor reha- P01 2DJ
bilitation in a complex virtual environment. Conference United Kingdom
Proceedings of the IEEE Engineering in Medicine &
Biology Soceity 2004; 7:4859–4861. E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0058

Feasibility of Articulated Arm Mounted Oculus Rift

Virtual Reality Goggles for Adjunctive Pain Control
During Occupational Therapy in Pediatric Burn Patients

Hunter G. Hoffman, PhD,1,2 Walter J. Meyer III, MD,2,3 Maribel Ramirez, BS,2,3 Linda Roberts, OTR,2
Eric J. Seibel, PhD,1 Barbara Atzori, PhD,4 Sam R. Sharar, MD,5,6 and David R. Patterson, PhD 5

Abstract

For daily burn wound care and therapeutic physical therapy skin stretching procedures, powerful pain medi-
cations alone are often inadequate. This feasibility study provides the first evidence that entering an immersive
virtual environment using very inexpensive (*$400) wide field of view Oculus Rift Virtual Reality (VR)
goggles can elicit a strong illusion of presence and reduce pain during VR. The patient was an 11-year-old male
with severe electrical and flash burns on his head, shoulders, arms, and feet (36 percent total body surface area
(TBSA), 27 percent TBSA were third-degree burns). He spent one 20-minute occupational therapy session with
no VR, one with VR on day 2, and a final session with no VR on day 3. His rating of pain intensity during
therapy dropped from severely painful during no VR to moderately painful during VR. Pain unpleasantness
dropped from moderately unpleasant during no VR to mildly unpleasant during VR. He reported going
‘‘completely inside the computer generated world’’, and had more fun during VR. Results are consistent with a
growing literature showing reductions in pain during VR. Although case studies are scientifically inconclusive
by nature, these preliminary results suggest that the Oculus Rift VR goggles merit more attention as a potential
treatment for acute procedural pain of burn patients. Availability of inexpensive but highly immersive VR
goggles would significantly improve cost effectiveness and increase dissemination of VR pain distraction,
making VR available to many more patients, potentially even at home, for pain control as well as a wide range
of other VR therapy applications. This is the first clinical data on PubMed to show the use of Oculus Rift for any
medical application.

Introduction nals from pain receptors to the brain is the foundation of tra-
ditional burn pain control, pharmacologic analgesics alone
The problem: uncontrolled pain
typically fail to control pain during wound debridement.1
he current standard of care = pain medications alone.
T For over 100 years, opioid narcotic pain medication has
been the cornerstone of pain control for severe burn patients
When relying on pharmacologies as the primary (and often
the only) treatment for pain, most patients with large severe
burn wounds report experiencing severe or higher pain during
during wound cleaning. Procedural pain is still managed largely daily wound debridement (worst pain intensity of seven or
as it has been managed for the past 100 years, pharmacologi- higher on a 0 to 10 scale).2 This is even true of soldiers.3,4 Pain
cally, through opioid narcotic analgesics, often in combination of five or higher is considered uncontrolled pain. Patients with
with anxiolytics. Analgesics reduce pain by interfering at a unusually large severe pediatric burn wounds are especially
neuronal level with the transmission of signals from pain re- challenging. Typically, the larger the severe burn, the longer
ceptors to the brain (e.g., neurotransmission).1 Although this the wound cleaning/debridement takes each day, and greater
pharmacologic blocking of physical transmission of pain sig- the number of days the patient receives wound care.

1
Human Photonics Laboratory, Mechanical Engineering, University of Washington, Seattle, Washington.
2
Psychiatry, Shriners Hospitals for Children, Galveston, Texas.
3
Department of Psychiatry, University of Texas Medical Branch, Galveston, Texas.
4
Burn Center, Meyer Children Hospital, Florence, Italy.
5
Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington.
6
Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington.

397
398 HOFFMAN ET AL.

FIG. 1. (a) VR during

wound cleaning of a soldier.
(b) VR of pediatric burn pa-
tient during passive range of
motion exercises. VR, virtual
reality. Photo credits and
copyright Hunter Hoffman,
UW, www.vrpain.com.

Because of the inadequacy of pharmacological interven- guins, woolly mammoths and flying fish by using a wireless
tions alone to control burn pain during wound debridement mouse (or sometimes head tracking) to aim and throw
and during occupational and physical therapy skin snowballs. Snowballs thrown by the patients impact objects
stretching exercises, adjunctive nonpharmacological in- in the virtual world with special effects and sound effects.
terventions could provide a valuable additional compo- Music by Paul Simon plays in the background, helping to
nent of a multiprogram burn pain treatment regimen. block out anxiety producing sounds from the hospital. Im-
Psychological interventions can facilitate the effects of mersive virtual reality visually isolates patients from the
standard pharmacologic analgesics. ‘‘real world.’’ The helmet typically used to deliver VR
blocks the patients’ view of the hospital room and substitutes
Immersive virtual reality pain distraction computer-generated images via small computer screens and
lenses positioned near the patient’s eyes.
The goal of immersive virtual reality (VR) is to give pa-
tients the illusion of visiting the virtual world, as if it is a
Research using wide field of view VR goggles
place they are visiting, an illusion known as ‘‘presence.’’ The
and interactive VR worlds
rationale of why VR could be valuable for pain control is
explained as follows. With burn patients, pain receptors send Research using wide field of view VR goggles and inter-
neural signals/information to the patient’s brain that the active virtual reality worlds has shown significant drops in
brain processes, resulting in the patient’s conscious experi- subjective burn pain in both case series as well as random-
ence of pain. This information processing requires atten- ized controlled trials. VR analgesia has been demonstrated in
tion.5,6 There is a limit to how much information the brain burn patients during wound debridement (see Figure 1a) and
can process at any given time.7 Virtual Reality (e.g, Snow- as shown in Figure 1b, during physical/occupational therapy
World) floods the brain with attention grabbing information skin stretching exercises.11,13 In one recent study of soldiers
from multiple senses. SnowWorld is unusually attention with combat-related burn injuries during wound cleaning,
grabbing, leaving less attention available for processing pain VR distraction with SnowWorld boosted patients ratings of
signals. Patients feel less pain, and spend less time thinking ‘‘fun during wound care’’ from ‘‘no fun at all’’ (with no VR),
about their pain.8–12 to ‘‘pretty fun’’ during VR.4
SnowWorld was the first virtual reality world specifically A number of laboratory studies have also explored the
designed for treating pain (www.vrpain.com). SnowWorld is potential of VR distraction as a non-pharmacologic analgesic.
custom designed to treat burn patients who are on powerful Laboratory studies have explored the relationship between the
pain medications, and in pain. During painful wound care immersiveness of the VR system and the magnitude of pain
procedures, patients interact with snowmen, igloos, pen- reduction during VR distraction.11,14–17 These studies have

FIG. 2. Pediatric burn pa-

tient was the first to try out
the Oculus Rift VR goggles
for VR pain distraction dur-
ing physical therapy. Photo
credits and copyright Hunter
Hoffman, UW, www.vrpain
.com.
OCULUS RIFT VIRTUAL REALITY PAIN DISTRACTION 399

FIG. 3. (a) SnowWorld, a VR world designed for distracting patients from acute procedural pain. During wound cleaning
and physical therapy, severe burn trauma patients typically report 35–50 percent reductions in worst pain intensity on
subjective pain rating scales.11,13 (b) Functional magnetic resonance imaging (fMRI) brain scan studies show large re-
ductions in pain-related brain activity in subjects using SnowWorld.19,20 SnowWorld still image by Ari Hollander and
Howard Rose, copyright Hunter Hoffman, UW, www.vrpain.com. fMRI brain image by Todd Richards and Aric Bills,
copyright Hunter Hoffman, UW, www.vrpain.com.

helped researchers design more effective VR systems. For in quality, but have remained expensive. However, a similar
example, in laboratory studies with healthy volunteer partic- breakthrough in VR goggle technology is in development,
ipants, allowing patients to interact with the virtual world via and scheduled for commercial sale in 2014 or 2015: the
throwing snowballs by clicking their computer mouse,16 and Oculus Rift, www.oculusvr.com (not available to consumers
use of wide field of view (large) goggles, have both been at the time this was written). The Oculus Rift goggles are
shown to significantly boost VR pain reduction compared to wide field of view, roughly similarly in FOV to VR goggles
less immersive VR.15 currently being used for VR pain distraction at several re-
In addition to reducing the amount of pain reported by gional burn centers, (e.g., the Rockwell Collins SR80 VR
participants during brief painful stimuli, studies using func- goggles, priced at $35,000).4 The new Oculus Rift goggles
tional Magnetic Resonance Imaging (fMRI) have shown large are being developed for mass production to be used to play
reductions in pain-related brain activity during VR.19 Healthy video games and movies. Instead of being built one at a time
volunteers received brief thermal stimuli at painful but toler- like the current wide field of view VR goggles, Oculus Rift
able temperatures during brain scans (pain on/off approxi- are mass produced. Fifty thousand Oculus Rift goggles have
mately every 30 seconds for approximately six minutes). Half reportedly already been manufactured and sold to software
of the stimuli were during no VR, and participants played developers, and when Oculus Rift goes commercial, the
SnowWorld in the brain scanner during the other three pain goggles are priced to sell to a very large market of PC video
stimuli (treatment order randomized). During VR, participants game players, a 20 billion dollar a year industry. The es-
reported large reductions in how much pain they experienced, timated selling price of the Oculus Rift goggles is *$400.
and their brains showed large reductions in pain-related brain (1/1000th the cost of the Rockwell Collins SR80 used in
activity in all five brain regions of interest, the thalamus, insula, several key VR analgesia studies). As evidence of the
anterior cingulate cortex, and the primary and secondary so-
matosensory cortices. A related laboratory pain study showed
that the amount of pain reduction from VR was comparable to
the amount of pain reduction from a moderate dose of hydro-
morphone typical of what a burn patient would receive during
wound care, and the greatest analgesia was achieved by com-
bining the two treatment modalities (pharmacologic and non-
pharmacologic).20

Critical Barriers to using immersive VR adjunctively,

(i.e., in addition to traditional pain medications),
for pediatric patients with large severe burn injuries
Despite the growing evidence that VR is effective during
painful medical procedures, VR is not yet widely used
clinically during everyday clinical practice. The expense of
wide field of view VR systems has limited dissemination.
Over the past 20 years, the price of VR computers has
dropped from $90,000 to less than $1,500, as graphics pro-
cessor and CPU speeds have been accelerated and minia- FIG. 4. Pain during passive range of motion exercises
turized for video game consumers. In contrast, during the during no VR, (gray bars) vs. pain during the same exercises
past 20 years, wide field of view VR goggles have improved while in VR (black bar).
400 HOFFMAN ET AL.

FIG. 5. SpiderWorld VR exposure therapy

for phobias.24 Photo credit Stephen Daga-
dakis, copyright Hunter Hoffman, www
.vrpain.com.

magnitude of this development, Oculus Rift was purchased these results suggest that the Oculus Rift VR goggles merit
by Facebook for 2 billion dollars in March 2014. more attention as a potential treatment for acute procedural
pain of burn patients. Randomized controlled studies are
Materials and Methods warranted. Availability of inexpensive, but highly immersive
VR goggles would significantly improve cost effectiveness
The current case study was conducted as a proof of con-
and increase dissemination of VR pain distraction, making VR
cept, to explore the feasibility of using the Oculus Rift
distraction available to many more patients, potentially even at
goggles to distract burn patients during occupational therapy
home, for pain control, and for a wide range of other VR
and other painful medical procedures. The patient was an 11-
therapy applications (e.g., VR exposure therapy for phobias,24
year-old male with severe electrical and flash burns on his
and post-traumatic stress disorder,25 and beyond; see Figure 5).
head, shoulders, arms, and feet (36 percent TBSA, 27 percent
TBSA third-degree burns), from an electrical accident where
Acknowledgments
high voltage electricity passed through his body. Because the
patient had severe burn wounds on his head, we mounted our Funding from Shriners Hospitals for Children Grant to
monocular Oculus Rift goggles to a robot-like arm goggle Walter Meyer III. NIH grants 2 R01 GM042725-17 and 1
holder.4 On day 1 (baseline), the patient spent some of his R01AR054115-01A1.
20 minutes of physical therapy with no VR (standard pain
medications alone). On day 2, the patient received the same Author Disclosure Statement
pain medications, and his occupational therapist conducted
No competing financial interests exist.
the same 20-minute passive range of motion skin stretching
exercises while the patient looked into the VR goggles (see
Fig. 2) and interacted with the world using a computer mouse References
(standard pain medications + VR, see Fig. 3a). On day 3, the 1. Malchow RJ, Black IH. The evolution of pain management
patient received 20 minutes of physical therapy with no VR, in the critically ill trauma patient: emerging concepts from
same as day 1. the global war on terrorism. Critical Care Medicine 2008;
36:S346–S357.
Results 2. Choiniere M, Melzack R, Rondeau J, et al. The pain of
burns: characteristics and correlates. Journal of Trauma
The GRS ratings18 of the patient are shown in Figure 4.
1989; 29:1531–1539.
Pain intensity and pain unpleasantness dropped during VR. 3. Maani C, Hoffman HG, DeSocio PA, et al. Pain control during
The patient reported having more fun during physical ther- wound care for combat-related burn injuries using custom
apy with VR than without it. Also, despite the fact that we articulated arm mounted virtual reality goggles. Journal of
used a custom robot-like arm mounted oculus rift goggles CyberTherapy and Rehabilitation 2008; 1:193–198.
holder with no head tracking, and a preconsumer software 4. Maani CV, Hoffman HG, Morrow M, et al. Virtual reality
developers prototype version of the helmet with considerably pain control during burn wound debridement of combat-
lower quality resolution than the forthcoming consumer related burn injuries using robot-like arm mounted VR
version, the patient rated his presence in VR as a 10 (on a goggles. Journal of Trauma 2011; 71:S125– S130.
graphic rating scale from 0 to 10), reporting that he went 5. Eccleston C. Role of psychology in pain management.
‘‘completely inside the computer generated world as if it was British Journal of Anaesthesia 2001; 87:144–152.
a place he visited.’’ 6. Eccleston C, Crombez G. Pain demands attention: a cog-
nitive-affective model of the interruptive function of pain.
Discussion Psychological Bulletin 1999; 125:356–366.
7. Kahneman D. (1973). Attention and effort. Englewood
Results showing reductions in pain intensity and pain Cliffs, NJ: Prentice-Hall, p. 246.
unpleasantness, during the 20 minutes of occupational ther- 8. Hoffman HG, Garcia-Palacios A, Kapa VA, et al. Im-
apy skin stretching exercises, are consistent with a growing mersive Virtual Reality for reducing experimental ischemic
literature showing reductions in pain during VR21,22 but re- pain. International Journal of Human-Computer Interaction
markably, in the current study, this was accomplished using a 2003; 15:469–486.
pair of *$400 VR goggles. Although preliminary, and al- 9. Hoffman HG. Virtual-reality therapy. Scientific American
though case studies are by nature scientifically inconclusive,23 2004; 291:58–65.
OCULUS RIFT VIRTUAL REALITY PAIN DISTRACTION 401

