For Burn Victims, a Computer-generated Virtual Reality Can Help to Control Pain by Means of

Introduction

Acute pain is a frequent medical trouble globe wide, merely children with big severe burn injuries (e.chiliad., twoscore% TBSA) feel some of the near painful procedures in medicine. During the course of their weeks in the hospital burn down centre'due south intensive care unit of measurement, children with big severe burns must have their wounds cleaned/scrubbed oftentimes to prevent infection and speed up healing. Opioid analgesics are widely regarded as effective and essential tools for acute pain management (Malchow and Black, 2008; Vijayan, 2011; McIntyre et al., 2016; Ballantyne, 2018; Krane, 2019). According to Berterame et al. (2016, p. 1664) "In developing countries, access to opioids is very limited. In 2009, more than than xc% of worldwide use of opioid analgesics occurred in the Usa, Canada, Commonwealth of australia, New Zealand, and several European countries. Employ in that year was deemed depression in 21 countries and very depression in more 100." Patients in Latin American oftentimes accept limited access to opioids for pain command (used for both analgesia and anesthesia). Yet even in the U.S.A., there are currently shortages of pharmaceutical medical opioid analgesics needed for astute pain command during medical procedures (Davis et al., 2018). And because of a large increase in opioid related overdose deaths unrelated to burn down patients (Chen et al., 2019), in that location is growing political and legal pressure level to further reduce reliance on opioids for hurting control in the U.Southward.A.

For patients treated with opioid pain medications (e.1000., patients treated in regional infirmary burn centers in the U.s.), opioid side effects (Dunwoody and Jungquist, 2018) limit dose levels, limiting analgesic effectiveness (Cherny et al., 2001; Malchow and Black, 2008; Clark et al., 2017; Ballantyne, 2018). And opioid tolerance/habituation is a challenge for patients with large astringent burns (Bittner et al., 2015), who typically receive the same painful procedures over and over, several times per week, often daily, during several weeks of hospitalization. Excessive hurting and/or repeated loftier opioid doses tin pathologically alter the patients pain perception system, disrupting the patient'south natural endogenous opioid analgesia organization (Schwaller and Fitzgerald, 2014; Ballantyne, 2018; Chambers, 2018), and can increase patient's risk of developing chronic hurting, anxiety disorders, and/or Mail service-Traumatic Stress Disorder (McGhee et al., 2011; Rosenberg et al., 2015, 2018; Pardesi and Fuzaylov, 2017; Peña et al., 2017).

Psychological factors such as fearfulness, anxiety, and depression can increase or amplify how much hurting patients subjectively experience during painful medical procedures (Hemington et al., 2017; Nitzan et al., 2019), making pain management fifty-fifty more challenging. What people are thinking well-nigh during wound care, and where patients straight their attention during medical procedures tin can influence pain intensity (Melzack and Wall, 1965). For example, if patients predict wound care is going to be painful, that tin can make their hurting worse. According to Fields (2018, p. S8) "…expectation of pain becomes a self-fulfilling prophecy through pinnacle down amplification of the pain indicate," and memories of previous painful procedures can also increase pain intensity (Noel et al., 2015).

Fortunately, only as psychological factors can brand pain worse, psychological treatments can assist reduce acute pain during medical procedures. For example, distraction techniques (e.yard., music) are widely used in clinical practice, and can exist used in addition to traditional hurting medications to aid control pain during burn wound care. Some studies show strong benefits of music therapy during burn wound intendance in patients (due east.g., Rohilla et al., 2018). But in other studies the benefits of listening to music during fire wound care had small effect sizes and/or non-significant results (Fratianne et al., 2001; Bellieni et al., 2013; van der Heijden et al., 2018), and/or involved patients with modest burn wounds (e.g., v% TBSA, Hsu et al., 2016).

For the extreme pain levels experienced by children with large astringent burn down wounds during burn down wound debridement in the intensive intendance unit, creating stronger non-pharmacologic hurting control techniques is a national and international priority (Keefe et al., 2018).

Immersive virtual reality is a promising new not-opioid psychological pain distraction technique. There is growing evidence that adjunctive immersive virtual reality distraction can significantly reduce how much hurting patients experience during a growing number of different painful medical procedures e.one thousand., during urological endoscopies, physical therapy afterwards surgery for cerebral palsy, venipuncture for onco-therapy, and pediatric dental procedures (Hoffman et al., 2011; Garrett et al., 2014; Scheffler et al., 2017; Atzori et al., 2018a,b; Indovina et al., 2018; Honzel et al., 2019).

Brain browse studies provide converging testify that VR reduces acute hurting. Using neuroimaging assessments, a laboratory functional magnetic resonance imaging study constitute that in addition to reducing subjective hurting ratings, VR reduced pain-related brain activity (Hoffman et al., 2004b). In a 2d fMRI brain browse written report, the amount of pain reduction from VR alone was comparable to the corporeality of pain reduction from a moderate dose of hydromorphone, and "VR + opioids" combined resulted in the largest pain reductions (Hoffman et al., 2007).

The logic for why VR would reduce hurting is based on an attentional machinery (Hoffman, 1998; Hoffman et al., 2000, 2006). The essence of immersive virtual reality analgesia is the patient'south illusion of going to a different place, the subjective experience of "feeling present" in the estimator generated globe, as if the virtual reality earth is a identify they are visiting (Slater and Wilbur, 1997). Human brains are express in how much information they can process (Kahneman, 1973). Pain requires attention. Researchers argue that the illusion of "being in that location" in virtual reality is unusually attending grabbing, reducing the amount of attentional resources the patient'southward brain has available for pain perception (Hoffman, 1998; Hoffman et al., 2000, 2003;Hoffman et al., 2004a).

According to a gate control theory explanation of psychological analgesia (Melzack and Wall, 1965, p. 978), "…psychological factors such equally past feel, attending, and emotion can influence pain response and perception…." Melzack and Wall proposed that the brain may inhibit nociceptive signals.

Regardless of the mechanism, several small clinical studies have shown encouraging preliminary testify that adjunctive VR can help reduce pain during burn wound care in adults (Hoffman et al., 2004a, 2011; van Twillert et al., 2007; Maani et al., 2011a,b; McSherry et al., 2018), and in children with minor burns, (Hoffman, 1998; Hoffman et al., 2000; Faber et al., 2013; Jeffs et al., 2014; Khadra et al., 2018). There is also preliminary bear witness that VR is more constructive than conventional distractions such as video games or movies. In the kickoff study to report using immersive virtual reality for pain control during a medical procedure, two adolescent boys with large burn injuries underwent staple removals from healing burn down skin grafts during immersive VR vs. while playing a Nintendo video game (no VR). Both patients reported large reductions in pain during staple removal during immersive virtual reality compared to their hurting during staple removal while playing the (no VR) traditional Mario Kart Nintendo video game (Hoffman et al., 2000) during the same wound care session. More recently, in a report by Jeffs et al. (2014) adolescent fire patients with small burns (5% TBSA) treated in an outpatient clinic reported significantly lower pain during virtual reality compared to a group that watched a movie during wound cleaning.

