Virtual Snow Cools Pain

Put on a modified bicycle helmet with an attached eyepiece. Feel it fit snugly against your face. Suddenly you are sailing through the air in a deep glacial canyon, a cool blue river lies below, and picturesque paper-doily snowflakes drift down. As you look around, you see snowmen, igloos, an occasional penguin, and a few murderous robots, standing on narrow ice shelves along the sides of the canyon. Press a button and snowballs shoot forward. Arcing tails streak across the sky as your snowballs fly toward their targets, which explode satisfyingly when you score a hit. You have fun playing in SnowWorld.

When the helmet is off, your every move hurts. Even with opiate pain medications, every touch causes excruciating pain. You are a burn patient having dressings changed at Seattle, Washington's Harborview Medical Center.

Luring Attention Away from Pain

"No matter what you do, they're going to feel the pain," says Dana Nakamura, an occupational therapist who has worked in Harborview's burn center since 1988. "We don't want to overmedicate them to where they can't participate in the rest of their day and they're just sleeping."

Besides medications, one way to lessen the pain is to find something that can distract the person from what is going on around them. "We use a lot of distraction, hypnosis, relaxation. It may even be distraction with music – picking favorite music to listen to during a procedure is one of the things that they've enjoyed," says Nakamura. Other methods she has used with her patients are guided imagery exercises and video games.

Distraction, according to Harborview staff psychologist David Patterson, an expert on pain management, is known to be an effective way to reduce pain and anxiety, especially in a hospital setting. Since 1996, Patterson and University of Washington (UW) experimental psychologist Hunter Hoffman have been conducting a study in the use of virtual reality for acute pain management in burn patients. And Nakamura says virtual reality is one of the most effective methods she has seen. "Distraction in general, with music and with video tapes, has long been known to lead to some pain reduction," Hoffman explains. "Pain requires conscious attention, so what we're doing is luring the spotlight of attention away from the wound care and the pain and into the virtual environment. That leaves less attention available for the patient to process the pain signals." Using what he calls "immersive virtual reality" is simply taking distraction to a new level.

"The essence of immersive virtual reality is the illusion of going inside the computer-generated virtual environment – the sense of being present in Snow World," says Hoffman. "The place where you think you are is the place where most of your attention is."

Finding Real Solutions in a Virtual Environment

An athletically built man with short, windblown blond hair and a soft Oklahoma accent, Hunter Hoffman does not fit the stereotype of the university researcher, and his career has not followed the usual academic track. In high school, he was more prone to getting into minor scrapes than to studying. Fortunately, he did well enough to get into the University of Tulsa.

Always a bit of a rebel, Hoffman said he was drawn to experimental psychology because he wanted to be in a field where he could be a part of a scientific revolution. After completing his undergraduate degree, Hoffman spent a year at Princeton University, conducting research with Marcia Johnson on "reality monitoring" (how people separate memories of real events from those of imagined events), before coming to graduate school at UW. Since 1993, Hoffman has been working at the UW's Human Interface Technology Lab (HITL), where he has focused on human memory and attention, and the illusion of presence. This work led him into virtual reality.

Virtual reality headgear has been around for a number of years. A simple monochrome version was even produced for a time by Nintendo for the "Virtual Boy" portable game system. To create an illusion of stereoscopic vision and to exclude external visual stimuli, all VR set-ups use a pair of eyepieces mounted as close to the head as possible. The better systems are built into what appear to be motorcycle or bicycle helmets equipped with high-resolution monitors for each eye (for true 3-D), and motion sensors to allow the scene to shift as the person moves their head.

Hoffman says that inexpensive commercial virtual reality glasses sacrifice peripheral vision for cost savings. "They have like a 22-degree view. It's so limited, it's like looking out of a box or peeking through a fence," he explains. The high-end systems, on the other hand have a 60- to 80-degree field of view, which greatly enhances the illusion of being in the world.

Working with Virtually Better, Inc in Atlanta, Georgia, therapists in the United States, Canada, and Israel are using virtual reality desensitization to treat a variety of phobias. In 1998, Hoffman began using VR to desensitize spider phobics, putting a spider into a 3-D virtual kitchen. Later, adding a motion-tracking glove and a toy spider, which the subject touched, "dramatically increased their illusion of going into the virtual environment, increased the sense of reality of the spider, and doubled the effectiveness of the treatment," he says. Meanwhile, other researchers are investigating the use of immersive VR for chemists to manipulate virtual molecules and for surgeons to practice surgical techniques. Work is even being done to allow surgeons to perform actual procedures by remote control using a combination of VR and robots.

Challenges and Surprising Successes

In the hospital setting, while VR distraction techniques work well for time-limited pain, even when acute, Patterson says, "Chronic pain is going to be a greater challenge. We think the potential's there, but chronic pain involves much more complex issues to screen." Further, the HITL team is working on a new "water-friendly" VR helmet for the burn patients. The helmet, with several thousand fiber-optic strands for each eyepiece, will have no electrical connections near the patient – a must for use in the scrub tanks where the most painful procedures are done.

Hoffman says he was not surprised to see the virtual reality therapy working with severe pain, but how well it appears to work did come as a shock. Burns are extremely painful, especially when the wounds are being cleaned or when the new skin is being stretched during physical therapy. "In a study with 12 patients," Hoffman reports, "approximately 75% of the patients showed pain reduction. The average amount of pain reduction was really big."

Says Nakamura, "There was one 14-year-old that stands out for me in particular. He had not even realized that we had already gone through all the stretching. When he came out of (SnowWorld) he said, 'When are you going to start moving my leg?'"

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