10. Hoffman HG, Doctor JN, Patterson DR, et al. Virtual re- ality: evidence from fMRI. Neuroreport 2004; 15:1245–
ality as an adjunctive pain control during burn wound care 1248.
in adolescent patients. Pain 2000; 85:305–309. 20. Hoffman HG, Richards TL, Van Oostrom T, et al. The
11. Hoffman HG, Chambers GT, Meyer WJ, 3rd, et al. Virtual analgesic effects of opioids and immersive virtual reality
reality as an adjunctive non-pharmacologic analgesic for distraction: evidence from subjective and functional brain
acute burn pain during medical procedures. Annals of Be- imaging assessments. Anesthesia and Analgesia 2007; 105:
havioral Medicine 2011; 41:183–191. 1776–1783.
12. van Twillert B, Bremer M, Faber AW. Computer-generated 21. Malloy KM, Milling LS. The effectiveness of virtual reality
virtual reality to control pain and anxiety in pediatric and distraction for pain reduction: a systematic review. Clinical
adult burn patients during wound dressing changes. Journal Psychology Review 2010; 30:1011–1018.
of Burn Care & Research 2007; 28:694–702. 22. Morris LD, Louw QA, Grimmer-Somers K. The effec-
13. Sharar SR, Carrougher GJ, Nakamura D, et al. Factors tiveness of virtual reality on reducing pain and anxiety in
influencing the efficacy of virtual reality distraction anal- burn injury patients: a systematic review. Clinical Journal
gesia during postburn physical therapy: preliminary results of Pain 2009; 25:815–826.
from 3 ongoing studies. Archives of Physical Medicine and 23. Campbell DT, Stanley JC. (1963). Experimental and quasi-
Rehabilitation 2007; 88:S43– S49. experimental design for research. Boston: Houghton Mif-
14. Hoffman HG, Sharar SR, Coda B, et al. Manipulating flin Company, p. 84.
presence influences the magnitude of virtual reality anal- 24. Garcia-Palacios A, Hoffman H, Carlin A, et al. Virtual
gesia. Pain 2004; 111:162–168. reality in the treatment of spider phobia: a controlled study.
15. Hoffman HG, Seibel EJ, Richards TL, et al. Virtual reality Behaviour Research and Therapy 2002; 40:983–993.
helmet display quality influences the magnitude of virtual 25. Difede J, Cukor J, Wyka K, et al. D-cycloserine augmen-
reality analgesia. Journal of Pain 2006; 7:843–850. tation of exposure therapy for post-traumatic stress disorder:
16. Wender R, Hoffman HG, Hunner HH, et al. Interacti- a pilot randomized clinical trial. Neuropsychopharmacology.
vity influences the magnitude of virtual reality analgesia. 2014; 39:1052–1058.
Journal of CyberTherapy and Rehabilitation 2009; 2:
27–33.
17. Dahlquist LM, McKenna KD, Jones KK, et al. Active and Address correspondence to:
passive distraction using a head-mounted display helmet: Dr. Hunter G. Hoffman
effects on cold pressor pain in children. Health Psychology Human Photonics Laboratory
2007; 26:794–780. Mechanical Engineering
18. Gracely RH, McGrath F, Dubner R. Ratio scales of sen- University of Washington
sory and affective verbal pain descriptors. Pain 1978; 5: Box 352142
5–18. Seattle, WA 98195
19. Hoffman HG, Richards TL, Coda B, et al. Modulation
of thermal pain-related brain activity with virtual re- E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.1514

Pain Management in Virtual Reality:

A Comprehensive Research Chart

Camelia Sulea, MD,1 Ahmad Soomro,2 Chelsie Boyd, MRes,1 and Brenda K Wiederhold, PhD, MBA, BCB, BCN1,3

H ere, we provide a comprehensive listing of re-

search done on pain management in virtual reality.
MEDLINE was searched in October 2013 for the keywords
‘‘virtual reality and pain.’’ Results from that search are pre-
sented herein.

Year Author Title Publication Topic

1981 Perry S, Heidrich Assessment of pain by burn patients Journal of Burn Care and Burn
G, Ramos E Rehabilitation 2:322–327
1984 Seyrek SK, Corah Comparison of three distraction Journal of the American Dental treatments
NL, Pace LF techniques in reducing stress in Dental Association
dental patients 108:327–329
1988 Watson D, Clark Development and validation of brief Journal of Personality and Affect
LA, Tellegen A measures of positive and negative Social Psychology
affect: the PANAS scales 54:1063–1070
1993 Troesch R, The influence of guided imagery on Oncology Nursing Forum Cancer
Delaney Y chemotherapy-related nausea and 20:1179–1185
vomiting
1994 Regan EC, Price KR The frequency of occurrence and Aviation, Space, and Side effects
severity of side-effects of Environmental Medicine
immersion virtual reality 65:527–530
1995 Farr C E-anesthesia: pulp fiction or virtual Dentistry Today 14:70–75 Anesthesia
reality
1996 Eguchi K Supportive care programs in cancer Supportive Care in Cancer Cancer
at the National Cancer Center in 4:266–269
Tokyo
1996 Ramachandran Synaesthesia in phantom limbs Proceedings of the Royal Phantom limb
VS, Rogers- induced with mirrors Society B: Biological
Ramachandran D Sciences 263:377–386
1996 Wiederhold MD, From virtual worlds to the IEEE Engineering in Chronic pain
Wiederhold BK therapist’s office: are virtual Medicine and Biology
reality techniques useful tools in 15:44–46
psychotherapy and diagnosis?
1997 Carson CL, Ameliorating adult’s acute pain Applied Nursing Research Phlebotomy
Grissom NL during phlebotomy with a 10:168–173
distraction intervention
1997 Cohen LL, Nurse coaching and cartoon Journal of Pediatric Immunization
Blount RL, distraction: an effective and Psychology 22:355–370
Panopoulos G practical intervention to
reduce child, parent, and nurse
distress during immunizations
(continued)

1
Virtual Reality Medical Institute, Brussels, Belgium.
2
NousMetrix, San Diego, California.
3
Interactive Media Institute, San Diego, California.

402
PAIN MANAGEMENT IN VIRTUAL REALITY 403

Year Author Title Publication Topic

1998 Ohsuga M, Possibility of virtual reality for Studies in Health Technology Mental care
Oyama H mental care and Informatics 58:82–90
1998 Ohsuga M, Tatsuno Bedside wellness—development of Studies in Health Technology Rehabilitation
Y, Shimono F, a virtual forest rehabilitation and Informatics 50:
et al. system 168–174
1998 Ilacqua GE Migraine headaches: coping Headache 34:99–102 Headache
efficacy of guided imagery
training
1999 Oyama H, Ohsuga Evaluation of the CyberPsychology and Cancer
M, Tatsuno Y, psychooncological effectiveness Behavior 2:81–84
Katsumata N of the bedside wellness system
1999 Schneider SM, Effects of virtual reality on CyberPsychology and Cancer
Workman ML symptom distress in children Behavior 2:125–134
receiving chemotherapy
2000 Hoffman HG, Use of virtual reality for adjunctive The Clinical Journal of Pain Burn patient
Patterson DR, treatment of adult burn pain 16:244–250
Carrougher GJ during physical therapy: a
controlled study
2000 Hoffman HG, Virtual reality as an adjunctive pain Pain 85:305–309 Burn patient
Doctor JN, control during burn wound care
Patterson DR, in adolescent patients
et al.
2000 Sullivan C, The effect of virtual reality during ASDC Journal of Dentistry Dental treatments
Schneider PE, dental treatment on child anxiety for Children 67:193–196
Musselman RJ, and behavior
et al.
2001 Hoffman HG, The effectiveness of virtual reality CyberPsychology and Dental procedures
Garcia-Palacios for dental pain control: a case Behavior 4:527–535
A, Patterson DR, study
et al.
2001 Hoffman HG, Effectiveness of virtual reality- Clinical Journal of Pain Pain control
Patterson DR, based pain control with multiple 17:229–235
Carrougher GJ, treatments
Sharar SR
2001 Anderson PL, Virtual reality: using the virtual Bulletin of the Menninger Improve quality of
Rothbaum BO, world to improve quality of life Clinic 65:78–91 life
Hodges L in the real world
2001 Pennant JH Anesthesia for laparoscopy in the Anesthesiology Clinics of Anesthesia
pediatric patient North America 19:69–88
2001 Cupal DD, Brewer Effects of relaxation and guided Rehabilitation Psychology Pain control
BW imagery on knee strength, 1:28–43
reinjury anxiety, and pain
following anterior cruciate
ligament reconstruction
2002 Schultheis MT, Virtual reality and Journal of Head Trauma Neuropsychology
Himelstein J, neuropsychology: upgrading the Rehabilitation 17:378–394
Rizzo AA current tools
2002 Poletto CJ, Van Elevating pain thresholds in humans IEEE Transactions on Depolarizing
Doren CL using depolarizing prepulses Biomedical Engineering prepulses
49:1221–1224
2002 Sander Wint S, Effects of distraction using virtual Oncology Nursing Forum Cancer
Eshelman D, reality glasses during lumbar 29:E8–E15
Steele J, punctures in adolescents with
Guzzetta CE cancer
2002 Fors EA, Sexton H, The effect of guided imagery and Journal of Psychiatric Fibromyalgia
Gotestam G amitriptyline on daily Research 36:179–187
fibromyalgia pain: a prospective,
randomized, controlled trial
(continued)
404 SULEA ET AL.

Year Author Title Publication Topic

2003 Gershon J, Zimand Use of virtual reality as a distractor CyberPsychology and Cancer
E, Lemos R, for painful procedures in a patient Behavior 6:657–661
et al. with pediatric cancer: a case
study
2003 Steele E, Grimmer Virtual reality as a pediatric pain CyberPsychology and Pain modulation
K, Thomas B, modulation technique: a case Behavior 6:633–638
et al. study
2003 Sveistrup H, Experimental studies of virtual CyberPsychology and Rehabilitation
McComas J, reality-delivered compared to Behavior 6:245–249
Thornton M, conventional exercise programs
et al. for rehabilitation
2003 Hoffman HG, The illusion of presence in CyberPsychology and Burn patient
Richards T, immersive virtual reality during Behavior 6:127–31
Coda B, et al. an fMRI brain scan
2003 Tse MM, Ng JK, Visual stimulation as pain relief for CyberPsychology and Leg ulcers
Chung JW Hong Kong Chinese patients with Behavior 6:315–320
leg ulcers
2003 Reger GM Effectiveness of virtual reality for Proceedings of the 2nd Venipuncture
attentional control to reduce International Workshop in
children’s pain during Virtual Rehabilitation,
venipuncture Piscataway, NJ, pp. 62–67
2003 Schneider SM Virtual reality for the treatment of San Diego, CA: Interactive Cancer
breast cancer Media Institute
2003 Schneider SM, Virtual reality intervention for older CyberPsychology and Cancer
Ellis M, Coombs women with breast cancer Behavior 6:301–307
WT, et al.
2003 Hoffman HG, Coda Virtual reality analgesia during San Diego, CA: Interactive Analgesia
BA, Sharar SR, thermal and electrical pain for Media Institute
et al. longer durations, and multiple
treatments
2004 Gershon J, Zimand A pilot and feasibility study of Journal of the American Cancer
E, Pickering M, virtual reality as a distraction for Academy of Child &
et al. children with cancer Adolescent Psychiatry
43:1243–1249
2004 Hoffman HG, Manipulating presence influences Pain 111:162–168 Analgesia
Sharar SR, Coda the magnitude of virtual reality
B, et al. analgesia
2004 Hoffman HG Virtual-reality therapy Scientific American 291: Burn patient
58–65
2004 Patterson DR, Virtual reality hypnosis: a case International Journal of Burn patient
Tininenko JR, report Clinical and Experimental
Schmidt AE, Hypnosis 52:27–38
Sharar SR
2004 Hoffman HG, Water-friendly virtual reality pain Journal of Clinical Burn patient
Patterson DR, control during wound care Psychology 60:189–195
Magula J, et al.
2004 Schneider SM, Virtual reality as a distraction Oncology Nursing Forum Cancer
Prince-Paul M, intervention for women receiving 31:81–88
Allen MJ, et al. chemotherapy
2004 Simmons D, A clinical trial of distraction Insight 29:13–16 Cataract surgery
Chabal C, techniques for pain and anxiety
Griffith J, et al. control during cataract surgery
2005 Wright JL, Virtual reality as an adjunctive pain Urology 66:1320 Pain control
Hoffman HG, control during transurethral
Sweet RM microwave thermotherapy
2005 Wismeijer AA, The use of virtual reality and Annals of Behavioral Analgesia
Vingerhoets AJ audiovisual eyeglass systems as Medicine 30:268–278
adjunct analgesic techniques:
a review of the literature
(continued)
PAIN MANAGEMENT IN VIRTUAL REALITY 405