There are a number of barriers to using VR in the ICU tubroom. The patients in the current study had a burn size of 40% Full Torso Surface Surface area (TBSA). As is frequently the case for patients with such unusually large severe burn down injuries, most of the burn down patients in our written report had head and face burns, preventing them from wearing a conventional commercially available head mounted VR helmet. Furthermore, fifty-fifty when treated with powerful hurting medications, pain during burn wound care procedures in the ICU hydrotank is oft "astringent to excruciating," which may make it harder for children to concentrate enough to play in VR during wound intendance. In theory, pain may go so attention grabbing that psychological distraction techniques cannot compete with pain for the patient's express attending (Eccleston and Crombez, 1999; Eccleston, 2001). In other words, some patients may not do good from VR if their astute procedural pain becomes too intense. Similarly, traditional distraction may fail if patients experience threatened during the wound intendance (McCaul and Malott, 1984; Crombez et al., 1998). High catastrophizers (people who take unusually negative emotions and pessimistic beliefs nearly their power to deal with the upcoming hurting) may have difficulty disengaging attention from pain information (Verhoeven et al., 2012; Van Loey et al., 2018).

To address these challenges, using a custom h2o-friendly VR system, the current pilot study tests for the offset time, whether adjunctive virtual reality can reduce the acute procedural pain of children with big astringent burn injuries during burn wound debridement/cleaning in the pediatric intensive care unit, in an understudied patient population, critically injured pediatric patients.

We hypothesize that compared to standard of intendance (standard pain medications + No VR), during adjunctive Yeah VR, children will report significant reductions in worst pain ratings. Our secondary hypothesis is that during VR, children will written report meaning reductions in hurting unpleasantness, and will spend less time thinking about pain during burn down wound debridement in the ICU hydrotank. We further hypothesize that VR will increase how much fun patients have during wound care, and that patients will be more satisfied with their pain direction during VR.

Materials and Methods

This enquiry was conducted betwixt January 2022 and Dec 2016, in accord with the Declaration of the Globe Medical Clan (world wide web.wma.cyberspace). The studies were approved by the IRB from UTMB, and all participants and their parents/legal guardians provided written informed consent/assent in accord with the Annunciation of Helsinki.

Most of the children in the current study were transported from Latin America to Shriners Hospitals for Children in Galveston Texas, U.S.A., where they were hospitalized, treated, and returned to their country of origin, post-belch.

Inclusion Criteria

Children were included in the report if they were (1) compliant and able to consummate subjective evaluations, (2) had no history of previous psychiatric (DSM-III-R Axis I) disorder(s), (3) were not demonstrating delirium, psychosis, or any form of organic brain disorder, (4) were able to communicate verbally in English or Castilian, and (v) had moderate or college worst pain during no VR on Day 1, (half dozen) were admitted to Shriners Hospitals for Children: Galveston Texas/Academy of Texas Medical Co-operative.

Children were excluded from the written report if (ane) they had a burn size <10% TBSA, (2) they were not capable of completing the study measures, (3) if no wound cleaning sessions were required, (4) if they had a history of previous psychiatric (DSM-III-R Axis I) disorder(s), (five) if they were demonstrating delirium, psychosis, or organic brain disorder, (half-dozen) if the kid was unable to communicate verbally in English language or Spanish, (7) if they had a history of significant cardiac, endocrine, neurologic, metabolic, respiratory, gastrointestinal, or genitourinary harm, (8) if they were receiving prophylaxis for alcohol or drug withdrawal, (nine) if they had a developmental inability, (10) if they were younger than vi years old, (11) if they were older than 17 years old, or (12) if they had burns of eyes, eyelids, or face so severe the burns precluded the use of VR equipment, (thirteen) or if patients reported having a previous history of severe move sickness.

Equipment

The electric current study introduced for the first time, a new portable water-friendly VR arrangement customized for the unique needs of pediatric patients with large severe burn down injuries during wound intendance in the intensive care unit hydrotank. As shown in Figure i, a custom robot-like articulated arm goggle holder was used in the current study to concur a pair of VR goggles nigh the patient's optics, so patients did non have to wear a VR helmet on their head. This "Magula arm" robot-like goggle holder minimized or ideally eliminated contact between the patient and the VR goggles. The VR goggles largely blocked the patient'southward view of the Intensive Care Unit hydrotank room. The goggles were MX90 VR goggles, from NVIS.com, with 90 degrees field of view diagonal, per heart, and 1,280 × one,024 pixels resolution per eye. All of the VR equipment in the current report was battery powered. A battery powered laptop and bombardment powered acoustic unit were used with the MX90 VR goggles. The 90 degrees diagonal field of view goggles increased the amount of peripheral vision stimulated. During the VR condition, patients were encouraged to interact with the virtual environment via a wireless computer mouse. Stereo speakers helped isolate patients from hearing hospital sounds. The custom robot-like articulated arm goggle holder was securely mounted to the frame of the Anthro medical cart. The VR goggles orientation could be adjusted and locked into position for a patient who was sitting up during wound intendance, or the goggles could be rotated and locked into position for a patient who was lying on their backs during wound care (meet Figure 2). The goggles stayed in one position, and the patient used their wireless mouse to look around, aim and shoot snowballs in SnowWorld (mouse-tracking instead of head tracking).

Figure 1. A patient playing SnowWorld during burn wound debridement in the ICU tankroom. Photo and copyright Hunter Hoffman, world wide web.vrpain.com.

Effigy 2. A patient looking into VR goggles during burn wound debridement in the ICU tank room. Photograph and copyright Hunter Hoffman, www.vrpain.com.

