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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 36  |  Issue : 1  |  Page : 5-9

Immersive virtual reality in pain management of burn injury – A review


1 Department of Plastic Surgery, J. N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Anaesthesiology, Pain Clinic, J. N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission07-Feb-2022
Date of Decision10-Mar-2022
Date of Acceptance11-Mar-2022
Date of Web Publication25-Apr-2022

Correspondence Address:
Prof. Hammad Usmani
Consultant Incharge, Pain Clinic, Department of Anaesthesiology, JN Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_15_22

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  Abstract 


Burns are one of the most severe forms of trauma to skin and tissue which results due to contact with hot substances (liquid or solid), radiation, radioactivity, electricity, friction, or contact with chemicals. Every year, nine million people are injured due to fire, heat, and hot substances worldwide, out of which 120,632 die (1.34%). In India, with a population of over 1.3 billion, the registered annual burn admissions are 7,00, 000–8,00, 000. This review is to identify studies on virtual reality (VR) therapy in the management of burn patients in terms of their pain, anxiety, and stress during treatment and rehabilitation, in the context of the scientific world of literature. Literatures from web-based scientific databases, PubMed, Cochrane, MEDLINE, and Clarivate, National Science Library, were searched to identify the studies conducted on the use of VR in the management of pain related to burns and their dressings. Randomized controlled trials and case series were included in this review. All these studies were organized and tabulated according to the methodology and type of interventions done. Few of the studies were also analyzed to present the highlighted current trends in VR and pain management. A brief overview of the observations at this center with the use of VR technology and its role in alleviating pain during the procedures for burn management has also been included. VR is a nonpharmacological complementary strategy with proven benefits in the management of burn patients. The findings of this literature review and analysis demonstrate that the use of VR in burn patients significantly reduces pain during treatment and rehabilitation and averts its consequences. VR can be easily used in the hospital setting and offers a safe, nonpharmacologic adjunctive therapy in the management of burn patients.

Keywords: Anxiety, burns, pain, virtual reality


How to cite this article:
Khurram F, Hussain A, Subramaniyam B, Usmani H. Immersive virtual reality in pain management of burn injury – A review. Indian J Pain 2022;36:5-9

How to cite this URL:
Khurram F, Hussain A, Subramaniyam B, Usmani H. Immersive virtual reality in pain management of burn injury – A review. Indian J Pain [serial online] 2022 [cited 2022 Aug 13];36:5-9. Available from: https://www.indianjpain.org/text.asp?2022/36/1/5/343823




  Introduction Top


Burns are one of the most severe forms of trauma to skin and tissue which results due to contact with hot substances (liquid or solid), radiation, radioactivity, electricity, friction, or contact with chemicals.[1] Every year, nine million people are injured due to fire, heat, and hot substances worldwide, out of which 120,632 die (1.34%).[2] In India, with a population of over 1.3 billion, the registered annual burn admissions are 700 000–800 000. The epidemiology of burn injuries in our country is different from that in the developed world.[3] Burns represent one of the main causes of morbidity, involving prolonged hospitalization and long recovery times.[4] The procedures for management, which include wound debridement, daily dressings, functional rehabilitation, and repair surgeries performed during hospitalization generate pain, physical trauma, and psychological stress to the patient.[5] Keeping in view these physical and psychological impacts, the nonpharmacological components in the management of these patients are complimentary to medicinal therapy, allowing an integrated approach to care.[6] Some nonpharmacological methods that have currently demonstrated favorable clinical effects in pain relief include hypnosis, cognitive-behavioral therapy, relaxation techniques, and interaction through television, music, and storytelling.[7],[8],[9] In addition to these methods, the rise of technology has led to the use of virtual reality (VR) for the treatment of burns as a complementary interaction and immersion therapy. It is a psychological technique based on distraction. Owing to its ability to allow the user to immerse and interact with computer-generated artificial environment, VR can give patients a perception of actually being in a different world. The more immersive the VR, the greater the experience and concentration on the virtual environment.[10] Thus, the use of VR distracts the patients in relation to different environmental stimuli, which can consequently reduce the pain and anxiety generated by seeing and experiencing wound care, i.e., change of burn dressings in cases of burns.[11],[12]

A systematic review on the use of VR in the treatment of burns analyzed nine studies, in which it was shown that this technology combined with pharmacological analgesics contributes to the reduction of pain and anxiety.[13] In other studies, the results point to the benefits of VR in relation to increased distraction, and patients reporting less time thinking about pain, which facilitates care such as dressing changes and physiotherapy in burn patients.[14],[15] Thus, VR presents itself as a potential and important technology for multidisciplinary health-care teams [Table 1].
Table 1: Comparison of different studies done on the use of virtual reality in burns

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Databases were searched with the objective of identifying the current scientific literature on the use of VR and its main effects in the treatment of burn patients.