Year Author Title Publication Topic

2005 Pesudovs K The development of a symptom Optometry & Vision Science Questionnaire
questionnaire for assessing 82:571; author reply
virtual reality viewing using a 571–572
head-mounted display
2005 Ames SL, The development of a symptom Optometry & Vision Science Questionnaire
Wolffsohn JS, questionnaire for assessing 82:168–176
McBrien NA virtual reality viewing using a
head-mounted display
2005 Das DA, Grimmer The efficacy of playing a virtual BMC Pediatrics 5:1 Burn patients
KA, Sparnon reality game in modulating pain
AL, et al. for children with acute burn
injuries: a randomized controlled
trial
2005 Sherstyuk A, Affordable virtual environments: Studies in Health Technology Pain treatment
Aschwanden C, building a virtual beach for and Informatics 111:
Saiki S clinical use 465–467
2005 Hoffman HG, Modulation of thermal pain-related Neuroreport 15:1245–1248 Analgesia
Richards TL, brain activity with virtual reality:
Coda B, et al. evidence from fMRI
2005 Schneider SM Virtual reality intervention for Orlando, FL: Oncology Cancer
chemotherapy symptoms Nursing Society
2005 Wolitzkya K, Effectiveness of virtual reality Psychology & Health 20: Cancer
Fivushb R, distraction during a painful 817–824
Zimand E, et al. medical procedure in pediatric
oncology patients
2005 Tse MM, Pun SP, Affective images: relieving chronic CyberPsychology and Chronic pain
Benzie IF pain and enhancing quality of life Behavior 8:571–579
for older persons
2005 Wiederhold BK Advances in the clinical delivery of American Psychological Pain control
virtual reality Association Annual
Convention, Washington,
DC, August 18–21, 2005
2005 deCharms R, Control over brain activation and St. Louis, MO: Washington Pain learned, fMRI
Maeda F, Glover pain learned by using real-time University School of
GH, Ludlow d functional MRI Medicine
2006 Patterson DR, Analgesic effects of posthypnotic Journal of Abnormal Thermal pain
Hoffman HG, suggestions and virtual reality Psychology 115:834–841
Palacios AG, distraction on thermal pain
Jensen MJ
2006 Hoffman HG, Virtual reality helmet display Journal of Pain 7:843–850 Analgesia
Seibel EJ, quality influences the magnitude
Richards TL, of virtual reality analgesia
et al.
2006 Magora F, Cohen Virtual reality immersion method of Israel Medical Association Ischemic pain
S, Shochina M, distraction to control Journal 8:261–265
Dayan E experimental ischemic pain
2006 Gold JI, Kim SH, Effectiveness of virtual reality for CyberPsychology and I.V. placement
Kant AJ, et al. pediatric pain distraction during Behavior 9:207–212
i.v. placement
2006 Murray CD, Immersive virtual reality as a CyberPsychology and Phantom limb
Patchick E, rehabilitative technology for Behavior 9:167–170
Pettifer S, et al. phantom limb experience: a
protocol
2006 Patterson DR, Hypnosis delivered through International Journal of Burn patients
Wiechman SA, immersive virtual reality for burn Clinical and Experimental
Jensen M, Sharar pain: a clinical case series Hypnosis 54:130–142
SR
2006 Haik J, Tessone A, The use of video capture virtual Journal of Burn Care & Burn patients
Nota A, et al. reality in burn rehabilitation: Research 27:195–197
the possibilities
(continued)
406 SULEA ET AL.

Year Author Title Publication Topic

2006 Murray CD, Can immersive virtual reality Studies in Health Technology Phantom limb
Patchick EL, reduce phantom limb pain? and Informatics 119:
Caillette F, et al. 407–412
2006 Hoffman HG, Using FMRI to study the neural CNS Spectrums 11:45–51 Analgesia
Richards TL, correlates of virtual reality
Bills AR, et al. analgesia
2006 Cole SW, Kato Clinical trial of re-mission: a video CyberTherapy 11, Cancer
PM, Marin- game for young people with Conference, Gatineau,
Bowling VM, cancer Canada, June 12–15
et al.
2006 Wiederhold BK Virtual Reality applications for Virtual Reality Conference, Rehabilitation
mental assessment and Alexandria, Virginia,
rehabilitation March 25–29
2006 Lange B, Wiliams Virtual Reality distraction for CyberTherapy 11, Minor medical
M, Fulton I, children receiving minor medical Conference, Gatineau, procedures
Craigie M procedures Canada, June 12–15
2007 Vazquez JLM, Using cybertherapy to reduce Journal of Anesthesia and Surgical anxiety
Santander A, postoperative anxiety in cardiac Clinical Research 4:363
Gao K, et al. recovery intensive care units
2007 Hoffman HG, The analgesic effects of opioids and Anesthesia & Analgesia Analgesic, opioids
Richards TL, immersive virtual reality 105:1776–1783
Van Oostrom T, distraction: evidence from
et al. subjective and functional brain
imaging assessments
2007 Dahlquist LM, Active and passive distraction using Health Psychology 26: Cold pressor pain
McKenna KD, a head-mounted display helmet: 794–801
Jones KK, et al. effects on cold pressor pain in
children
2007 Li S, Kay S, Virtual reality: towards a novel Studies in Health Technology Ankylosing
Hardicker NR treatment environment for and Informatics 127: spondilitis
ankylosing spondylitis 190–196
2007 Gold JI, Belmont The neurobiology of virtual reality CyberPsychology and Pain reduction
KA, Thomas DA pain attenuation Behavior 10:536–544
2007 Wiederhold MD, Virtual reality and interactive Pain Medicine 8:S182–S188 Pain distraction
Wiederhold BK simulation for pain distraction
2007 Mühlberger A, Pain modulation during drives CyberPsychology, Behavior, Pain modulation
Wieser MJ, through cold and hot virtual and Social Networking
Kenntner- environments 10:516–522
Mabiala R, et al.
2007 van Twillert B, Computer-generated virtual reality Journal of Burn Care & Burn patients
Bremer M, to control pain and anxiety in Research 28:694–702
Faber AW pediatric and adult burn patients
during wound dressing changes
2007 Chan EA, Chung Application of a virtual reality Journal of Clinical Nursing Burn patients
JW, Wong TK, prototype for pain relief of 16:786–793
et al. pediatric burn in Taiwan
2007 Mosso JL, Rizzo S, Cybertherapy—new applications Studies in Health Technology Discomfort
Wiederhold B, for discomfort reductions. and Informatics 125: reduction
et al. Surgical care unit of heart, 334–336
neonatology care unit, transplant
kidney care unit, delivery room-
cesarean surgery and ambulatory
surgery, 27 case reports
2007 Windich-Biermeier Effects of distraction on pain, fear, Journal of Pediatric Oncology Cancer
A, Sjoberg I, and distress during venous port Nursing 24:8–19
Dale JC, et al. access and venipuncture in
children and adolescents with
cancer
(continued)
PAIN MANAGEMENT IN VIRTUAL REALITY 407

Year Author Title Publication Topic

2008 Gregoretti C, Analgo-sedation of patients with Drugs 68:2427–2443 Burn patients
Decaroli D, burns outside the operating room
Piacevoli Q,
et al.
2008 Sharar SR, Miller Applications of virtual reality for Expert Review of Burn patients
W, Teeley A, pain management in burn-injured Neurotherapeutics 8:1667–
et al. patients 1674
2008 Oneal BJ, Virtual reality hypnosis in the International Journal of Chronic neuropathic
Patterson DR, treatment of chronic neuropathic Clinical and Experimental pain
Soltani M, et al. pain: a case report Hypnosis 56:451–462
2008 Hoffman HG, Virtual reality pain control during Clinical Journal of Pain Burn patients
Patterson DR, burn wound debridement in the 24:299–304
Seibel E, et al. hydrotank
2008 Dahlquist LM, Effects of videogame distraction Journal of Pediatric Cold pressor pain
Weiss KE, using a virtual reality type head- Psychology 34:574–584
Clendaniel LD, mounted display helmet on cold
et al. pressor pain in children
2008 Mott J, Bucolo S, The efficacy of an augmented Burns 34:803–808 Burn patients
Cuttle L, et al. virtual reality system to alleviate
pain in children undergoing burns
dressing changes: a randomised
controlled trial
2008 Sharar SR, Factors influencing the efficacy of Archives of Physical Postburn physical
Carrougher GJ, virtual reality distraction Medicine and therapy
Nakamura D, analgesia during postburn Rehabilitation 88:S43–S49
et al. physical therapy: preliminary
results from 3 ongoing studies
2008 Maani C, Hoffman Pain control during wound care for Journal of Cybertherapy and Wound care
HG, Desocio combat-related burn injuries Rehabilitation 1:193–198
PA, et al. using custom articulated arm
mounted virtual reality goggles
2008 Wiederhold MD, Pain management with cell phone CyberTherapy 13: Changing Cell phone pain
Wiederhold BK technology the Face of Healthcare, management
June 23–25, 2008, San
Diego, CA
2009 Furman E, Virtual reality distraction for pain The Journal of the American Dental treatments
Jasinevicius TR, control during periodontal Dental Association
Bissada NF, scaling and root planning 140:1508–1516
et al. procedures
2009 Miller K, Rodger Multi-modal distraction. Using Burns 36:647–658 Burn patients
S, Bucolo S, technology to combat pain in
et al. young children with burn injuries
2009 Cheetham M, Virtual milgram: empathic concern Frontiers in Human Empathy
Pedroni AF, or personal distress? Evidence Neuroscience 3:29
Antley A, et al. from functional MRI and
dispositional measures.
2009 Morris LD, Louw The effectiveness of virtual reality Clinical Journal of Pain Burn patients
QA, Grimmer- on reducing pain and anxiety in 25:815–826
Somers K burn injury patients: a systematic
review
2009 Casale R, Damiani Mirror therapy in the rehabilitation American Journal of Physical Amputation
C, Rosati V of lower-limb amputation: are Medicine & Rehabilitation
there any contraindications 88:837–842
2009 Leibovici V, Effects of virtual reality immersion Pain Research & Pruritus
Magora F, Cohen and audiovisual distraction Management 14:283–286
S, Ingber A techniques for patients with
pruritus
2009 Carrougher GJ, The effect of virtual reality on pain Journal of Burn Care & Burn patients
Hoffman HG, and range of motion in adults Research 30:785–791
Nakamura D, with burn injuries
et al.
(continued)
408 SULEA ET AL.

Year Author Title Publication Topic

2009 Powell W, Stevens Treadmill interface for virtual Studies in Health Technology Pain reduction
B, Simmonds M reality vs. overground walking: a and Informatics 144:
comparison of gait in individuals 198–203
with and without pain
2009 Shahrbanian S, Scientific evidence for the Studies in Health Technology Acute/chronic pain
Ma X, Korner- effectiveness of virtual reality for and Informatics 144:40–43
Bitensky N, pain reduction in adults with
Simmonds MJ acute or chronic pain
2009 Markus LA, Virtual reality: feasibility of Burns 35:967–969 Burn patients
Willems KE, implementation in a regional
Maruna CC, burn center
et al.
2009 Sarig-Bahat H, Cervical motion assessment using Spine (Phila Pa 1976) Cervical motion
Weiss PL, virtual reality 34:1018–1024
Laufer Y
2009 Mosso JL, Gorini Virtual reality on mobile phones to Studies in Health Technology Surgery
A, De La Cerda reduce anxiety in outpatient and Informatics 142:
G, et al. surgery 195–200
2009 Mahrer NE, The use of virtual reality for pain Current Pain and Headache Pain control
Gold JI control: a review Reports 13:100–109
2009 Askay SW, Virtual reality hypnosis Contemporary Hypnosis Hypnosis
Patterson DR, 26:40–47
Sharar SR
2009 Rutter CE, Sustained efficacy of virtual reality Journal of Pain 10:391–397 Cold pressor pain
Dahlquist LM, distraction
Weiss KE
2009 Nilsson S, The use of virtual reality for needle- European Journal of Cancer
Finnström B, related procedural pain and dis- Oncology Nursing 13:102–
Kokinsky E, tress in children and adolescents 109
Enskär K in a paediatric oncology unit
2009 Cole J, Crowle S, Exploratory findings with virtual Disability and Rehabilitation Phantom limb
Austwick G, reality for phantom limb pain; 31:846–854
Slater DH from stump motion to agency and
analgesia
2009 Meng FG, Wu CY, Virtual reality imaging technique in Journal of Clinical Neuralgia
Liu YG, Liu L percutaneous radiofrequency Neuroscience 16:449–451
rhizotomy for intractable
trigeminal neuralgia
2009 Konstantatos AH, Predicting the effectiveness of Burns 35:491–499 Burn patients
Angliss M, virtual reality relaxation on pain
Costello V, et al. and anxiety when added to PCA
morphine in patients having
burns dressings changes
2009 Hoffman HG, Virtual reality pain control during CyberPsychology and Motion exercises,
Patterson DR, physical therapy range of motion Behavior 12:47–49 trauma
Soltani M, et al. exercises for a patient with mul-
tiple blunt force trauma injuries
2009 O’Dell MW, Lin Stroke rehabilitation: strategies to Annual Review of Medicine Rehabilitation
CC, Harrison V enhance motor recovery 60:55–68
2009 Wood DP, Webb- Combat-related post-traumatic stress Military Medicine 174: Post-traumatic stress
Murphy J, disorder: a case report using 1215–1222 disorder (PTSD)
Center K, et al. virtual reality graded exposure
therapy with physiological
monitoring with a female Seabee
2009 Wood DP, Murphy Cost effectiveness of virtual reality Studies in Health Technology PTSD
J, McLay R, graded exposure therapy with and Informatics 144:
et al. physiological monitoring for the 223–229
treatment of combat related post
traumatic stress disorder
(continued)
PAIN MANAGEMENT IN VIRTUAL REALITY 409