The portable robot-like arm goggle holder was designed by Hoffman and Magula and built by Jeff Magula, an advanced musical instrument maker at the Academy of Washington in Seattle. Once finished, the water-friendly VR arrangement was then safety inspected by Clinical Engineering science at the University of Washington, and was inspected again by Clinical Engineering at Shriners Hospitals for Children. The equipment was likewise approved for employ in the Intensive Care Unit of measurement and the equipment cleanliness was monitored by infection control at Shriners Hospitals for Children. Later on each use, the VR cart/portable VR system was returned to the Psychology Department at Shriners Galveston, where it was plugged in to recharge the batteries after each use. As shown in Figure 2, the goggles were partially covered with disposable plastic, which was discarded subsequently each utilize. The equipment was systematically disinfected later each use using chemical disinfectants, and was periodically supercleaned using ultraviolet radiation (using a portable UV lamp wand, UV protective glasses, while wearing latex gloves). For instance, the UVC Blade Handheld Germicidal Fixtures past American Ultraviolet. The VR system was periodically tested for pathogens, using swabs that were then analyzed by Shriners infection control, to test for the presence of bacteria. Culture samples (swabs) were sent to the microbiology laboratory at Shriners hospital in Galveston for immediate assay. The post-cleaning tests all came back every bit "safe" (no pathogens). There was no significant problem with infection, using the current VR system, which minimized or eliminated physical contact between the patient and the VR goggles.

Measures

Afterwards each wound care session, subjects received the post-obit instructions once prior to answering each of five separate questions. "Please indicate how you felt during wound care today by making a mark anywhere on the line. Your response doesn't have to be a whole number."

For the primary dependent measure, using Graphic Rating Scales (GRS), later on the wound intendance session, patients answered the following GRS ratings. Pain was measured using Graphic Rating Scales (GRS) (Jensen and Karoly, 2001; Jensen, 2003). In the electric current report, the GRS tool was used to appraise 3 reports of the pain experience ("worst hurting," "hurting unpleasantness," and "time spent thinking about pain") that stand for to iii separable components of the pain experience; sensory pain, affective pain, and cerebral hurting, respectively. The GRS is a ten-unit of measurement horizontal line labeled with number and word descriptors. Descriptor labels were associated with each mark to help the respondent rate pain magnitude in each domain. For worst pain, the GRS descriptors were no pain at all, mild hurting, moderate pain, severe pain, and excruciating pain. For hurting unpleasantness, the GRS descriptors were not unpleasant at all, mildly unpleasant, moderately unpleasant, severely unpleasant, and excruciatingly unpleasant. For fourth dimension spent thinking near pain, the GRS descriptors were none of the time, some of the time, half of the time, virtually of the time, all of the fourth dimension.

The Graphic Rating Scale has previously been used to appraise pain intensity in children eight and older and has been documented to exist the preferred report method for young children (Tesler et al., 1991). The GRS is more sensitive than simple descriptive pain scales and patients can hands reply these pain ratings despite having no previous experience. Visual Analog Scales accept been validated for use in children anile 7 and higher (Bringuier et al., 2009).

A unmarried rating "to what extent did you feel like you 'went into' the virtual globe," adapted from Slater et al. (1994) was also used in the present study to appraise user presence in the virtual earth. Descriptor labels were I did not feel like I went inside at all, mild sense of going inside, moderate sense of going within, potent sense of going inside, I went completely inside the computer generated earth. Hendrix and Barfield (1995) showed the reliability of a similar VR presence rating. The measure's ability to notice treatment effects (Hoffman et al., 2004c) is preliminary evidence of our VR presence measure's validity. Patients also rated how existent the objects seemed in virtual reality, descriptors were completely fake, somewhat real, moderately real, very real, indistinguishable from a existent object. Patients rated how satisfied they were with their pain management during No VR vs. during VR, with descriptors completely unsatisfied, mostly unsatisfied, one-half satisfied, mostly satisfied, completely satisfied, and patients rated nausea as a result of VR, using a graphic rating scale with descriptors no nausea at all, mild nausea, moderate nausea, severe nausea, vomit. All text was translated into Spanish for Spanish speaking participants using an official translator (xc% of the participants in this report were Spanish only speaking). To appraise whether patients in the upper quartile on catastrophizing showed pain reduction during immersive Virtual Reality, we administered the Pain Catastrophizing Scale for Children (PSC-C) (Sullivan et al., 1995; Crombez et al., 2003). The PCS total score is calculated by summing the 13-detail responses, and provides a skilful alphabetize of the catastrophizing construct through the inclusion of highly correlated subscales of helplessness, rumination, and magnification. Higher scores on the PCS-C are indicative of greater hurting-related catastrophizing. The PCS-C has been validated for use with children (Crombez et al., 2003).

Experimental Design

There is loftier variability in the analgesic effectiveness of any given dose of pharmacologic analgesia from i burn wound care session to the next (Khadra et al., 2018). And furthermore, pain medication dose levels can as well vary from mean solar day to mean solar day. For these reasons, in the current preliminary study, a statistically powerful within-subjects, inside-wound intendance design was used (Maani et al., 2011a). During VR, patients played SnowWorld, an interactive 3D snowy canyon in virtual reality during some portions of wound care, vs. No VR during comparable portions of the aforementioned wound care session. Childrens' worst pain during "No VR" (treatment as usual pain medications) vs. their worst hurting during "Yes VR" was measured during at least i 24-hour interval of wound care, and was measured for up to 10 study days the patient used VR. Initial treatment gild was randomized using blocked randomization, based on random number sequences generated using world wide web.random.org. All patients received their usual pain medications on all study days, i.e., VR was always used adjunctively, in improver to usual traditional pain medications.

During wound care, the nurses cut off and removed the patient's gauze bandages, and began cleaning the patients burn wounds, using warm wet washcloths and a hand held warm water shower hose to scrub and rinse abroad expressionless tissue and debris out of the burn wound. During wound debridement, patients received No VR and Yes VR during approximately equally painful portions of the same wound care session. The patient began receiving wound treat 5 min with Yes VR vs. 5 min with No VR, Yes VR for 5 more minutes, etc. repeatedly alternate between No VR and Yep VR every 5 min. Whether patients received Yep VR or No VR during the first 5 min treatment segment was randomized (blocked randomization using a random sequence generated at random.org). During the portions of their burn wound care that they received VR, the inquiry staff positioned the VR goggles weightlessly virtually the patient's eyes, with lilliputian or no physical contact betwixt the VR goggles and the patient, using a robot-like-arm goggle holder (Maani et al., 2008). The patient looked into the VR goggles, and interacted with the virtual reality earth.

All patients used SnowWorld (see Figure iii) during all VR sessions. SnowWorld is a non-profit VR world specifically designed for hurting distraction of immobilized severe burn patients, including children. SnowWorld is designed to give burn patients the illusion of going inside a snowy 3D coulee (Hoffman et al., 2001, 2004b,c; see as well Bloemink et al., 2006, p. 104–106). In SnowWorld (www.vrpain.com), patients interacted with snowmen, igloos, penguins, wooly mammoths, and flying fish past throwing snowballs, using a wireless computer mouse to aim and trigger snowballs while keeping their heads and bodies motionless. During VR, patients heard music (east.g., Paul Simon'due south vocal Graceland, and several Spanish songs), and 3D audio effects e.thou., ice breaking when a snowball hits a snowman. Mammoths trumpeted angrily when pelted.