This review is to identify studies on VR therapy in the management of burn patients, in terms of their pain, anxiety, and stress during treatment and rehabilitation, in the context of the scientific world of literature. Literatures from web-based scientific databases, PubMed, MEDLINE, and Clarivate were searched for to identify the studies done on the use of VR in the management of pain related to burns and their dressings.[16] Case series and randomized controlled trials (RCTs) were included. All these studies were organized and tabulated according to the methodology and type of interventions done. Few of the studies were also analyzed to present the highlighted current trends in VR and pain management. We have also discussed our experience with the VR technology and its role in alleviating pain during burns and related procedures.

We have used Metaverse's head-mounted device (oculus), and a few games/applications were used for distraction.


  Pain Top


Pain following burn injuries and that related to its treatment is one of the most intense and severe types of pain. Pain during burn wound care further adds to the trauma experienced by these patients from the burn itself. This reduces the quality of life by ensuing behavioral and maladaptive responses, such as agitation, anger, anxiety, defiance, aggression, hyperactivity, and dissociation. Managing pain associated with burn wound care is challenging and complex related to several factors. The severe episodic pain during burn treatments often remains unalleviated by opioid and nonopioid analgesics alone. Distraction is one such nonpharmacologic intervention recommended for use in children and adolescents in managing acute procedural pain including burn wound care pain.[17] VR shows great potential as an engaging, interactive, effective distraction technique for kids and adults during painful health-care procedures such as dressings and physiotherapy. An RCT by Jeffs et al. shows that VR is a powerful, engaging distraction in lessening pain perception during burn wound dressing in the adolescent population in the ambulatory setting even without requiring wearing the head mount display helmet. They also proposed that studies with larger sample sizes are warranted to replicate findings and extend to other populations including inpatient settings and on other types of procedures. With further empirical support for the benefits of VR and improvement in and reduced cost of VR technology, routine use of VR in clinical settings may become more feasible and commonplace.[17]

In a similar study, Morris et al. concluded that the low-cost VR system can be recommended as a safe, economically feasible, and clinically useful adjunct therapy to the current developing world burn pain management regimens. The low-cost VR system offers the developing countries an opportunity to improve their health services in burn rehabilitation which may not have been possible before due to minimum resources.[9]

Hua et al. in their RCT showed that the use of VR distraction can significantly reduce pain during dressing changes in children with chronic lower-limb wounds as compared to standard distraction methods. They also indicated that the VR device could potentially improve clinical efficiency by reducing the length of time needed for each dressing change.[18]

Another study by Maani et al. provides the first evidence from a controlled study that adjunctive immersive VR reduced pain in patients of combat-related burn injuries during severe burn wound debridement and dressing. Pain reduction during VR was greatest in patients with the highest pain during no VR. These patients were the first to use a unique custom robot-like arm-mounted VR goggle system.[15]

A similar study done by Schmitt et al. proved that the immersive VR is a useful and powerful adjunct for enhancing pain control during rehabilitation therapy in the pediatric burn population. When added to standard pharmacologic analgesia, VR distraction therapy produced a statistically significant and clinically meaningful reduction in subjective patient pain ratings, as well as a significant increase in perceived “fun” during the dressings.[19]

Xiang et al. in their study concluded that a smartphone VR game was effective in reducing self-reported pain during pediatric burn dressing changes. Nurses also reported that VR-pain alleviation tool (PAT) could be easily implemented in their clinical practice.[20]

Rousseaux et al. in their study showed the importance of hypnosis, VR, and VR hypnosis (VRH) to reduce pain in patients and healthy volunteers. Although VR pain distraction is now well-documented and commonly used in commercial, scientific, and clinical fields, VRH is far from being as widespread as the distractive version of VR reported in the literature.[21]


  Anxiety Top


Patterson et al. reported a randomized controlled study of 21 hospitalized trauma patients to assess the analgesic efficacy of VRH hypnotic induction and analgesic suggestion delivered by customized (VR) hardware/software. Subjective pain ratings were obtained immediately and 8 h after VRH (used as an adjunct to standard analgesic care) and compared to both adjunctive VR without hypnosis and standard care alone. VRH patients reported less pain intensity and less anxiety compared to control groups.[22]

Another study by Yohannan et al. aimed at demonstrating the feasibility and measuring outcomes on pain, anxiety, active range of motion, function, enjoyment, and the presence with the adjunctive use of Nintendo Wii™ (Nintendo of America Inc., Redmond, WA) during acute burn rehabilitation. Participants were alternated and stratified based on the location of burn into Wii or control group. Although statistical significance was not reached in any category, feasibility was supported, and the overall pattern for outcomes was positive for the Wii group, the most favorable being for pain reduction.[23]

Konstantatos et al. indicated that single-use VR relaxation added to morphine PCA infusion can significantly increase pain intensity ratings during and after dressings changes in a population of burns patients when compared to patients using PCA morphine infusion alone. This difference occurred despite a lack of significant change in anxiety ratings.[24]

Parker et al. affirmed that, without causing complication, the Nintendo Wii, an interactive game console, reduced pain more than routine exercise therapy alone, particularly for those with higher baseline levels of pain.[25]


  Range of Motion Top


Parry et al. evaluated ROM and pain outcome with two different types of therapy for exercise administration.[26] They observed that interactive video games were equally effective as ST for planar and functional ROM recovery and resulted in quicker recovery of ROM with less pain experienced. Such video games are a useful adjunct to therapy and should be considered a rehabilitative tool within the hospital and for home use after discharge in pediatric patients recovering from burn injury.