Year Author Title Publication Topic

2009 Walker ML, Virtual reality-enhanced partial Archives of Physical Stroke
Ringleb SI, body weight-supported treadmill Medicine and
Maihafer GC, training poststroke: feasibility Rehabilitation 91:115–122
et al. and effectiveness in 6 subjects
2009 Kott K, De Leo G, Virtual reality gaming for treadmill Journal of CyberTherapy and Cerebral palsy
Lesher K, et al. training: improved functional Rehabilitation 2:35–42
ambulation in children with
cerebral palsy
2010 Sarig Bahat H, The effect of neck pain on cervical Archives of Physical Neck pain
Weiss PL, kinematics, as assessed in a Medicine and
Laufer Y virtual environment Rehabilitation 91:1884–
1890
2010 Bayat A, Ramaiah Analgesia and sedation for children Expert Review of Burn patients
R, Bhananker undergoing burn wound care Neurotherapeutics
SM 10:1747–1759
2010 Dahlquist LM, Virtual-reality distraction and cold- CyberPsychology, Behavior, Cold pressor pain
Herbert LJ, pressor pain tolerance: does and Social Networking
Weiss KE, avatar point of view matter? 13:587–591
Jimeno M
2010 Huang SW Comments on ‘‘Feasibility and Burns 37:354; author reply Burn patients
potential effect of a low-cost 354–355
virtual reality system on reducing
pain and anxiety in adult burn
injury patients during
physiotherapy in a developing
country.’’
2010 Zschaler S Increased pain through Schmerz 24:629–630 Morphine vs. virtual
psychological therapy? reality
Combination of PCA morphine
therapy with virtual reality by
awake dressing change:
paradoxical effects
2010 Ramachandran VS, Using mirror visual feedback Medical Hypotheses 75: Fibromyalgia
Seckel EL and virtual reality to treat 495–496
fibromyalgia
2010 Malloy KM, The effectiveness of virtual reality Clinical Psychology Review Pain reduction
Milling LS distraction for pain reduction: a 30:1011–1018
systematic review
2010 Gaggioli A, A myoelectric-controlled virtual Studies in Health Technology Phantom limb
Amoresano A, hand for the assessment and and Informatics 154:
Gruppioni E, treatment of phantom limb pain 220–222
et al. in trans-radial upper extremity
amputees: a research protocol
2010 Gutierrez- Presence, involvement and efficacy Studies in Health Technology Pain control
Maldonado J, of a virtual reality intervention on and Informatics 154:
Gutierrez- pain 97–101
Martinez O,
Loreto D, et al.
2010 Patterson DR, Virtual reality hypnosis for pain International Journal of Physical trauma
Jensen MP, associated with recovery from Clinical and Experimental
Wiechman SA, physical trauma Hypnosis 58:288–300
Sharar SR
2010 Sato K, Fukumori Nonimmersive virtual reality mirror Pain Medicine 11:622–629 Chronic pain
S, Matsusaki T, visual feedback therapy and its
et al. application for the treatment of
complex regional pain syndrome:
an open-label pilot study
2010 Sarig-Bahat H, Neck pain assessment in a virtual Spine (Phila Pa 1976) Neck pain
Weiss PL, environment 35:E105–E112
Laufer Y
(continued)
410 SULEA ET AL.

Year Author Title Publication Topic

2010 Morris LD, Louw Feasibility and potential effect of a Burns 36:659–664 Burn patients
QA, Crous LC low-cost virtual reality system on
reducing pain and anxiety in
adult burn injury patients during
physiotherapy in a developing
country
2010 Kwekkeboom KL, Mind-body treatments for the pain- Journal of Pain and Symptom Cancer
Cherwin CH, Lee fatigue-sleep disturbance symp- Management 39:126–138
JW, Wanta B tom cluster in persons with cancer
2010 Dahlquist LM, Effects of videogame distraction Journal of Pediatric Cold pressor pain
Weiss KE, Law and a virtual reality type head- Psychology 35:617–625
EF, et al. mounted display helmet on cold
pressor pain in young elementary
school-aged children
2010 Wiederhold MD, Virtual reality and interactive CyberTherapy & Pain distraction
Wiederhold BK simulation for pain distraction: Rehabilitation 3:14–19
an overview
2010 Wood DP, Lessons learned from 350 virtual- CyberPsychology, Behavior, PTSD
Wiederhold BK, reality sessions with warriors and Social Networking
Spira J diagnosed with combat-related 13:3–11
posttraumatic stress disorder
2011 Lamont K, Chin M, Mirror box therapy: seeing is Explore (NY) 7:369–372 Phantom limb
Kogan M believing
2011 Maani CV, Virtual reality pain control during Journal of Trauma 71: Burn patients
Hoffman HG, burn wound debridement of S125–S130
Morrow M, et al. combat-related burn injuries
using robot-like arm mounted VR
goggles
2011 Li A, Montaño Z, Virtual reality and pain Pain Management 1:147–157 Current trends
Chen VJ, Gold JI management: current trends and
future directions
2011 Gutiérrez-Martı́nez Control over the virtual Studies in Health Technology Cold pressor pain
O, Gutiérrez- environment influences the and Informatics 167:
Maldonado J, presence and efficacy of a virtual 111–115
Loreto-Quijada reality intervention on pain
D
2011 Gutierrez- Interactive and passive virtual Studies in Health Technology Cold pressor pain
Maldonado J, reality distraction: effects on and Informatics 167:69–73
Gutierrez- presence and pain intensity
Martinez O,
Cabas-Hoyos K
2011 Alvarez AG, Dal Virtual learning object for the Revista Latino-Americana de Acute pain
Sasso GT simulated evaluation of acute Enfermagem 19:229–237
pain in nursing students
2011 Hänsel A, Seeing and identifying with a European Journal of Pain Decrease pain
Lenggenhager B, virtual body decreases pain 15:874–879 perception
von Känel R, perception
et al.
2011 Morris LD, Virtual reality exposure therapy as BMC Musculoskeletal Fibromyalgia
Grimmer- treatment for pain catastrophizing Disorders 12:85
Somers KA, in fibromyalgia patients: proof-
Spottiswoode B, of-concept study (study protocol)
Louw QA
2011 Maani CV, Combining ketamine and virtual Pain Medicine 12:673–678 Burn patients
Hoffman HG, reality pain control during severe
Fowler M, et al. burn wound care: one military
and one civilian patient
2011 Hoffman HG, Virtual reality as an adjunctive non- Annals of Behavioral Parkinson
Chambers GT, pharmacologic analgesic for Medicine 41:183–191
Meyer WJ 3rd, acute burn pain during medical
et al. procedures
(continued)
PAIN MANAGEMENT IN VIRTUAL REALITY 411

Year Author Title Publication Topic

2011 Griffin HJ, The effect of real and virtual visual Journal of Neurology Gluteal hidradenitis
Greenlaw R, cues on walking in Parkinson’s 258:991–1000
Limousin P, disease
et al.
2011 Danilov AB, [Virtual reality in treatment of pain Zhurnal Nevrologii I Pain syndromes
Gak SV syndromes] Psikhiatrii Imeni S.S.
Korsakova 111:81–85
2011 Schmitt YS, A randomized, controlled trial of Burns 37:61–68 Burn patients
Hoffman HG, immersive virtual reality
Blough DK, analgesia, during physical
et al. therapy for pediatric burns
2011 Law EF, Dahlquist Videogame distraction using virtual Journal of Pediatric Cold pressor pain
LM, Sil S, et al. reality technology for children Psychology 36:84–94
experiencing cold pressor pain:
the role of cognitive processing
2011 Bell KM, Bechara Influence of number of operated Spine (Phila Pa 1976) Cervical motion
BP, Hartman levels and postoperative time on 36:263–268
RA, et al. active range of motion following
anterior cervical decompression
and fusion procedures
2011 Zeher MJ, Armiger Using a virtual integration Studies in Health Technology Phantom limb
RS, Burck JM, environment in treating phantom and Informatics 163:
et al. limb pain 730–736
2011 Wood DP, Webb- Reality graded exposure therapy Studies in Health Technology PTSD
Murphy J, with physiological monitoring for and Informatics 163:
McLay RN, the treatment of combat related 696–702
et al. post traumatic stress disorder: a
pilot study
2011 McLay RN, Wood A randomized, controlled trial of CyberPsychology, Behavior, PTSD
DP, Webb- virtual reality-graded exposure and Social Networking
Murphy JA, therapy for post-traumatic stress 14:223–229
et al. disorder in active duty service
members with combat-related
post-traumatic stress disorder
2012 Spyridonis F, Evaluating the usability of a virtual Conference Proceedings of Wheelchair users
Gronli TM, reality-based Android application the IEEE Engineering in
Hansen J, in managing the pain experience Medicine & Biology
Ghinea G of wheelchair users Society 2012:2460–2463
2012 Seifert AR Absence of verbal recall or memory Journal of Rehabilitation Avoidance learning
for symptom acquisition in fear Research & Development
and trauma exposure: a 49:1209–1220
conceptual case for fear
conditioning and learned nonuse
in assessment and treatment
2012 Asl Aminabadi N, The impact of virtual reality Journal of Dental Research, Dental treatments
Erfanparast L, distraction on pain and anxiety Dental Clinics, Dental
Sohrabi A, et al. during dental treatment in 4–6 Prospects 6:117–124
year-old children: a randomized
controlled clinical trial
2012 Brown NJ, Rodger Efficacy of a children’s procedural Trials 13:238 Burn patients
S, Ware RS, preparation and distraction
et al. device on healing in acute burn
wound care procedures: study
protocol for a randomized
controlled trial
2012 Chang CM, Chang An interactive game-based shoulder Journal of Patient Preference Rehabilitation
YC, Chang HY, wheel system for rehabilitation and Adherence 6:821–828
Chou LW
(continued)
412 SULEA ET AL.

Year Author Title Publication Topic

2012 Llobera J, Virtual reality for assessment of Experimental Brain Research Chronic pain
González- patients suffering chronic pain: a 225:105–117
Franco M, case study
Perez-Marcos D,
et al.
2012 Sil S, Dahlquist The effects of coping style on J Behav Med [Epub ahead of Cold pressor pain
LM, Thompson virtual reality enhanced print]
C, et al. videogame distraction in children
undergoing cold pressorpain
2012 Michiels S, De The assessment of cervical sensory Gait & Posture 38:1–7 Neck pain
Hertogh W, motor control: a systematic
Truijen S, et al. review focusing on measuring
methods and their clinimetric
characteristics
2012 Gutiérrez- The use of virtual reality for Psicothema 24:516–522 Cold pressor pain
Maldonado J, coping with pain with healthy
Gutiérrez- participants
Martı́nez O,
Loreto-Quijada
D, Nieto-Luna R
2012 Won AS, Collins Non-immersive, virtual reality mir- Pain Medicine 13:1257–1258 Facial pain
TA ror visual feedback for treatment
of persistent idiopathic facial pain
2012 Keefe FJ, Huling Virtual reality for persistent pain: a Pain 153:2163–2166 Persistent pain
DA, Coggins new direction for behavioral pain
MJ, et al. management
2012 Teeley AM, Virtual reality hypnosis pain control American Journal of Clinical Multiple fractures
Soltani M, in the treatment of multiple Hypnosis 54:184–194
Wiechman SA, fractures: a case series
et al.
2012 Kipping B, Rodger Virtual reality for acute pain re- Burns 38:650–657 Burn patients
S, Miller K, duction in adolescents undergo-
Kimble RM ing burn wound care: a
prospective randomized con-
trolled trial
2012 Flor H New developments in the Current Opinion in Psychiatry Persistent pain
understanding and management 25:109–113
of persistent pain
2012 Louw Q, Grimmer- Measuring children’s distress Journal of Pain Research Burn patients
Somers K, during burns dressing changes: 4:263–277
Schrikk A literature search for measures
appropriate for indigenous
children in South Africa
2012 Kho ME, Damluji Feasibility and observed safety of Journal of Critical Care Rehabilitation
A, Zanni JM, interactive video games for 27:219.e1–e6
Needham DM physical rehabilitation in the
intensive care unit: a case series
2012 Humphries C The mystery behind anesthesia: The Wall Street Journal, pp. Chronic pain
technology review published by D1, D2
MIT
2012 Wiederhold BK, Managing pain in military NATO Science for Peace and Military population
Wiederhold M populations with virtual reality Security Series—E: Human
and Societal Dynamics
2012 Alphonso AL, Use of a virtual integrated Studies in Health Technology Phantom limb
Monson BT, environment in prosthetic limb and Informatics 181:
Zeher MJ, et al. development and phantom limb 305–309
pain
2012 Stetz MC, Brown Comparing distraction/relaxation NATO Science for Peace and Chronic pain
KS, Folen RA, modalities with chronic pain Security Series—E: Human
et al. patients and Societal Dynamics
(continued)
PAIN MANAGEMENT IN VIRTUAL REALITY 413