Figure 3. SnowWorld. An icy 3D canyon in virtual reality. Image past Ari Hollander and Howard Rose, copyright Hunter Hoffman, www.vrpain.com.

Later on the wound intendance session was over, patients briefly rated how much pain they had experienced during No VR vs. during Aye VR using graphic rating scales. The patient's burns were rebandaged, the patient was wheeled dorsum to their hospital room and returned to their hospital beds, and the inquiry staff thoroughly cleaned and disinfected the VR equipment.

Statistical Analyses

IBM SPSS (2018) statistical analyses of the primary and secondary hypotheses involved an apriori two-tailed within-subjects paired t-test, with blastoff = 0.05.

Results

Patients participated between January 2022 and December 2016. Out of the 62 patients initially screened, 48 pediatric patients met our apriori inclusion criterion of having a moderate or higher "worst hurting" rating during No VR on Solar day 1 (33 hispanic males children, xi hispanic female children from developing Latin American countries, and also iii not-hispanic female children and i non-hispanic male from the United States). The mean size of the patient'due south severe burn injuries was 40 percent Total Torso Surface Area (TBSA) burned, 28% third caste burns. Patients' ages ranged from 6 to 17 years of age at time of enrollment (Hateful age was 12 years old). Seventy-seven percent of the patients had mitt burns, 85% had arm burns, 44% had foot burns, 79% had leg burns, 71% had neck/caput burns, 79% had trunk/trunk burns, and 23% had groin burns. Regarding the (sometimes overlapping) etiology of their burns, 81% had burns involving flame, 6% scalds, 25% electrical, and zero patients had chemical burns.

Examination of Our Principal Hypothesis

The patients GRS pain ratings on Day ane are shown in Tabular array 1 and Figure four. On Twenty-four hour period ane, on a null to 10 graphic rating scale, using a paired t-test, VR significantly reduced children's "worst hurting" ratings during fire wound cleaning procedures in the ICU. On 24-hour interval ane, worst pain during No VR = 8.52 (SD = 1.75) vs. during Yes VR = 5.10 (SD = 3.27), t ₍₄₇₎ = 7.xi, p < 0.001, SD = 3.33, CI = 2.45–four.38, Cohen'due south d = 1.03, indicating a large effect size.

Table 1. Ways (Standard Departure) in "No-VR" condition vs. "Yeah-VR" status.

Figure 4. Patients with moderate or college pain ratings during wound intendance on Twenty-four hours 1.

Descriptive Statistics Well-nigh "Worst Hurting" Ratings

On Mean solar day 1, the number of patients reporting excruciating hurting (worst pain = 10) during wound care was 22 patients, which dropped to merely five patients reporting excruciating pain (worst pain = ten) during Yes VR, and Cohen'due south d showed a strong effect size of VR analgesia. However, many of those patients with pain of 10 during No VR but dropped to 8 during VR (i.e., they dropped from excruciating pain during No VR down to astringent pain during VR, merely nonetheless reported astringent pain during adjunctive VR).

On 24-hour interval one, xl% of the 48 patients even so reported hurting of 7 or higher (severe to excruciating) during VR, despite receiving powerful traditional pharmacologic hurting medications combined with immersive virtual reality.

On average, patients spent hateful = 16.56 min of wound care during No VR vs. 12.89 min during VR, t ₍₄₄₎ = 2.47, p < 0.05, SD = 9.97, CI =0.67–6.66, east.g., patients could not apply VR while having their faces or heads cleaned. On Day 1, xiv of the 48 patients spent exactly the same amount of time during No VR (13.21 min) and during VR (13.21 min). These 14 patients also reported large and statistically significant reductions in hurting during VR, worst hurting during No VR = 8.fifty (SD = i.83), VR = iv.43 (SD = iii.08), t ₍₁₃₎ = iv.56, p < 0.005, SD = iii.34, CI = 2.xiv–vi.00.

The hateful number of days that patients rated their pain during Aye VR vs. during No VR was four study days. Collapsed beyond days, VR significantly reduced worst pain: Worst pain during "No VR" (Hateful = 7.09, SD = 2.10) vs. worst hurting during "Yes virtual reality" (Hateful = 4.29, SD = 2.55), t ₍₄₇₎ = 7.32, p < 0.001, SD = two.65, CI = 2.01–3.57, Cohen'due south d = ane.06, big effect size.

Consistent with the prediction that VR would go along to reduce pain when used day later 24-hour interval, a one-way within-subjects ANOVA comparing worst hurting during "No VR" minus worst pain during "Yes VR" deviation scores for days 1–7 showed no significant difference in the size of the VR analgesia issue over days ane–7, Wilks' Lamda F _{(4, half-dozen)} = 1.l, p = 0.36, NS.

In exploratory analyses, patients scoring in the upper quartile on the children's pain catastrophizing score (PSC-C) in the current sample, showed significant VR analgesia. For patients scoring in the upper quartile on catastrophizing, hateful worst hurting during No VR = 7.00 (SD = three.56), vs. VR = 2.86 (SD = 3.63), t ₍₆₎ = ii.fourscore, p < 0.05, SD = 2.56, CI = 0.34 vs. 5.09. Patients scoring in the lower quartile in the current sample also showed significant VR analgesia, mean worst pain ratings during No VR = 6.00 (SD = iv.04), and during VR = 2.86 (SD = 2.85), t _{(half dozen)} = 4.01, p < 0.01, SD = 1.03, CI = 1.61–6.67.

Test of Secondary Hypotheses

As shown in Tabular array 1 and Figure 4, on secondary GRS measures, on Day 1, pediatric burn patients reported large and significant reductions in pain on secondary measures of "pain unpleasantness" and "time spent thinking near pain during wound intendance." Although children reported having 27% more than fun during VR, the increment in fun on Day 1 was not statistically significant in the paired t-test. The children were significantly more satisfied with their pain management during VR, on boilerplate. Patients reported only a moderate illusion of "existence there" within the 3D calculator generated earth equally if it was a place they visited. VR nausea was nearly zero (<one on a x point calibration).

