Hunter G. Hoffman

Background Nearly 2.8 million people are hospitalized in the USA annually for traumatic injuries, which include orthopedic and internal organ injuries. Early post-injury pain is predictive of poor outcomes, including inability to eventually return to work, and long-term psychological distress. The goal of the present study was to improve our scientific understanding of trauma-related pain by examining (1) the nature and frequency of inpatient trauma pain and (2) the associations between inpatient trauma pain, education, opioid analgesic equivalent use, pain catastrophizing, and sleep quality. Method The study included 120 patients hospitalized at a major level I regional trauma center for the care of (1) closed long bone or calcaneus fractures and/or (2) an intraabdominal injury caused by blunt force trauma and requiring surgical repair (i.e., laparotomy). Medical records were reviewed to obtain demographic information and information about opioid use during hospitalization. In addition, participants were administered measures of average pain intensity, pain catastrophizing, and sleep quality. Results Education, opioid analgesic equivalents, catastrophizing, and poor sleep quality together accounted for 28% of the variance of average pain intensity over a 24-h period (p < .001), with each variable making a significant independent association. Conclusion Two of the factors associated with pain intensity in the study sample—catastrophizing and sleep quality—are modifiable. It is therefore possible that interventions that target these variables in patients who are hospitalized for trauma could potentially result in better long-term outcomes, including a reduced risk for developing chronic pain. Research to evaluate this possibility is warranted.

In the decade following the attack on the World Trade Center, over 2.3 million American military personnel were deployed to Iraq and Afghanistan. Lengthy tours of duty and multiple re-deployments were characteristic of these operations. Research findings demonstrate that prolonged exposure to combat increases the risk of developing posttraumatic stress disorder (PTSD). The current study was a randomized controlled clinical trial designed to assess the effectiveness of a novel intervention to treat combat-related PTSD in returning Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) warfighters. A cognitive behavior treatment approach augmented with virtual reality exposure therapy (VRE) was developed, and administered for 10 treatment sessions over 5 weeks. Comparisons with a control group receiving minimal attention (MA) for 5 weeks revealed that the VRE group had significant reductions in the avoidance/numbing symptoms on the Clinician Administered PTSD Scale (CAPS). The VRE group also had significant reductions in guilt at post-treatment compared to the control group.

Introduction. Excessive pain during medical procedures is a widespread problem but is especially problematic during daily wound care of patients with se

War-fighters exposed to combat are at high risk for developing posttraumatic stress disorder (PTSD), a complex and challenging condition to treat. Cognitive behavioral therapies (CBT) have been empirically validated as effective treatments for PTSD resulting from sexual assault, vehicular accidents, and disasters. Exposure, imaginal or in vivo, to the traumatic event is a central component of successful CBT treatment. Early studies indicate that CBT with brief virtual reality exposure (VRE) is beneficial in treating PTSD. The case study examined the effectiveness of brief VRE in treating combat-related PTSD.

Despite medication with opioids and other powerful pharmacologic pain medications, most patients rate their pain during severe burn wound care as severe to excruciating. Excessive pain is a widespread medical problem in a wide range of patient populations. Immersive virtual reality (VR) distraction may help reduce pain associated with medical procedures. Recent research manipulating immersiveness has shown that a high tech VR helmet reduces pain more effectively than a low tech VR helmet. The present study explores the effect of interactivity on the analgesic effectiveness of virtual reality. Using a double blind design, in the present study, twenty-one volunteers were randomly assigned to one of two groups, and received a thermal pain stimulus during either interactive VR, or during non-interactive VR. Subjects in both groups individually glided through the virtual world, but one group could look around and interact with the environment using the trackball, whereas participants in the other group had no trackball. Afterwards, each participant provided subjective 0–10 ratings of cognitive, sensory and affective components of pain, and the amount of fun during the pain stimulus. Compared to the non-interactive VR group, participants in the interactive VR group showed 75% more reduction in pain unpleasantness (p < .005) and 74% more reduction in worst pain (p < .005). Interactivity increased the analgesic effectiveness of immersive virtual reality.