Year Author Title Publication Topic

2013 Faber AW, Repeated use of immersive virtual Journal of Burn Care & Burn patients
Patterson DR, reality therapy to control pain Research 34:563–568
Bremer M during wound dressing changes
in pediatric and adult burn
patients
2013 Cacau Lde A, The use of the virtual reality as The Revista Brasileira de Rehabilitation
Oliveira GU, intervention tool in the Cirurgia Cardiovascular
Maynard LG, postoperative of cardiac surgery 28:281–289
et al.
2013 Martini M, Perez- What color is my arm? Changes in Frontiers in Human Pain perception
Marcos D, skin color of an embodied virtual Neuroscience 7:438
Sanchez-Vives arm modulates pain threshold
MV
2013 Giggins OM, Biofeedback in rehabilitation Journal of NeuroEngineering Rehabilitation
Persson UM, and Rehabilitation 10:60
Caulfield B
2013 Villiger M, Bohli Virtual reality-augmented Neurorehabilitation & Neural Neurorehabilitation
D, Kiper D, et al. neurorehabilitation improves Repair 27:675–683
motor function and reduces
neuropathic pain in patients with
incomplete spinal cord injury
2013 Shiri S, Feintuch A virtual reality system combined Pain Medicine 14:621–627 Pediatric headache
U, Weiss N, with biofeedback for treating
et al. pediatric chronic headache—
a pilot study
2013 Diers M, Flor H [Phantom limb pain. Psychological Schmerz 27:205–211; quiz Phantom limb
treatment strategies] 212–213
2013 Loreto-Quijada D, Testing a virtual reality intervention European Journal of Pain Pain control
Gutiérrez- for pain control 17:1403–1410
Maldonado J,
Gutiérrez-
Martı́nez O,
Nieto R
2013 Botella C, Garcia- Virtual reality in the treatment of CyberPsychology, Behavior, Fibromyalgia
Palacios A, fibromyalgia: a pilot study and Social Networking
Vizcaı́no Y, 16:215–223
et al.
2013 Crews RT, Yalla A growing troubling triad: diabetes, Journal of Aging Research Diabetes, falls
SV, Fleischer aging, and falls 2013:342650
AE, Wu SC
2013 de Tommaso M, Virtual visual effect of hospital Pain Research and Treatment Chronic migraine
Ricci K, Laneve waiting room on pain modulation 2013:515730
L, et al. in healthy subjects and patients
with chronic migraine
2013 Bouchard S, Empathy toward virtual humans CyberPsychology, Behavior, Empathy
Bernier F, depicting a known or unknown and Social Networking
Boivin É, et al. person expressing pain 16:61–71
2013 Baas JM Individual differences in predicting Biological Psychology 92: Anxiety
aversive events and modulating 17–25
contextual anxiety in a context
and cue conditioning paradigm

Address correspondence to:

Prof. Brenda K. Wiederhold
Virtual Reality Medical Institute
30 Clos Chapelle aux Champs, Box 1.3030
1200 Brussels
Belgium

E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014 CLOSING EDITORIAL
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0197

Future Directions:
Advances and Implications of Virtual
Environments Designed for Pain Management

Brenda K. Wiederhold, PhD, MBA, BCB, BCN,1,2 Ahmad Soomro,3 Giuseppe Riva, PhD, MS,4,5
and Mark D. Wiederhold, MD, PhD, FACP 6

Abstract

Pain symptoms have been addressed with a variety of therapeutic measures in the past, but as we look to the
future, we begin encountering new options for patient care and individual health and well-being. Recent studies
indicate that computer-generated graphic environments—virtual reality (VR)—can offer effective cognitive
distractions for individuals suffering from pain arising from a variety of physical and psychological illnesses.
Studies also indicate the effectiveness of VR for both chronic and acute pain conditions. Future possibilities for
VR to address pain-related concerns include such diverse groups as military personnel, space exploration teams,
the general labor force, and our ever increasing elderly population. VR also shows promise to help in such areas
as drug abuse, at-home treatments, and athletic injuries.

Background leveraged to manage much more persistent and detrimental

pain symptoms.
Pain requires cognitive attention.5 Since humans have a
A ccording to the International Association of Pain,
pain is an unpleasant sensory and emotional experi-
ence associated with actual or potential tissue damage. It
limited attentional capability,6 a computer-generated simula-
tion of three-dimensional environments that can be interacted
is a ubiquitous symptom underlying most illnesses, and it with in a seemingly realistic manner—virtual reality (VR)—is
diverges into two unique forms: acute and chronic. Acute capable of transporting an individual into an alternate reality
pain serves a biological purpose, as it usually occurs at the without physically leaving their current environment.7 VR has
onset of painful incidents such as procedural operations, re- been found to reduce performance on divided attention tasks,8
covery and rehabilitation, childbirth, dental work, burns, and patients have less attentional capacity to focus on in-
fractures, and so on. If acute pain is not treated properly, it coming signals from pain receptors as they shift their focus to
can become chronic.1 Chronic pain is characterized by pain interaction with the virtual environment (VE).
that outlasts normal time of healing, or pain that is associated VEs can also be used to train patients on preventative and
with a disease or injury. If chronic pain is not treated prop- rehabilitative procedures.9 When used in combination with
erly, it can worsen over time and lead to a reduction in quality electrophysiological state-sensing devices such as electroen-
of life.2 Pain of any sort is generally associated with psy- cephalograph (EEG), electrocardiograph (ECG), electromyo-
chophysiological factors because emotional and behavioral gram (EMG), and other technology, rich patient biofeedback
responses have the ability to influence the development of data can be observed. Commercially available handheld de-
illness and the outcome of treatment, and vice versa.3 Psy- vices and peripheral gaming accessories such as Razer Hydra,
chological models are incorporated into pain therapy, since Leap Motion 3D controller, Myo armband, and the Virtuix
they provide a better understanding of the cognitive, emo- Omni treadmill (to name a few) can be used to incorpo-
tional, and behavioral manifestations of pain.4 In extreme rate dynamic control mechanisms into VR simulations.
cases, pharmacological and interventional therapies can be The release of the Oculus Rift Developer’s Kit (costing

1
Virtual Reality Medical Institute, Brussels, Belgium.
2
Interactive Media Institute, San Diego, California.
3
NousMetrix, San Diego, California.
4
Catholic University, Milan, Italy.
5
Istituto Auxologico Italiano, Milan, Italy.
6
Virtual Reality Medical Center, San Diego, California.

414
FUTURE DIRECTIONS 415

approximately US$275) head-mounted display (HMD) in 3. Pharmacotherapy (pharmacological therapy). The oral
2013 shed light on a new era of inexpensive VR visualization administration of medicinal drugs to relieve pain symptoms is
systems. Because of the game-like scenarios that can be pro- known as pharmacotherapy. WHO guidelines elicit a ‘‘pain
grammed, several studies have reported that patients actually ladder’’ for the consumption of pharmacological analgesics
have ‘‘fun’’ during treatment with VR.10,11 for patients experiencing severe pain that cannot be addressed
Costing up to US$635 billion each year in medical treat- solely with nonmedicinal therapy.16 The ladder starts with
ment costs and lost productivity in the United States,12 nonopioid drugs such as cannabinoids, paracetamol, dipyrone,
US$417 billion in Europe,13 (chronic) pain management is nonsteroidal anti-inflammatory drugs (NSAIDs), or COX-2
not as ‘‘fun’’ an issue for policy makers. The World Health inhibitors. If pain is not considerably addressed using non-
Organization (WHO) estimates that 22% of the global pop- opioids, further progression could require consumption of a
ulation has some degree of chronic pain.14 Though an in- mild opioid such as codeine phosphate, dextroproxyphene, or
creased understanding of biological mechanisms underlying tramadol in conjunction with nonopioids. If pain persists, or
pain symptoms, diagnostic procedures, and therapeutic ap- the patient is experiencing onset of sudden severe pain
plications have been explored, current treatments for pain symptoms, strong opioids such as morphine, diamorphine,
often do not result in the complete alleviation of symptoms.15 fentanyl, buprenorphine, oxymorphine, oxycodone, or hy-
dromorphone can be issued in conjunction with nonopioids. In
General Overview of Pain Management Therapies patients experiencing neuropathic pain, tricylic antidepres-
sants, class I antiarrhythmics, and anticonvulants are com-
Pain management can be divided into four categories (see
monly issued to relieve pain symptoms.
Fig. 1).
4. Intervention therapy. The use of interventional appli-
1. Physiotherapy (physical therapy). The practice of using
cations to diagnose or locate the patient’s source of pain or
acupuncture, thermal agents, light therapy, electrotherapy,
provide relief is known as intervention therapy. Treatments
therapeutic exercise, and some behavior therapy all fall under
include injection therapy, surgical intervention, nerve blocks,
the category of physiotherapy, which is the treatment of pain
neuroaugmentation, implantable devices or drug delivery
by promotion of mobility, functional ability, and routine
systems, and direct brain stimulation (to name a few). Inter-
physical intervention.
ventional procedures are most commonly used in combination
2. Psychotherapy (psychological therapy). Problems ad-
with standard analgesic methods to reduce opioid side effects
dressed by psychotherapy are centered on the mental well-
and to achieve a better analgesic efficiency.
being of patients. Techniques involve exploration of thoughts,
feelings, and behavior for the purpose of achieving higher
Room for Improvement
levels of functionality and quality of life. Cognitive Behavior
Therapy (CBT) teaches patients to analyze and restructure In a general Western healthcare model, patients who ex-
their thought processes while becoming more aware and in perience symptoms of pain must consult a primary care
control of physiological factors that correlate with mental specialist with the hope of obtaining a diagnosis and curative
state—factors such as heart rate, respiration, and so on. treatment. When such a treatment is unavailable, these

FIG. 1. Virtual reality (VR) pain man-

agement is an interdisciplinary to therapy
designed to attack pain symptoms with an
omnidirectional approach.
416 WIEDERHOLD ET AL.