A similar study (viz. CTRI/2021/08/035828 dated 19.08.2021) on the application of VR technology in the alleviation of pain during acute burn care dressings and during rehabilitation phase has been initiated at our set-up with the VR headset (128 GB with Qualcomm Snapdragon 835 system, maker: The Oculus Quest, a division of Facebook inc., Menlo Park, CA, USA) [Figure 1]. Patients were instructed to play different games during the dressing change and painful physiotherapy, used twice a week for 4 weeks [Figure 2]. Fifty patients studied so far, all have showed a good compliance. The use of VR technology is showing 30––40% reduction in numerical rating scale pain scores (worst pain, time spent thinking about the pain, and pain unpleasantness by 30, 35, and 37%, respectively) as compared to the no VR usage. Average ROM improvement is also observed to be greater with the VR games.
Figure 1: Patients of burn injury of hands performing virtual reality therapy

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Figure 2: Relay of head mount display on the LCD screen

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  Conclusion Top


VR is a nonpharmacological complementary strategy with proven benefits in the management of burn patients. The findings of this literature review and analysis demonstrate that the use of VR significantly reduces pain and its consequences, such as anxiety. In addition, the use of VR, apart from increasing fun, reduces the time of painful procedures, the hospitalization time, and favors epithelization of the injury. Although the advantages of VR are known and proven, it is necessary to extend and explore the use of this technology in other realities, especially in the developing world. It is also necessary to improve the methodological rigor of the studies, as well as the types of intervention, and research methodology including design, measures, results, and data collection forms. VR can be easily used in the hospital setting and offers a safe, nonpharmacologic adjunctive therapy in the management of burn patients.

Financial support and sponsorship

Nil.

Conflicts of interest

Prof. Hammad Usmani is Editor-in-Chief of IJP.

Dr. Aftab Hussain is the Associate Editor of IJP.



 
  References Top

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2.
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Morris LD, Louw QA, Crous LC. Feasibility and potential effect of a low-cost virtual reality system on reducing pain and anxiety in adult burn injury patients during physiotherapy in a developing country. Burns 2010;36:659-64.  Back to cited text no. 9
    
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Carrougher GJ, Hoffman HG, Nakamura D, Lezotte D, Soltani M, Leahy L, et al. The effect of virtual reality on pain and range of motion in adults with burn injuries. J Burn Care Res 2009;30:785-91.  Back to cited text no. 11
    
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Morris LD, Louw QA, Grimmer-Somers K. The effectiveness of virtual reality on reducing pain and anxiety in burn injury patients: A systematic review. Clin J Pain 2009;25:815-26.  Back to cited text no. 13
    
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Maani CV, Hoffman HG, Fowler M, Maiers AJ, Gaylord KM, Desocio PA. Combining ketamine and virtual reality pain control during severe burn wound care: One military and one civilian patient. Pain Med 2011;12:673-8.  Back to cited text no. 14
    
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Maani CV, Hoffman HG, Morrow M, Maiers A, Gaylord K, McGhee LL, et al. Virtual reality pain control during burn wound debridement of combat-related burn injuries using robot-like arm mounted VR goggles. J Trauma 2011;71:S125-30.  Back to cited text no. 15
    
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Jeffs D, Dorman D, Brown S, Files A, Graves T, Kirk Q, et al. Effect of virtual reality on adolescent pain during burn woundcare. J Burn Care Res 2014;35:395-408.  Back to cited text no. 17
    
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Hua Y, Qiu R, Yao WY, Zhang Q, Chen XL. The effect of virtual reality distraction on pain relief during dressing changes in children with chronic wounds on lower limbs. Pain Manag Nurs 2015;16:685-91.  Back to cited text no. 18
    
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Schmitt YS, Hoffman HG, Blough DK, Patterson DR, Jensen MP, Soltani M, et al. A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns. Burns 2011;37:61-8.  Back to cited text no. 19
    
20.
Xiang H, Shen J, Wheeler KK, Patterson J, Lever K, Armstrong M, et al. Efficacy of smartphone active and passive virtual reality distraction vs. standard care on burn pain among pediatric patients: A randomized clinical trial. JAMA Netw Open 2021;4:e2112082.  Back to cited text no. 20
    
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Patterson DR, Jensen MP, Wiechman SA, Sharar SR. Virtual reality hypnosis for pain associated with recovery from physical trauma. Int J Clin Exp Hypn 2010;58:288-300.  Back to cited text no. 22
    
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25.
Parker M, Delahunty B, Heberlein N, Devenish N, Wood FM, Jackson T, et al. Interactive gaming consoles reduced pain during acute minor burn rehabilitation: A randomized, pilot trial. Burns 2016;42:91-6.  Back to cited text no. 25
    
26.
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