The current study included 48 pediatric patients total. As shown in Table 2, in an exploratory analysis, to see if children from developing countries show VR analgesia, the subset (sub-analysis) of 44 patients from developing Latin American countries were analyzed separately from the four patients from the United States. As predicted, children from developing countries showed meaning reductions in worst pain during VR, too equally significant reductions in pain unpleasantness (the emotional component of pain) and significant reductions in time spent thinking about pain during wound intendance (the cognitive component of pain). Encouragingly, analyzed separately, the four participants from the United States also showed the predicted patterns of large reductions of hurting during VR.

Table 2. Ways (Standard Divergence) in "No-VR" status vs. "Yes-VR" condition.

Give-and-take

This pilot report provides preliminary evidence that immersive virtual reality tin can aid reduce the hurting of children with large severe burn wounds during burn down wound cleaning in the Intensive Care Unit. Although using VR in the ICU hydrotank room was challenging and required creating custom equipment, in the current study, on Solar day ane, patients reported significant reductions in worst pain (pain intensity), children spent less time thinking about their pain during VR, children reported significant reductions in pain unpleasantness, and the children reported 27% college ratings of fun during wound intendance during virtual reality. In addition, these pediatric patients were also significantly more satisfied with their hurting management during virtual reality, they reported a moderate illusion of presence in VR (i.east., a moderately strong illusion of "beingness in that location" in the VR computer generated globe during wound care), and VR nausea was nearly zero (<1 on a ten point calibration). Patients who received VR during more than i day of wound care continued to report the predicted design of reductions in worst hurting during multiple wound intendance sessions. And patients with a tendency toward negative emotions and pessimistic beliefs about their power to deal with the upcoming hurting (i.due east., patients in the upper quartile on catastrophizing), still benefitted from virtual reality distraction.

The reductions in worst pain ratings in the current report are like to the pattern of VR analgesia reported in previous studies of 12 U.South. soldiers with gainsay-related burn down injuries (TBSA of 21%) during wound care in their hospital beds. The soldiers spent 6 min in No VR vs. vi min of wound intendance during VR (Maani et al., 2011a). In the current study the mean burn size was over xl%, the patients were all children, and the sample size was larger (north = 48 patients). Furthermore, in the electric current report, on average, patients spent over 12 min in VR and over 12 min in No VR, the wound care was conducted in the ICU instead of in the patients infirmary beds, and the current study is the kickoff to use a portable h2o-friendly VR system.

Limitations

The demographics and characteristics of the participants of this pediatric pain study may limit generalization of findings of this study to other populations. Of interest is that 44 of the 48 patients were Spanish speaking patients from developing Latin American countries. Equally predicted, in an exploratory sub-assay, the 44 children from developing Latin American countries showed statistically significant reductions in pain during VR. Encouragingly, analyzed separately, the 4 participants from the U.s. too showed the predicted patterns of large reductions of pain during VR. The VR system used in the current report was customized for apply in the ICU hydrotank room, for patients with head and facial burns. Future randomized controlled trials inquiry is needed to make up one's mind whether the electric current results replicate, and generalize to other VR systems.

Despite these limitations, the current study makes several important original contributions to the literature, and the results of the current study could have important implications for clinical practice: (a) this is the beginning report ever to try to use virtual reality during burn wound care in the intensive care unit, (b) the patients had unusually severe burn down injuries much larger than burn injuries treated in any previous burn debridement VR analgesia study, (c) all of the patients were children, and 44 out of the 48 patients were Spanish speaking children from developing Latin American Countries, (d), the current study shows for the first time that children with large severe burns were mostly able to play SnowWorld during severely painful medical procedures, and (e) playing SnowWorld in virtual reality significantly reduced worst hurting ratings during wound care.

In the current report, a custom portable water-friendly VR system was used that did not accept to physically contact the patient. The equipment was advisedly cleaned with sterilizing cloths after each use, and the equipment was periodically swabbed/tested by the hospitals infection control squad to test for the presence of any bacterial or viral pathogens. There was no problem with infection in the current study, using the custom VR organisation, which minimized or eliminated physical contact between the patient and the VR goggles. For patients with express power to clothing VR helmets, modified VR systems that reduce contact surfaces (Hoffman et al., 2014) are highly recommended for utilize of VR during burn down wound care for patients with severe unbandaged head and/or face burns. Nosotros also recommend discarding disposable foam liners that touch on the patients face after each use. Fire patients are especially vulnerable to infections when unbandaged (during wound care), and VR equipment should be monitored by infection command, specially when used in the Intensive Care Unit.

Decision

The results from the current pilot report back up our hypothesis that immersive virtual reality tin can significantly reduce acute pain during burn wound care, even in pediatric patients with large severe fire wounds treated in the hydrotanks in the Intensive Care Unit. And VR continued to reduce pain when used day after solar day.

Future Directions

Virtual reality (VR) may eventually prove to exist "opioid sparing" during hospitalization (Kipping et al., 2012; McSherry et al., 2018). Additional research and development is needed on how to make VR analgesia more powerful (Wender et al., 2009), how to make pharmacologic pain medications more constructive (McIntyre et al., 2016), and how to best combine pharmacologic pain medications and VR analgesia, to maximize total hurting command. Evolution of more powerful new non-pharmacologic pain management techniques is a national and international priority (Keefe et al., 2018), and Virtual Reality has stiff potential as a new direction for behavioral medicine (Keefe et al., 2012).

Fortunately, VR analgesia is not limited to severe burn down patients, but could potentially exist used for a wide range of painful medical procedures, and could be especially valuable for highly populated, lower income developing countries (4/5ths of the World'southward population), where large severe burns and other serious injuries are more than common, and powerful pharmacologic analgesics are more scarce or unavailable. Boosted research and evolution of VR analgesia is recommended.

Data Availability

The datasets for this study will not be made publicly bachelor because IRB restrictions.

Ethics Statement

This research was conducted in accordance with the Proclamation of the Globe Medical Association (world wide web.wma.net). The studies were approved by the IRB from UTMB, and all participants provided written informed consent/assent in accordance with the Annunciation of Helsinki.

Writer Contributions

All authors listed have fabricated a substantial, direct and intellectual contribution to the work, and approved it for publication.

Funding

This research was financed past Shriners Hospitals for Children, Tampa Florida (award ID #71011-GAL, PI Walter Meyer), with help from a charitable donation from the MayDay Fund (PI Walter Meyer). The portable h2o friendly VR system was developed via NIH grant R01GM042725 to DP.

Disharmonize of Interest Statement

All authors have completed the ICMJE uniform disclosure and declare support for the submitted work.