patients ‘‘expect’’ a prescription for analgesic medication to Fit board, and sensor data are used as a control mechanism
relieve their symptoms. Some of these medications might in the game environment. One study showed significant im-
relieve acute pain in the short term, but their utility for provements in dynamic balance, functional mobility, and a
treating long-term chronic pain can be controversial. Studies reduced risk for falling in elderly patients when playing Wii
suggest only 32% of patients placed on long-term opioids17 Fit.22 Another study, focused on the link between elderly
and 50% placed on antidepressants18 experience a pain re- diabetic patients and injuries due to falling, concluded that VR
duction. In addition to an ambiguous success rate, a sample has the potential to train patients in balance, strength, and gait
of orally consumed pharmacological drugs can produce a so as to reduce the risk of falling.23 For additional analysis on
substance dependency in patients.19 A 2010 U.S. Department performance, neuromuscular movements can be monitored
of Health and Human Services Nation Survey on Drug Use using electromyography (EMG). Several studies have shown
and Health (NSDUH) reported that approximately 1.7 mil- that when this biofeedback is delivered through a display,
lion people had a pain reliever dependency.20 Side effects sound, or haptic signal, it can serve as a correctional mecha-
such as mental illness or even noneffectiveness increase pain nism for the patient and as a monitoring mechanism for the
management opportunity costs and likelihood of unwanted therapist.24 VR displays can integrate biofeedback notifica-
results. Extreme caution must be taken when issuing stronger tions into simulations just as games might use status bars,
medicinal drugs, since they oft come with side effects that numerical displays, and written or spoken notifications. Quite
can impede patient progress if appropriate considerations are like videogames, in fact, VEs are interacted with through a
not acknowledged. variety of human–computer interaction (HCI) factors, which
In 2011, the Health Ministry of New South Wales, Aus- gives therapists the option of incorporating environment
tralia, reported the following issues associated with the control mechanisms that rely on handheld and peripheral
current model of care for pain management: an overdepen- gaming accessories requiring mobility. An example of such a
dence on pharmacotherapy, lack of services approaching mechanism was used earlier, when we mentioned the Wii Fit
pain problems using biopsychosocial approaches, lack of board. Another example is the Virtuix Omni (omnidirectional)
timely access to existing services, an increasing demand for treadmill, which allows users to ‘‘walk in all directions, while
pain management particularly in populations suffering standing in one spot,’’ and enables researchers/therapists to
chronic pains as a result of surviving conditions that are expose patients to VEs that must be navigated through by
associated with or lead to persistent pain, and a lack of tar- walking. Numerous studies have shown the effect of treadmill
geted services for clients experiencing pain who have dif- training on rehabilitative populations.25 It is only recently that
fering needs.21 Having taken these issues into consideration, interdisciplinary researchers/therapists have affordable, com-
we observe how VR therapy can be utilized as a low-cost mercially available tools to utilize to create more engaging and
intervention for a variety of pain-related symptoms. motivating physical therapy environments.
VR represents an opportunity to both enrich and intensify
VR Intervention as a Pain Management Technique the experience patients have when receiving physiotherapy.
The dramatically interactive nature of VR requires patients
VR is a technology that has emerged as an affordable
to become more involved in the therapy process and can
solution for pain management therapy, proven effective in
significantly improve both compliance and therapeutic re-
helping patients cope with pain arising from numerous ail-
sults. During physiotherapy, the main impediment to prog-
ments, being acute or chronic. Table 1 displays a number of
ress is often pain. VR can help overcome this pain so patients
recent (2012–2014) publications that show the efficacy of
may more rapidly proceed through the therapeutic hierarchy.
VR in the treatment of a variety of pain symptoms.
VR exposes patients to computer-generated sights and
sounds, creating visual and auditory stimulus that would VR and psychotherapy
otherwise be presented through the physical environment.
A 17-country study examined the incidence of mental
This method of intervention provides either distraction or
disorders among people with comorbid single or multiple
training to patients suffering pain symptoms. Distraction
pain conditions. Results indicated that mental disorders fol-
therapy has been applied in clinical practice for decades;
lowed a linear pattern, with the lowest rates found among
the foundation of logic backing the technique is based on the
individuals with no pain, intermediate rates among those
assumption that there exist psychological elements in the
with one pain symptom, and highest rates among those ex-
perception of pain. It is thought that the more attention
periencing multiple pain symptoms.26 Psychological factors
someone pays to harmful stimulus, the more intense the re-
are highly correlated with pain; depression, anxiety, and
alization of the pain. Thus, VEs are used to distract patients
posttraumatic stress disorder (PTSD) are frequent by-
from ongoing treatments in a seamless fashion, so as to cause
products of traumatic physical injury and chronic pain.27 VR
minimal amount of actual pain. Just like many other inter-
used within a CBT model can train patients on shifting at-
vention therapies, VR intervention is being used in combi-
tention away from pain or stress-inducing thoughts.28 Self-
nation with other analgesic strategies such as training to
management (SM) is an action taken by the patient to
attack pain symptoms with an omnidirectional approach
manage or minimize the impact of pain.29 Along with guided
(Fig. 1).
in-clinic therapy, patients have the opportunity to heal with
at-home mobile interfaces like those that have been used in
VR and physiotherapy
numerous studies to monitor and assist patients in SM over
Wii Fit from Nintendo (and other videogames) has shown long periods of time.30 VR can provide a mobile experience
that peripheral devices can be used to interact with games with that is programmable and useful for targeting patients with
new meaning. Game players balance themselves on the Wii special needs.31
 Table 1. Recent Studies that Show the Efficiency of Virtual Reality (VR) in the Treatment of a Variety of Pain Symptoms
Pain/discomfort
Study studied Treatment N Findings
Ortiz-Catalan Phantom limb pain— Phantom movements were predicted 1 chronic PLP patient who had shown A reduction of time at higher pain intensity levels, as
et al. (2014) chronic using myoelectric pattern recognition resistance to a variety of treatments well as the appearance of periods of lower or absent
and then used as input for VR and AR for 48 years pain within 18 weeks
environments, including a racing game
Loreto-Quijada General pain/discomfort Figures that represented pain were 64 undergraduate students asked to Interaction with VR led to significant increases in pain
et al. (2013) displayed to subjects, who were asked evaluate arousal and valence in threshold and tolerance, as well as significantly greater
to evaluate in terms of arousal and response to a figure representing underestimation of time
valence; pain figure was then paired pain
with shock, and nonpain figure was
paired with no shock
Bidarra et al. Dental treatment pain— VR gaming distraction — Preliminary evaluation of dentist and game design
(2013) acute domains that influence prototype development for an
at-the-dentist VR distraction system
Botella et al. Fibromyalgia (FM)— 10 sessions of 2 hours group cognitive 6 women diagnosed with FM, with a Results indicate high levels of satisfaction of VR use by
(2013) chronic, neuropathic behavioral treatment for FM supported mean age of 55 years old 6 patients and reduction in impairment caused by FM
by VR (range = 47–65; SD = 7.6) and a mean symptoms
duration of diagnosis of 11 years
Kipping et al. Pediatric burn VR exposure, prospective randomized 41 adolescents aged between 11 and Statistically significant reduction in pain scores during
(2012) wounds—acute controlled trial using 17 years dressing removal, and significantly less doses of
nonpharmacological methods, Entonix given to those receiving VR exposure

417
Villiger et al. Neuropathic pain VR training, uncontrolled 14 iSCI patients were treated over 4 Positive changes reported by patients, improvements in
(2013) in patients with weeks in 16 to20 sessions of 45 lower limb function, reduced intensity and
incomplete spinal minutes unpleasantness score on Neuropathic Pain Scale
cord injury (iSCI)— (NPS), and stability of finding even after 12 to 16
chronic weeks of training termination
Cacau Lde et al. Cardiac rehabilitation VR cardiac rehabilitation vs. traditional 30 patients exposed to VR, 30 patients VR group shows lower reduction in functional
(2013) postoperatively— cardiac rehabilitation not exposed to VR assessed through performance on first day after surgery as compared to
acute functional independence measure control group, no significant difference in performance
(FIM), 6-minute walk test (6MWT), on discharge day, a significant decrease in pain score
and Nottingham Health Profile at the third assessment, higher energy level in first
(NHP) evaluation, no statistical significance for emotional
reactions, physical ability, or social interaction, shorter
length of stay, and higher 6MWD
Giggins et al. Pediatric headache— VR biofeedback pain management 10 adolescents attending an outpatient Ratings of pain, daily functioning, and quality of life
(2013) chronic pediatric neurology clinic were improved significantly at 1 and 3 months post-treatment
treated by a system which
combined VR and biofeedback
Wiederhold Pain in military Review — Funded by NATO, United States Army, Defense
et al. (2012) populations Ministry of Austria, and Defense Ministry of Croatia
Stetz et al. Pain in military CBT to manage pain 42 chronic pain patients from the Statistically significant drop in pain rating in technology-
(2012) populations Tripler Army Medical Center, older assisted sessions than during standard modality
than 17 years of age, intact sensory
deficits, and cognitively enabled to
follow directions
418 WIEDERHOLD ET AL.

VR exposure therapy targets anxiety disorders in patients

with pain symptoms by exposing them to stimuli that trigger
unwanted psychophysiological behaviors and training them to
condition their psychophysiological responses accordingly.
Low-cost EEG systems can be used to monitor real-time brain
activity during mobile and immobile tasks in VR.32 This adds
another dimension of analysis for monitoring patients with
psychological problems because emotional correlates can be
drawn from reading spatio-temporal source dynamics and
event potentials during different tasks.33

VR and pharmacotherapy
Patients can use VR as an adjunct to pharmaceutical drugs
for an increased analgesic efficiency. A study, focused on
burn pain reduction in adolescent populations undergoing
wound dressing, found that patients experienced a significant
reduction in pain scores and dosage of Entonix with VR as
opposed to otherwise.34 The combined usage of VR and
pharmaceutical drugs has also been utilized in treating by-
products of trauma, such as PTSD, with no recorded evi-
dence of negative side effects in the well-being of the pa-
tient.35 The ingestion of pharmaceutical drugs can activate
primary physiological systems. VR treatment acknowledges FIG. 2. Areas and populations that could benefit with in-
these changes and offers methods for promoting activation of terdisciplinary incorporation of VR.
systems otherwise unacknowledged by drug treatment.
Affairs was provided $56 billion (from the 2014 Executive
VR and other interventional therapies
Budget) for war veteran healthcare services, which ‘‘include
Attention to acute pain during interventional treatments innovative programs to educate and support veterans’ care-
can be repressed with the use of VR devices.36,37 A pilot givers, enhance veteran’s access to care through telehealth
study conducted on VR distraction at the dentist found that technologies, and support equitable, high-quality care for
when designing these interfaces, special attention had to be women veterans in an appropriate and safe environment.’’45
paid for different patient and therapist domains. For example,
devices interfering with the work of the dentist could cause a Space exploration
disturbance during the procedure, and devices that were not
Difficulties associated with illness and injury have ac-
engaging enough could fail to distract patients.38
counted for more space exploration failures than any other
technical or environment reason.46 There is room for incor-
Future Implications
porating VR into space exploration as a countermeasure to
Approximately US$14.6 billion over the next 10 years has deal with the threat of traumatic incidences occurring during
been allocated by the 2014 U.S. Executive Budget to ‘‘im- extravehicular activity, onset of neuropathic pain during
plement innovative policies to train new health care providers missions, and other pain-inducing incidents. Low back pain
and ensure that the future health care workforce is prepared to in microgravity is one of the most common problems expe-
deliver high-quality and efficient health care services.’’39 rienced by astronauts.47 A portable wireless VR solution for
Below, we explore areas and populations that may benefit back pain telemonitoring has been previously explored to
from the incorporation of VR into existing training and meet similar application requirements.48 Opportunities such
treatment protocols (Fig. 2). as these provide reason for the two interdisciplinary fields to
marry so they can potentially produce a synergy.
Military populations
Geriatric populations
Military personnel exposed to traumatic incidents have a
high risk for developing PTSD. Incidents may result in in- Injury prevention in elderly populations continues to be an
juries such as severed limbs, traumatic brain injury (TBI), and issue, as one out of three adults aged 65 or older falls each
other acute and chronic pain conditions. Treatment typically year. Falls are the leading cause of both fatal and nonfatal
requires administration of opioid drugs. Studies have shown injuries. Arthritis is another big issue among geriatric pop-
that these drugs may induce a high dependency in patients, ulations, costing the United States up to US$128 billion per
thus the need to investigate new methods for providing effi- year in medical costs and lost productivity.48,49 Approxi-
cient pain relief to veterans.28 One area of investigation is mately 50 million adults are affected with some form of
phantom limb pain, and VR applications are being studied to arthritis. The U.S. Center for Disease Control and Prevention
investigate advancing treatments for this syndrome further.40 was provided approximately US$14 million from the presi-
There has been a significant amount of work in applying VR dent’s 2014 Executive Budget to expand and disseminate
therapies to wounded warriors,28,41–44 and room for im- evidence-based programs for the treatment of arthritis.50 The
provement still remains. The U.S. Department of Veteran’s European Commission also adopted the European Innovative
 Table 2. Global Funding for Advancing Pain Management Techniques and Research
Agency Location Goals Additional Information
American Fibromyalgia United States Researching treatment, cause, and cure for www.afsafund.org
Syndrome Association, Inc. fibromyalgia syndrome
American Pain Society United States Providing grants to investigate pain www.americanpainsociety.org
British Pain Society United Kingdom Providing grants to investigate pain www.britishpainsociety.org
Canadian Pain Society Canada Providing grants to investigate pain www.canadianpainsociety.ca
Defense Advanced Research United States Development of innovative military technology www.darpa.mil
Programs Agency
Department of Defense United States Involved in funding defense medical research www.defense.gov
European Innovative Partnership European Union Commercially feasible innovative concepts www.ec.europa.eu/research/innovation-union
Horizon 2020 European Union Increasing Europe’s global competitiveness by ec.europa.eu/programmes/horizon2020/
driving innovative research
Mayday Fund United States/Canada Clinical interventions, pediatric pain, pain www.maydayfund.org
in non-verbal populations, emergency
treatments
NASA Innovative Advanced United States and some Innovative, interdisciplinary space exploration www.nasa.gov/directorates/spacetech/niac

419
Concepts international opportunity concepts
National Institute of Arthritis United States Issues related to arthritis, musculoskeletal and www.niams.nih.gov
and Musculoskeletal and Skin skin disorders
Diseases
National Institute on Aging United States Issues related to aging www.nia.nih.gov
National Institute of Health Pain United States Advancing pain treatment, medication, and www.painconsortium.nih.gov
Consortium research for pain-related diseases
National Science Foundation United States Funding various project related to pain and www.nsf.gov
disease
National Sleep Foundation United States Pain and sleep www.sleepfoundation.org
Solving Kids Cancer Therapeutic International Pediatric cancer http://solvingkidscancer.org
Development Initiative
Thrasher Research Fund International Prevention, diagnosis and treatment of chil- www.thrasherresearch.org
dren’s diseases
Department of Veteran’s Affairs United States War veterans www.va.gov
William T. Grant Foundation United States Illness affecting youth aged 5–25 years in the www.wtgrantfoundation.org
United States
420 WIEDERHOLD ET AL.