For soldiers returning from OIF/OEF with severe combat-related burn injuries from IED attacks, approx. 28% may also be affected by PTSD. Virtual Reality Exposure (VRE) is a promising new treatment for PTSD. Most completers show clinically meaningful reductions in PTSD and depression. VRE helps patients process, habituate to, and stop avoiding memories and strong emotions associated with their memories of traumatic events. D-Cycloserine pills can accelerate fear extinction learning, the essence of exposure therapy. Our study explores the feasibility of using VRE combined with D-Cycloserine to augment cognitive behavioral therapy for treating PTSD in soldiers/warfighters healing from combat-related burn injuries. Pre, mid- and several post-treatment CAPS and depression scores measure treatment success. Challenges to treating combat-related PTSD, and special challenging to treating PTSD in patients with severe combat-related burn injuries, will be discussed. With thousands of U.S. soldiers returning from Iraq and Afghanistan with PTSD, a new unusually effective and efficient treatment protocol that is attractive to young video game generation soldiers, and also works with burn patients could prove valuable. A randomized controlled study may be conducted in the future, if warranted by the findings of the current feasibility study and pending funding.

The pain associated with burn injuries is intense, unremitting and often exacerbated by anxiety, depression and other complicating patient factors. On top of this, modern burn care involves the rep...

Objective Most burn-injured patients rate their pain during burn wound debridement as severe to excruciating. We explored the adjunctive use of water-friendly, immersive virtual reality (VR) to distract patients from their pain during burn wound debridement in the hydrotherapy tank (hydrotank). Setting This study was conducted on inpatients at a major regional burn center. Patients Eleven hospitalized inpatients ages 9 to 40 years (mean age, 27 y) had their burn wounds debrided and dressed while partially submerged in the hydrotank. Intervention Although a nurse debrided the burn wound, each patient spent 3 minutes of wound care with no distraction and 3 minutes of wound care in VR during a single wound care session (within-subject condition order randomized). Outcome Measures Three 0 to 10 graphic rating scale pain scores (worst pain, time spent thinking about pain, and pain unpleasantness) for each of the 2 treatment conditions served as the primary dependent variables. Results Patients reported significantly less pain when distracted with VR [eg, “worst pain” ratings during wound care dropped from “severe” (7.6) to “moderate” (5.1)]. The 6 patients who reported the strongest illusion of “going inside” the virtual world reported the greatest analgesic effect of VR on worst pain ratings, dropping from severe pain (7.2) in the no VR condition to mild pain (3.7) during VR. Conclusions Results provide the first available evidence from a controlled study that immersive VR can be an effective nonpharmacologic pain reduction technique for burn patients experiencing severe to excruciating pain during wound care. The potential applications of VR analgesia to other painful procedures (eg, movement or exercise therapy) and other pain populations are discussed.

Immersive virtual reality (VR) is a novel form of distraction analgesia, yet its effects on pain-related brain activity when used adjunctively with opioid analgesics are unknown. We used subjective pain ratings and functional magnetic resonance imaging to measure pain and pain-related brain activity in subjects receiving opioid and/or VR distraction. Healthy subjects (n = 9) received thermal pain stimulation and were exposed to four intervention conditions in a within-subjects design: (a) control (no analgesia), (b) opioid administration [hydromorphone (4 ng/mL target plasma level)], (c) immersive VR distraction, and (d) combined opioid + VR. Outcomes included subjective pain reports (0-10 labeled graphic rating scales) and blood oxygen level-dependent assessments of brain activity in five specific, pain-related regions of interest. Opioid alone significantly reduced subjective pain unpleasantness ratings (P < 0.05) and significantly reduced pain-related brain activity in the insula (P < 0.05) and thalamus (P < 0.05). VR alone significantly reduced both worst pain (P < 0.01) and pain unpleasantness (P < 0.01) and significantly reduced pain-related brain activity in the insula (P < 0.05), thalamus (P < 0.05), and SS2 (P < 0.05). Combined opioid + VR reduced pain reports more effectively than did opioid alone on all subjective pain measures (P < 0.01). Patterns of pain-related blood oxygen level-dependent activity were consistent with subjective analgesic reports. These subjective pain reports and objective functional magnetic resonance imaging results demonstrate converging evidence for the analgesic efficacy of opioid administration alone and VR distraction alone. Furthermore, patterns of pain-related brain activity support the significant subjective analgesic effects of VR distraction when used as an adjunct to opioid analgesia. These results provide preliminary data to support the clinical use of multimodal (e.g., combined pharmacologic and nonpharmacologic) analgesic techniques.