Acknowledgments

Cheers to the patients and their parents for volunteering to participate in this written report. Thank you to the wound care staff, and to Drs. Laura and Marta Rosenberg at Shriners Hospitals for Children in Galveston TX. Thanks to Jeff Magula (and as well Eric J. Seibel and Bill Russell) for the custom VR system, and thank you to Pecker Russell and Maribel Ramirez, for early on pilot research on water-friendly VR in the ICU at Shriners Galveston. We would also similar to thank Kristen Darken and all of the several teams of VR worldbuilders at Multigen-Paradigm, SimWright, Howard Abrams, and Duff Hendrickson, who have created the original SnowWorld 2001 and SnowWorld 2003, and thank you to Ari Hollander and Howard Rose for the latest version of the University of Washington's SnowWorld (2006) used in the electric current study (world wide web.vrpain.com). Cheers to the Ladies of the Nile, and Shriners Hospitals for Children Lath of Directors, and to Dr. Steve Wolf, and to the Mexican Michou y Mao Foundation for their generous encouragement and support. Special thanks to singer/songwriter Paul Simon for suggesting we utilise Graceland with SnowWorld.

References

Atzori, B., Hoffman, H. K., Vagnoli, L., Patterson, D. R., Al-Halabi, W. H. G., Messeri, A., et al. (2018b). Virtual Reality analgesia during venipuncture effectiveness among pediatric patients with onco-hematological diseases. Front end. Psychol. 9:2508. doi: 10.3389/fpsyg.2018.02508

CrossRef Full Text | Google Scholar

Atzori, B., Lauro Grotto, R., Giugni, A., Calabrò, M., Alhalabi, W., and Hoffman, H. G. (2018a). Virtual reality analgesia for pediatric dental patients. Front Psychol. 9:2265. doi: 10.3389/fpsyg.2018.02265

PubMed Abstract | CrossRef Full Text | Google Scholar

Bellieni, C. V., Cioncoloni, D., Mazzanti, S., Bianchi, M. E., Morrone, I., Becattelli, R., et al. (2013). Music provided through a portable media histrion (iPod) blunts pain during physical therapy. Pain Manag. Nurs. xiv, e151–e155. doi: 10.1016/j.pmn.2011.09.003

PubMed Abstract | CrossRef Full Text | Google Scholar

Berterame, S., Erthal, J., Thomas, J., Fellner, S., Vosse, B., Clare, P., et al. (2016). Apply of and barriers to admission to opioid analgesics: a worldwide, regional, and national study. Lancet. 387, 1644–1656. doi: 10.1016/S0140-6736(16)00161-6

PubMed Abstract | CrossRef Full Text | Google Scholar

Bittner, Due east. A., Shank, East., Woodson, L., and Martyn, J. A. (2015). Astute and perioperative care of the burn down-injured patient. Anesthesiology 122, 448–464. doi: ten.1097/ALN.0000000000000559

PubMed Abstract | CrossRef Total Text | Google Scholar

Bloemink, B., Hodge, B., Lupton, Due east., and McQuaid, Yard. (2006). Pattern Life Now, National Blueprint Triennial. New York, NY: Cooper-Hewitt, National Pattern Museum, Smithsonian Institution. Available online at: world wide web.cooperhewitt.org

Google Scholar

Bringuier, S., Dadure, C., Raux, O., Dubois, A., Picot, Grand. C., and Capdevila, X. (2009). The perioperative validity of the visual analog feet scale in children: a discriminant and useful instrument in routine clinical practice to optimize postoperative pain management. Anesth. Analg. 109, 737–744. doi: 10.1213/ane.0b013e3181af00e4

PubMed Abstruse | CrossRef Full Text | Google Scholar

Chambers, C. T. (2018). From evidence to influence: dissemination and implementation of scientific knowledge for improved pain research and management. Pain 159(Suppl i), S56–S64. doi: ten.1097/j.pain.0000000000001327

PubMed Abstruse | CrossRef Total Text | Google Scholar

Chen, Q., Larochelle, K. R., Weaver, D. T., Lietz, A. P., Mueller, P. P., Mercaldo, Southward., et al. (2019). Prevention of prescription opioid misuse and projected overdose deaths in the United States. JAMA Netw. Open. two:e187621. doi: ten.1001/jamanetworkopen.2018.7621

PubMed Abstruse | CrossRef Full Text | Google Scholar

Cherny, Due north., Ripamonti, C., Pereira, J., Davis, C., Fallon, M., McQuay, H., et al. (2001). Strategies to manage the adverse effects of oral morphine: an evidence-based report. J. Clin. Oncol. nineteen, 2542–2554. doi: 10.1200/JCO.2001.19.9.2542

PubMed Abstract | CrossRef Full Text | Google Scholar

Clark, A., Imran, J., Madni, T., and Wolf, Due south. E. (2017). Nutrition and metabolism in fire patients. Burns Trauma. 17:xi. doi: x.1186/s41038-017-0076-xh

CrossRef Full Text | Google Scholar

Crombez, M., Bijttebier, P., Eccleston, C., Mascagni, T., Mertens, G., Goubert, L., et al. (2003). The child version of the pain catastrophizing scale (PCS-C): a preliminary validation. Pain 104, 639–646. doi: 10.1016/S0304-3959(03)00121-0

PubMed Abstract | CrossRef Full Text | Google Scholar

Crombez, Chiliad., Eccleston, C., Baeyens, F., and Eelen, P. (1998). When somatic information threatens, catastrophic thinking enhances attentional interference. Pain 75, 187–198. doi: x.1016/S0304-3959(97)00219-4

PubMed Abstract | CrossRef Full Text | Google Scholar

Davis, M. P., McPherson, M. L., Mehta, Z., Behm, B., and Fernandez, C. (2018). What parenteral opioids to use in confront of shortages of morphine, hydromorphone, and fentanyl. Am. J. Hosp. Palliat. Care 35, 1118–1122. doi: 10.1177/1049909118771374

PubMed Abstract | CrossRef Full Text | Google Scholar

Eccleston, C., and Crombez, G. (1999). Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychol. Bull. 125, 356–366. doi: 10.1037//0033-2909.125.3.356

PubMed Abstract | CrossRef Total Text | Google Scholar

Faber, A. West., Patterson, D. R., and Bremer, M. (2013). Repeated use of immersive virtual reality therapy to control hurting during wound dressing changes in pediatric and adult burn patients. J. Burn Intendance Res. 34, 563–568. doi: ten.1097/BCR.0b013e3182777904

PubMed Abstract | CrossRef Full Text | Google Scholar

Fratianne, R. B., Prensner, J. D., Hutson, Thou. J., Super, D. M., Yowler, C. J., and Sandley, J. M. (2001). The effect of music-based imagery and musical alternate date on the burn down debridement process. J. Burn Care Rehabil. 22, 47–53. doi: ten.1097/00004630-200101000-00010