Partnership on Active and Healthy Ageing initiative with the Injury Surveillance System, more than 1.9 million individ-
goal to add 2 years to the average healthy lifespan of Euro- uals were treated for a sports-related injury in an emergency
peans by 2020.51 With resources such as these, we expect to medical facility.54 VR can be incorporated during athletic
see significant advances in the implementation of VR devices conditioning to prevent injury, and during rehabilitation as a
with geriatric populations experiencing pain symptoms in the vehicle on the road to recovery.
future.
Conclusions
Pain due to cancer and other chronic injuries
The use of VR to treat pain and manage patients with a
VR has been used in the treatment of illnesses that often variety of medical conditions has been well established. VR
result in chronic pain. Yet there remains a need for further distraction is effective during medical and surgical proce-
exploration of VR treatment methods used in conjunction dures, acute pain, chronic pain, pain with rehabilitation,
with traditional analgesics to relieve pain symptoms in these chronic pain of cancer, diabetic neuropathic pain, and related
populations. Because pain is not monomorphic, patients can conditions such as pruritus. The technique is safe and ef-
develop intolerance to treatments. This ushers in the use of fective and has been used on patients with migraine head-
VR where medication cannot go. VR simulations can be aches. The often relaxing and stress-reducing capabilities of
programmed to change in response to patient pain, dialing up virtual environments demonstrate wide applicability in be-
the ‘‘dosage’’ as more relief is needed, and dialing down the havioral medicine and patients with psychophysiological
‘‘dosage’’ as less is necessary. This ability to control the disorders. These disorders, such as functional abdominal
CyberDoseª may prove useful as more self-care is admin- pain, muscle sprain, fibromyalgia and neuropathic pain, and
istered by patients in their home environment. postherpetic neuralgia, are very common in primary care
practices. There is significant national and international at-
Occupational injuries tention focused on pain management in the occupational and
On average, up to 12 people die every day due to occu- clinical settings.
pational injury and illness. In 2012, out of 3,945 U.S. worker Table 2 describes some of the funding mechanisms avail-
fatalities in the private industry, 775 (19.6%) were in con- able and those funding agencies that have made pain research
struction. Leading causes for worker deaths on construction one of their priorities. We encourage readers to take advantage
sites were falls, followed by object impalement, and elec- of these and other funding resources to continue research on
trocution.52 VR techniques can be implemented to train labor more effective and innovative pain reduction strategies.
force on preventative techniques to reduce the number of
fatalities and injuries in the workspace. In addition, the Author Disclosure Statement
millions of injuries that occur each year in the workplace can No competing financial interests exist.
be effectively treated using VR to guide both cognitive and
physical rehabilitation.
References
Drug abuse 1. Casey CY, Greenberg MA, Nicassio PM, et al. Transition
from acute to chronic pain and disability: a model including
The National Institute for Drug Abuse has begun a re- cognitive, affective, and trauma factors. Pain 2008; 134:
search program to examine the intersection of pain treatment 69–79.
with the abuse of and addiction to opioid medications. Goals 2. Lamé IE, Peters ML, Vlaeyen JWS, et al. Quality of life in
are centered on developing alternative pain management chronic pain is more associated with beliefs about pain,
solutions (such as VR) with reduced addiction potential, and than with pain intensity. European Journal of Pain 2005;
elucidating risk or protective factors associated with opioid 9:15–24.
abuse and addiction. 3. Keefe FJ, Lumley M, Anderson T, et al. Pain and emotion:
new research directions. Journal of Clinical Psychology
Safe at-home treatments 2001; 57:587–607.
4. Eccleston C. Role of psychology in pain management.
The National Institute for Health’s 8th Pain Symposium in British Journal of Anaesthesia 2001; 87:144–152.
2012 was primarily focused on exploring self-management 5. Eccleston C, Crombez G. Pain demands attention: a cog-
techniques for pain management.53 VR applications are nitive affective model of the interruptive function of pain.
promising for the advancement of at-home medical services Psychological Bulletin 1999; 125:356–366.
because they enable mobility, remote patient monitoring, and 6. Kahneman D. (1973) Attention and effort. Englewood
treatment specialization capabilities. Much work still needs Cliffs, NJ: Prentice-Hall.
to be done to quantify the benefits of using topical agents and 7. Thalman NM, Thalmann D. (1999) Virtual reality software
other safe self-applied techniques such as VR for at-home and technology. Encyclopedia of computer science and
pain management purposes. technology. Vol. 41. Marcel Dekker, Boca Raton, FL:
Marcel Dekker, pp. 17–31.
Athletic injuries 8. Lengenfelder J, Schultheis MT, Al-Shibabi T, et al. Di-
vided attention and driving: a pilot study using virtual re-
Accidents that occur during athletic activity can cause ality technology. Journal of Head Trauma Rehabilitation
injuries in the form of sprains, knee injuries, swollen mus- 2002; 17:26–37.
cles, fractures, dislocations, and more. According to the U.S. 9. Kizony R, Katz N, Weiss PL. (2004) Virtual reality based
Consumer Product Safety Commission’s National Electronic intervention in rehabilitation: relationship between motor
FUTURE DIRECTIONS 421

and cognitive abilities and performance within virtual en- Security Series—E: Human & Societal Dynamics 2012;
vironments for patients with stroke. In Proceedings of the 91:75–93.
5th International Conference on Disability, Virtual Reality 29. Lorig KR, Holman H. Self-management education: history,
and Associated Technology. Oxford, UK: The University of definition, outcomes, and mechanisms. Annals of Beha-
Reading, pp. 19–26. vioral Medicine 2012; 26:1–7.
10. Hoffman HG, Chambers GT, et al. Virtual reality as an 30. Chukoskie L, Soomro A, Townsend J, et al. (2013)
adjunctive non-pharmacologic analgesic for acute burn ‘‘Looking’’ better: designing an at-home gaze training
pain during medical procedures. The Society for Behavioral system for children with ASD. 6th International IEEE/
Medicine 2011; 41:183–191. EMBS Conference on Neural Engineering. pp. 1246–1249.
11. Maani C, Hoffman HG, DeSocio PA, et al. Pain control 31. Wiederhold MD, Wiederhold BK. (2008) Pain management
during wound care for combat-related burn injuries using with cell phone technology. Proceedings of the Cyber-
custom articulated arm mounted virtual reality goggles. Therapy Conference: Changing the Face of Healthcare, San
Journal of CyberTherapy & Rehabilitation 2008; 1:193–198. Diego, CA: IEEE Publishing, pp. 1246–1249.
12. Committee on Advancing Pain Research, Care, and Edu- 32. Pfurtscheller G, Leeb R, Faller J, et al. (2011) Brain–
cation; Institute of Medicine. (2011) Relieving pain in computer interface systems used for virtual reality control.
America: a blueprint for transforming prevention, care, In Virtual Reality. InTech, pp. 1–20.
education, and research. Washington, D.C.: The National 33. Makeig S, Kothe C, Bigdely-Shamlo N, et al. Evolving
Academies Press. signal processing for brain–computer interfaces. Proceed-
13. Wenig CM, Schmidt CO, Kohlmann T, et al. Costs of back ings of the IEEE 2012; 100:1567–1584.
pain in Germany. European Journal of Pain 2008; 13:280–286. 34. Kipping B, Rodger S, Miller K, et al. Virtual reality for
14. World Health Organization. (2013) World health statistics. acute pain reduction in adolescents undergoing burn wound
Geneva: WHO. care: a prospective randomized controlled trial. Burns
15. Turk DC. Clinical effectiveness and cost-effectiveness of 2012; 38:650–657.
treatments for patients with chronic pain. Clinical Journal 35. Wiederhold MD, Wiederhold BK. Virtual reality and
of Pain 2002; 18:355–365. pharmaceuticals: enhanced synergy to improve clinical
16. World Health Organization. (1996) Cancer pain relief. care. CyberTherapy & Rehabilitation 2013; 1:10–12.
With a guide to opioid availability. 2nd ed. Geneva: WHO. 36. Wiederhold MD, Wiederhold B.K. Virtual reality and in-
17. Turk DC, Loeser, JD, Monarch, ES. Chronic pain: purposes teractive simulation for pain distraction. Pain Medicine
and costs of interdisciplinary rehabilitation programs. TENS: 2007; 8:S182–S188.
Trends in Evidence-Based Neuropsychiatry 2002; 4:64–69. 37. Wiederhold MD, Wiederhold B.K. Virtual reality and in-
18. Onghena P, Van Houdenhove B. Antidepressant-induced teractive simulation for pain distraction. CyberTherapy &
analgesia in chronic nonmalignant pain: a meta-analysis of Rehabilitation 2010; 3:14–19.
39 placebo-controlled studies. Pain 1992; 49:205–219. 38. Bidarra R, Gambon D, Kooij R, et al. (2013) Gaming at
19. Turjanski N, Lloyd GG. Psychiatric side-effects of medi- the dentist’s—serious game design for pain and discom-
cations: recent developments. Journal of Continuing Pro- fort distraction. In Games for Health. Springer Vieweg,
fessional Development 2005; 11:58–70. pp. 207–215.
20. Department of Health and Human Services. (2011) Results 39. Department of Health and Human Services. (2014) The
from the 2011 National Survey on Drug Use and Health: budget for fiscal year 2014. Washington, DC: HHS.
summary of national findings. Washington, DC: HHS. 40. Zeher MJ, Armiger R, Burck J, et al. Using a virtual inte-
21. New South Wales Ministry of Health. (2011) NSW pain gration environment in treating phantom limb panic. Study
management report. New South Wales: NSW. for Health Technology Information 2011; 163:730–736.
22. Gardner B. Effectiveness of the Nintendo Wii Fit games 41. Stetz MC, Brown KS, Folen RA, et al. Comparing distraction/
on the balance of a community-dwelling older adult in relaxation modalities with chronic pain. Pain syndromes—
Eastern North Carolina. Unpublished master’s thesis, East from recruitment to returning troops. NATO Science for
Carolina University, Greenville, NC. Peace & Security Series—E: Human & Societal Dynamics
23. Crews RT, Yalla SV, Fleischer AE, et al. A growing 2012; 91:171–177.
troubling triad: diabetes, aging, and falls. Journal of Aging 42. Rizzo A, Buckwalter G, Forbell E, et al. Virtual reality
Research 2013; 2013:1–6. applications to address the wounds of war. Psychiatric
24. Giggins OM, Persson UM, Caulfield B. Biofeedback in Annals 2013; 43:123–138.
rehabilitation. Journal of Neuroengineering & Rehabilita- 43. Wiederhold MD, Wiederhold BK. A review of pain manage-
tion 2013; 10:1–11. ment techniques for military populations. Pain syndromes—
25. Laufer Y, Dickstein R, Chefez Y, et al. The effect of from recruitment to returning troops. NATO Science for
treadmill training on the ambulation of stroke survivors in Peace & Security Series—E: Human & Societal Dynamics
the early ages of rehabilitation: a randomized study. Journal 2012; 91:217–228.
of Rehabilitation Research & Development 2001; 38:69–78. 44. McLay RN, Wood DP, Webb-Murphy JA, et al. A ran-
26. Gureje O, Von Korff M, Kola L, et al. The relation between domized, controlled trial of virtual reality-graded exposure
multiple pain and mental disorders: results from World therapy for post-traumatic stress disorder in active duty
Mental Health Surveys. Pain 2008; 135:82–91. service members with combat-related post-traumatic stress
27. Wiseman T, Foster K, Curtis K. Mental health following disorder. Cyberpsychology, Behavior, & Social Network-
traumatic physical injury: an integrative literature review. ing 2011; 14:223–229.
Injury 2012; 44:1–7. 45. Department of Veteran’s Affairs. (2014) The budget for
28. Wiederhold BK, Wiederhold MD. Managing pain in mili- fiscal year 2014. Washington, DC: VA.
tary populations with virtual reality. Pain syndromes—from 46. Summers RL, Johnston SL, Marshburn TH, et al. Emergencies
recruitment to returning troops. NATO Science for Peace & in space. Annals of Emergency Medicine 2005; 46:177–184.
422 WIEDERHOLD ET AL.

47. Styf JR, Hutchinson K, Carlsson S. Depression, mood state, 53. National Institute of Health. (2013) The 8th Annual NIH
and back pain during microgravity conditions. Psychoso- Pain Consortium Symposium on Advances in Pain Research:
matic Medicine 2001; 63:862–864. Integrating Self-Management Strategies for Chronic Pain.
48. Bichindaritz I, Vaidya S, Jain A, et al. A portable wireless Washington, DC: HHS.
solution for back pain telemonitoring: a 3D-based, virtual 54. Consumer Product Safety Commission. (2012) NEISS data
reality approach. Computational Intelligence in Healthcare highlights. Bethesda, MD.
2010; 4:425–461.
49. Center for Disease Control and Prevention. (2012) Arthritis:
meeting the challenge of living well. Washington, DC: HHS. Address correspondence to:
50. Center for Disease Control and Prevention. (2014) The Prof. Brenda K. Wiederhold
budget for fiscal year 2014. Washington, DC: HHS. Virtual Reality Medical Institute
51. European Innovation Partnership on Active and Healthy 30 Clos Chapelle aux Champs, Box 1.3030
Ageing. (2013) Excellent innovation for ageing. Brussels: 1200 Brussels
EU. Belgium
52. Department of Labor. (2014) Occupational safety and health
administration common statistics. Washington, DC: DofL. E-mail: [email protected]
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014 COLUMNS
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.1510

CyberSightings

C yberSightings is a regular feature in CYBER that

covers the news relevant to the Cyberpsychology com-
munity, including scientific breakthroughs, latest devices,
disillusionment may soon be reversed. This is thanks to the
new interest in virtual reality raised by the Oculus Rift (re-
cently acquired by Facebook for $2 billion), Sony’s Project
conferences, book reviews, and general announcements of Morpheus, and similar immersive displays, which are still at
interest to researchers and clinicians. We welcome input for the take-off stage in the Hype Cycle. Oculus Rift’s chief
inclusion in this column, and relevant information and sug- scientist Michael Abrash makes no mystery of the fact that
gestions can be sent [email protected]. his main ambition has always been to build a metaverse such
as the one described in Neal Stephenson’s (1992) cyberpunk
In the Spotlight novel Snow Crash. As he writes on the Oculus blog
(www.oculusvr.com/blog/introducing-michael-abrash-oculus-
Is the metaverse still alive? In the last decade, online
chief-scientist/), ‘‘Sometime in 1993 or 1994, I read Snow
virtual worlds such as Second Life and the like have become
Crash and for the first time thought something like the
enormously popular. Since their appearance on the technol-
Metaverse might be possible in my lifetime.’’ Furthermore,
ogy landscape, many analysts have regarded shared 3D vir-
despite the negative comments and deluded expectations, the
tual spaces as a disruptive innovation, which would have
metaverse keeps attracting new users: on its 10th anniversary
rendered the Web itself obsolete. This high expectation at-
on June 23, 2013, an infographic reported that Second Life had
tracted significant investment from large corporations such
more than one million users visit around the world monthly,
as IBM, which started building their virtual spaces and of-
more than 400,000 new accounts per month, and 36 million
fices in the metaverse. Then, when it became clear that these
registered users. So will Michael Abrash’s metaverse dream
promises would not be kept, disillusionment set in, and vir-
come true? Even if one looks into the crystal ball of the Hype
tual worlds started losing their edge. However, this is not a
Cycle, the answer is not easily found.
new phenomenon in high tech, happening over and over
again. The U.S. consulting company Gartner has developed a
Upcoming Meetings
very popular model to describe this effect, called the ‘‘Hype
Cycle.’’ The Hype Cycle provides a graphic representation 22nd International Conference on User Modeling,
of the maturity and adoption of technologies and applica- Adaptation, and Personalization
tions. It consists of five phases, which show how emerging Aalborg, Denmark
technologies will evolve. In the first, technology trigger July 7–11, 2014
phase, a new technology is launched, which attracts the in- www.um.org/umap2014/
terest of media. This is followed by the peak of inflated
expectations, characterized by a proliferation of positive 6th International Conference on Intelligent Technologies
articles and comments, which generate overexpectations for Interactive Entertainment
among users and stakeholders. In the next trough of disillu- Chicago, Illinois
sionment phase, these exaggerated expectations are not ful- July 9–11, 2014
filled, resulting in a growing number of negative comments www.intetain.org/2014/show/home/
generally followed by a progressive indifference. In the slope
of enlightenment, the potential of the technology for further 8th IADIS International Conference on Interfaces
applications becomes more broadly understood, and an in- and Human–Computer Interaction
creasing number of companies start using it. In the final Lisbon, Portugal
plateau of productivity stage, the emerging technology es- July 15–17, 2014
tablishes itself as an effective tool, and mainstream adoption www.hcii2014.org/
takes off.
So at what stage in the Hype Cycle are virtual worlds now?
After the 2006–2007 peak, metaverses entered the downward Compiled by Andrea Gaggioli, PhD
phase of the Hype Cycle, progressively losing media interest, Department of Psychology,
investments, and users. Many high tech analysts still consider Catholic University of Milan, Italy
this decline an irreversible process. However, the negative and Applied Technology for Neuro-Psychology Lab,
outlook that headed shared virtual worlds into the trough of Istituto Auxologico Italiano, Milan, Italy

423
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.1511

CyberEurope

I n this feature, we will try to describe the characteristics

of current cyberpsychology research in Europe. In par-
ticular, CyberEurope aims at describing the leading research
Information and communications technology
The information and communications technology (ICT)
sector represents 4.8% of the EU economy and accounts for
groups and projects running on the other side of the Ocean.
25% of total business expenditure in research and develop-
ment. The transformative power of ICT can also help address
Horizon 2020 Cross-Cutting Issues (I) many of Europe’s most pressing societal challenges in areas
Horizon 2020 is the European Framework Programme for such as health, the environment, and fostering secure and
research and innovation. It is subsequent to FP7 and covers inclusive societies. In Horizon 2020, the EU is investing at
the period 2014–2020. Horizon 2020 supports research and least 25% more in ICT research than in previous research
innovation projects and programs in ground-breaking basic programs. This will support the full range, from high risk,
research, strategic and applied research, demonstration pro- ground-breaking research to innovation that can deliver rev-
jects, and close-to-market activities. olutionary business breakthroughs, often on the basis of
The Horizon 2020 Work Programme 2014–2015, pub- emerging technologies. Around e1.2 billion of funding for
lished in December 2013 (http://ec.europa.eu/research/ ICT is available through the first Horizon 2020 calls.
participants/portal/desktop/en/home.html), sets out the fund- The ICT part of the first Horizon 2020 Work Programme
ing opportunities under the different parts of the program. focuses on the development of a new generation of compo-
Each part describes the overall objectives, the respective nents and systems, including micro- and nano-electronics
calls, and the topics within each call. and photonics technologies, next generation computing,
As discussed in the previous issues, Horizon 2020 con- infrastructures, technologies and services for the future
sists of three pillars: (a) excellence in the science base, (b) Internet, content technologies, and advanced interfaces and
industrial leadership, and (c) societal challenges. However, robotics.
it also includes seven cross-cutting issues that have been
mainstreamed in the different parts of the Work Programme, Social sciences and humanities
ensuring a more integrated approach. We will discuss the
first four in this issue. Social sciences and humanities (SSH) research is fully
integrated into each of the pillars of Horizon 2020 and each
Innovation of the specific objectives. It is a key objective that SSH will
contribute to the evidence base for policy making at inter-
Substantial support will be provided for innovation national, EU, national, and regional levels. In addition, SSH
through activities such as prototyping, testing, demonstrat- is at the heart of the societal challenge ‘‘Europe in a changing
ing, piloting, large-scale product validation, and market world: Inclusive, innovative and reflective societies’’ (part
replication. Significant support to demand side approaches 13 of the Work Programme).
will be another important feature, notably precommercial Almost 200 topics in the programmed parts of Horizon
and first commercial public procurement of innovation, as 2020 are relevant to SSH. This represents around 35% of the
well as regulation to foster innovation and standard setting. total topics in the Work Programme. All these are flagged by
There will also be the piloting of new forms and sources of the system designed for searching the Work Programme. The
innovation, including public sector and social innovation, as estimated budget for SSH related topics is more than e400
well as pilots on private sector services and products. million (in addition to funding available through the ERC
and the MSCA).
Spreading excellence and widening participation A detailed overview of all the steps for funding can be found
The existence of internal disparities in research and in- in the Horizon 2020 online manual (http://ec.europa.eu/
novation performance within the EU hinders some Member research/participants/portal/desktop/en/funding/guide.html).
States from meeting their full potential. Low performance is
also reflected in the participation patterns of some Member Compiled by Giuseppe Riva, PhD
States in framework programs, with limiting factors such as a Department of Psychology,
low level of national investment in research and innovation Catholic University of Milan, Italy
and reduced access to research networks. The first calls will and Applied Technology for Neuro-Psychology Lab,
include offers of funding of a total of e50 million targeting Istituto Auxologico Italiano, Milan, Italy
those Member States through measures such as teaming,
twinning, and ERA chairs. Sources: European Commission and European Union

424
 Cyberpsychology, Behavior,
and Social Networking
Instructions for Authors
Statement of Purpose and Policy Important: Please upload individual files of all manuscript
material—do NOT upload a single PDF file containing all
The Journal will accept original manuscripts which con-
text, figure, and table files of your article. Once all individual
tain material that has not been reported elsewhere, except in
files are uploaded on to Manuscript Central, the system will
the form of an abstract of not more than 400 words. Prior
automatically create a single PDF proof for you and the peer-
abstract presentations should be described in a footnote to the
review process.
title. Submissions should be accompanied by a letter re-
questing evaluation for publication.
Disclosure Statement
Manuscripts must be submitted online using the following
url: Immediately following the Acknowledgments section, in-
clude a section entitled ‘‘Author Disclosure Statement.’’
http://mc.manuscriptcentral.com/cyberpsych
This text must be part of your actual manuscript file.
Please read ALL instructions to authors before sub- In this portion of the article, authors must disclose any
mitting. commercial associations that might create a conflict of
interest in connection with submitted manuscripts. This
Manuscript Submission and Copyright statement should include appropriate information for EACH
Agreement Form author, thereby representing that competing financial
interests of all authors have been appropriately disclosed
The Copyright Agreement form (available from web site
according to the policy of the Journal. It is important that all
at www.liebertpub.com/media/content/transfer_of_copyright
conflicts of interest, whether they are actual or potential, be
.pdf.) should be submitted once your article has been ac-
disclosed. This information will remain confidential while
cepted for publication. Manuscripts cannot be published
the article is being reviewed and will not influence the
without this form. The corresponding author is responsible for
editorial decision.
obtaining signatures of coauthors. Authors not permitted to
Please see the Uniform Requirements for Manuscripts
release copyright must still return the form signed under the
Submitted to Biomedical Journals at www.icmje.org/index.
statement of the reason for not releasing the copyright. Upon
html#conflicts for further guidance.
acceptance of your article, please fax the Copyright Agreement
If no conflicts exist, the authors must state ‘‘No competing
form to 914-740-2108.
financial interests exist.’’

Preparation of Manuscript Tables and Illustrations

Prepare manuscripts double spaced in Microsoft Word. Each table and figure should be prepared in separate
Leave ample margins on both sides, top and bottom. files. Do not include tables or figures as part of the
The title page should include the author’s names and af- main text file. Use arabic numerals to number tables.
filiations, the source of a work or study (if any), and a running Remember each table must stand alone-i.e., contain all
title of about 45 characters. Please indicate the name, ad- necessary information in the caption, and the table itself
dress, phone number, fax number, and e-mail address of must be understood independently of the text. Details of
the author to whom correspondence should be addressed. The experimental conditions should be included in the table
second page should consist of an abstract of not more footnotes. Information that appears in the text should
than 250 words, which should be self-explanatory without not be repeated in tables, and tables should not con-
reference to the text. One possible format could be: abstract, tain data that can be given in the text in one or two
introduction, materials and methods, results, discussion, sentences.
acknowledgments, and references. Number pages consec- Figures/images should be presented according to
utively. Consult an issue of the Journal for the exact format. these guidelines:
 Do not include any illustrations as part of your text file.
Guidelines on Length  Do not prepare any figures in Word as they are not
Manuscript length varies according to the type of article workable.
and subject matter. Original research articles and Reviews  Line illustrations must be submitted at 1200 DPI.
should be a maximum of 3000 words excluding the refer-  Halftones and color photos should be submitted at 300
ences and tables Rapid Communications should be a max- DPI.
imum of 2000 words.  Please submit only TIFF or EPS files.
  Color art must be saved as CYMK not RGB or Journal articles:
INDEX. If RGB files are submitted, the files will be
Murray BE, Singh KV, Markowitz SM. Evidence for
converted to CYMK, and some slight color variation may
clonal spread of a single strain of Enterococcus. Journal
occur.

of Infectious Diseases 1991; 163:780-5.
Do NOT submit PowerPoint or Excel files. Adobe is
the software of choice. Books:
Please name your artwork files with the submitting authors Lezak MD. (1995). Neuropsychological assessment. New
name i.e. SmithFig1.tif, SmithTable2.tif etc. Label figures York: Oxford University Press.
and tables inside the files in addition to naming the file with
Book Chapters:
the figure or table numbers. Authors who do not follow
these guidelines may have their submission returned to Ruoff KL. (1995) Streptococcus. In: Murray PR, Baron EJ,
them without being reviewed. eds. Manual of clinical microbiology. Washington, D.C.:
ASM Press, pp. 299-307.
Additional Information About Art Files References in text must be cited in numerical order using
Converting Word or Excel files: Perhaps the best and superscript numbers. Do not use author/date format. If it is
easiest way to convert Word or Excel files into a format necessary to cite an abstract, this should be designated. Au-
which is suitable for print is to scan them using the thors are responsible for the accuracy of the references, and
below guidelines: are reminded that inaccurate references are highly frustrating
to the reader, the cited author, and indexing services.
 All files should be scanned at 100% size.
 300 dpi Permissions
 Final color mode: cmyk
 save file as: .tif or .eps The author must obtain permission to reproduce figures,
tables and text from previously published material. Written
If you need directions on how to convert a Power permission must be obtained from the original copyright holder
Point slide to acceptable format go to www.liebertpub.com/ (generally the publisher, not the author or editor) of the journal
MEDIA/pdf/ppconvert.pdf or book concerned. An appropriate credit line should be in-
Color publication of figures is encouraged, but the cost cluded in the figure legend or table footnote, and full publication
for color printing must be subsidized by the author(s). Color information should be included in the reference list. Adaptions
costs apply to all manuscripts, including those invited, un- of figures or tables must carry a citation in the figure legend or
less the contributor has made prior arrangements with the table footnote and there must be a full reference given in the
Publisher. reference list. Written permission must be obtained from
Please consider these costs when preparing your manu- the author of any unpublished material cited from other lab-
script for submission. Contact publisher for color costs. oratories, and should accompany the manuscript.
A list of figure legends should be supplied at the end of the
manuscript, double spaced. Magnifications should be in- Reprints
cluded where appropriate. Illustrations will not be returned
Reprints may be ordered by following the special instruc-
unless requested. ZIP disks containing figures may be ac-
tions that will accompany page proofs, and should be ordered
cepted only if it is Photoshop or Illustrator TIF or EPS format.
at the time the corresponding author returns the corrected page
All other disks will be rejected.
proofs to the Publisher. Reprints ordered after an issue is
A complete, separately collated set must be submitted with
printed will be charged at a substantially higher rate.
each copy of the manuscript. Illustrations can be printed in
color with a subsidy from the author and are encouraged. Publisher
Contact the publisher for details.
The Journal is published by Mary Ann Liebert, Inc., 140
Huguenot Street, 3rd Floor, New Rochelle, NY 10801-5215.
References
Telephone: (914) 740–2100; fax: (914) 740–2108; info@
References MUST be presented in the following style: liebertpub.com

www.liebertpub.com/cyber

View publication stats