PubMed Abstract | CrossRef Total Text | Google Scholar

Garrett, B., Taverner, T., Masinde, W., Gromala, D., Shaw, C., and Negraeff, G. (2014). A rapid evidence assessment of immersive virtual reality every bit an adjunct therapy in astute hurting management in clinical do. Clin. J. Pain 30, 1089–1098. doi: 10.1097/AJP.0000000000000064

PubMed Abstruse | CrossRef Full Text | Google Scholar

Hemington, K. S., Cheng, J. C., Bosma, R. L., Rogachov, A., Kim, J. A., and Davis, K. D. (2017). Beyond negative pain-related psychological factors: resilience is related to lower pain affect in good for you adults. J. Hurting eighteen, 1117–1128. doi: ten.1016/j.jpain.2017.04.009

PubMed Abstruse | CrossRef Full Text | Google Scholar

Hendrix, C., and Barfield, West. (1995). "Presence in virtual environments as a function of visual and auditory cues," in Proceedings of VRAIS'95 (Los Alamitos, CA: Research Triangle Park, NC, IEEE Computer Order Press) 74–82. doi: 10.1109/VRAIS.1995.512482

CrossRef Full Text | Google Scholar

Hoffman, H. Thou. (1998). Virtual reality: a new tool for interdisciplinary psychology inquiry. CyberPsychol. Behav. 1, 195–200. doi: ten.1089/cpb.1998.1.195

CrossRef Full Text | Google Scholar

Hoffman, H. K., Chambers, G. T., Meyer, Due west. J., 3rd, Arceneaux, L. L., Russell, W. J., Seibel, E. J., et al. (2011). Virtual reality every bit an adjunctive non-pharmacologic analgesic for astute burn down pain during medical procedures. Ann. Behav. Med. 41, 183–191. doi: 10.1007/s12160-010-9248-7

PubMed Abstruse | CrossRef Full Text | Google Scholar

Hoffman, H. G., Doctor, J. North., Patterson, D. R., Carrougher, G. J., and Furness, T. A. III. (2000). Use of virtual reality as an adjunctive handling of adolescent fire pain during wound care: a case report. Pain 85, 305–309. doi: x.1016/S0304-3959(99)00275-4

CrossRef Full Text | Google Scholar

Hoffman, H. G., Garcia-Palacios, A., Kapa, V. A., Beecher, J., and Sharar, Southward. R. (2003). Immersive virtual reality for reducing experimental ischemic pain. Int. J. Hum. Comp. Collaborate. 15, 469–486. doi: 10.1207/S15327590IJHC1503_10

CrossRef Full Text | Google Scholar

Hoffman, H. G., Meyer, West. J., 3rd, Ramirez, M., Roberts, 50., Seibel, E. J., Atzori, B., et al. (2014). Feasibility of articulated arm mounted Oculus Rift Virtual Reality goggles for adjunctive hurting control during occupational therapy in pediatric burn patients. Cyberpsychol. Behav. Soc. Netw. 17, 397–401. doi: ten.1089/cyber.2014.0058

PubMed Abstract | CrossRef Full Text | Google Scholar

Hoffman, H. One thousand., Patterson, D. R., Carrougher, Grand. J., and Sharar, South. R. (2001). Effectiveness of virtual reality-based pain command with multiple treatments. Clin. J. Pain 17, 229–235. doi: 10.1097/00002508-200109000-00007

PubMed Abstract | CrossRef Full Text | Google Scholar

Hoffman, H. Thou., Patterson, D. R., Magula, J., Carrougher, K. J., Zeltzer, K., Dagadakis, S., et al. (2004a). H2o-friendly virtual reality pain command during wound intendance. J. Clin. Psychol. lx, 189–95. doi: 10.1002/jclp.10244

PubMed Abstract | CrossRef Full Text | Google Scholar

Hoffman, H. G., Richards, T. L., Coda, B., Bills, A. R., Blough, D., Richards, et al. (2004b). Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI. Neuroreport fifteen, 1245–1248. doi: x.1097/01.wnr.0000127826.73576.91

PubMed Abstruse | CrossRef Total Text | Google Scholar

Hoffman, H. G., Richards, T. L., Van Oostrom, T., Coda, B. A., Jensen, One thousand. P., Blough, D. K., et al. (2007). The analgesic furnishings of opioids and immersive virtual reality distraction: bear witness from subjective and functional brain imaging assessments. Anesth. Analg. 105, 1776–1783. doi: 10.1213/01.one.0000270205.45146.db

PubMed Abstract | CrossRef Full Text | Google Scholar

Hoffman, H. G., Seibel, E. J., Richards, T. Fifty., Furness, T. A., Patterson, D. R., and Sharar, Southward. R. (2006). Virtual reality helmet display quality influences the magnitude of virtual reality analgesia. J. Pain 7, 843–850. doi: 10.1016/j.jpain.2006.04.006

PubMed Abstract | CrossRef Full Text | Google Scholar

Hoffman, H. K., Sharar, South. R., Coda, B., Everett, J. J., Ciol, 1000., Richards, T., et al. (2004c). Manipulating presence influences the magnitude of virtual reality analgesia. Hurting 111, 162–168. doi: x.1016/j.pain.2004.06.013

PubMed Abstruse | CrossRef Total Text | Google Scholar

Honzel, E., Murthi, S., Brawn-Cinani, B., Colloca, G., Kier, C., Varshney, A., et al. (2019). Virtual reality, music and hurting: developing the premise for an interdisciplinary approach to hurting management. Pain. doi: x.1097/j.pain.0000000000001539. [Epub alee of print].

PubMed Abstract | CrossRef Full Text | Google Scholar

Hsu, K. C., Chen, 50. F., and Hsiep, P. H. (2016). Effect of music intervention on burn patients' pain and anxiety during dressing changes. Burns 42, 1789–1796. doi: 10.1016/j.burns.2016.05.006

PubMed Abstract | CrossRef Full Text | Google Scholar

Indovina, P., Barone, D., Gallo, L., Chirico, A., De Pietro, Thousand., and Antonio, G. (2018). Virtual reality as a distraction intervention to salve pain and distress during medical procedures: a comprehensive literature review. Clin. J. Hurting 34, 858–877. doi: x.1097/AJP.0000000000000599

PubMed Abstract | CrossRef Full Text | Google Scholar

Jeffs, D., Dorman, D., Chocolate-brown, Southward., Files, A., Graves, T., Kirk, E., et al. (2014). Result of virtual reality on boyish pain during burn wound care. J. Burn Intendance Res. 35, 395–408. doi: 10.1097/BCR.0000000000000019

PubMed Abstruse | CrossRef Full Text | Google Scholar

Jensen, 1000. P., and Karoly, P. (2001). "Self-report scales and procedures for assessing pain in adults," in Handbook of Pain Assessment, 2nd ed., eds Turk, D. C. and Melzack, R. (New York, NY: Guilford Press). 15–34.

PubMed Abstract | Google Scholar

Kahneman, D. (1973). Attention and Effort. Englewood Cliffs, NJ: Prentice-Hall.

Google Scholar

Keefe, F. J., Huling, D. A., Coggins, M. J., Keefe, D. F., Zachary Rosenthal, M., Herr, N. R, et al. (2012). Virtual reality for persistent pain: a new direction for behavioral pain management. Pain 153, 2163–2166. doi: x.1016/j.pain.2012.05.030

PubMed Abstract | CrossRef Full Text | Google Scholar

Keefe, F. J., Main, C. J., and George, S. Z. (2018). Advancing psychologically informed do for patients with persistent musculoskeletal pain: Promise, pitfalls, and solutions. Phys. Ther. 98, 398–407. doi: 10.1093/ptj/pzy024

PubMed Abstract | CrossRef Full Text | Google Scholar

Khadra, C., Ballard, A., Déry, J., Paquin, D., Fortin, J. Due south., Perreault, I., et al. (2018). Projector-based virtual reality dome environment for procedural hurting and anxiety in immature children with burn injuries: a pilot study. J. Pain Res. 14, 343–353. doi: 10.2147/JPR.S151084

CrossRef Total Text | Google Scholar

Kipping, B., Rodger, S., Miller, G., and Kimble, R. One thousand. (2012). Virtual reality for acute hurting reduction in adolescents undergoing fire wound care: a prospective randomized controlled trial. Burns 38, 650–657. doi: ten.1016/j.burns.2011.11.010

PubMed Abstruse | CrossRef Full Text | Google Scholar

Maani, C., Hoffman, H. 1000., DeSocio, P. A., Morrow, M., Galin, C., Magula, J., et al. (2008). Hurting control during wound care for combat-related burn injuries using custom articulated arm mounted virtual reality goggles. J. CyberTher. Rehabil. 1, 193–198.

Google Scholar

Maani, C. V., Hoffman, H. G., Fowler, Chiliad., Maiers, A. J., Gaylord, Grand. 1000., and Desocio, P. A. (2011a). Combining ketamine and virtual reality hurting control during severe burn wound care: one military and one civilian patient. Pain Med. 12, 673–678. doi: ten.1111/j.1526-4637.2011.01091

PubMed Abstract | CrossRef Full Text | Google Scholar

Maani, C. Five., Hoffman, H. G., Morrow, M., Maiers, A., Gaylord, Yard., McGhee, L. 50., et al. (2011b). Virtual reality pain control during burn wound debridement of combat-related burn injuries using robot-similar arm mounted VR goggles. J. Trauma 71(1 Suppl), S125–S130. doi: 10.1097/TA.0b013e31822192e2

PubMed Abstract | CrossRef Total Text | Google Scholar

Malchow, R. J., and Black, I. H. (2008). The evolution of pain management in the critically ill trauma patient: emerging concepts from the global war on terrorism. Crit. Intendance Med. 36, S346–357. doi: x.1097/CCM.0b013e31817e2fc9

PubMed Abstract | CrossRef Full Text | Google Scholar

McGhee, 50. Fifty., Slater, T. M., Garza, T. H., Fowler, K., DeSocio, P. A., and Maani, C. V. (2011). The relationship of early pain scores and posttraumatic stress disorder in burned soldiers. J. Burn Care Res. 32, 46–51. doi: 10.1097/BCR.0b013e318204b359

PubMed Abstruse | CrossRef Full Text | Google Scholar

McIntyre, M. K., Clifford, J. L., Maani, C. Five., and Burmeister, D. M. (2016). Progress of clinical practice on the management of fire-associated pain: Lessons from animal models. Burns 42, 1161–1172. doi: 10.1016/j.burns.2016.01.023

PubMed Abstract | CrossRef Full Text | Google Scholar

McSherry, T., Atterbury, M., Gartner, S., Helmold, E., Searles, D. 1000., and Schulman, C. (2018). Randomized, crossover written report of immersive virtual reality to decrease opioid utilise during painful wound care procedures in adults. J. Burn Care Res. 39, 278–285. doi: 10.1097/BCR.0000000000000589

PubMed Abstract | CrossRef Full Text | Google Scholar

Nitzan, U., Hecht, Yard., Braw, Y., Maoz, H., Levkovitz, Y., Yarnitsky, D., et al. (2019). Initial evaluation of pain intensity amid depressed patients as a possible mediator between depression and hurting complaints. Front Psychiatr x:48. doi: ten.3389/fpsyt.2019.00048

PubMed Abstract | CrossRef Full Text | Google Scholar

Noel, M., Rabbitts, J. A., Tai, G. G., and Palermo, T. M. (2015). Remembering pain later on surgery: a longitudinal examination of the part of pain catastrophizing in children's and parents' think. Pain 156, 800–808. doi: 10.1097/j.pain.0000000000000102

PubMed Abstract | CrossRef Full Text | Google Scholar

Pardesi, O., and Fuzaylov, Grand. (2017). Pain management in pediatric fire patients: review of recent literature and hereafter directions. J. Burn Care Res. 38, 335–347. doi: x.1097/BCR.0000000000000470

PubMed Abstract | CrossRef Total Text | Google Scholar

Peña, R., Suman, O. East., Rosenberg, M., Andersen, C. R., Herndon, D. Due north., and Meyer, West. J. (2017). One-year comparison of a community-based do plan versus a day hospital-based exercise plan on quality of life and mental health in severely burned children. Arch. Phys. Med. Rehabil. doi: 10.1016/j.apmr.2017.10.023

PubMed Abstruse | CrossRef Full Text | Google Scholar

Rohilla, L., Agnihotri, M., Trehan, S. Chiliad., Sharma, R. K., and Ghai, S. (2018). Event of music therapy on pain perception, anxiety, and opioid use during dressing modify amidst patients with burns in Bharat: A quasi-experimental, cross-over airplane pilot written report. Ostomy Wound Manage. 64, 40–46. doi: 10.25270/owm.2018.10.4046

PubMed Abstract | CrossRef Full Text | Google Scholar

Rosenberg, Fifty., Rosenberg, Grand., Robert, R., Richardson, 50., Precipitous, Due south., Holzer, C. East., et al. (2015). Does acute stress disorder predict subsequent posttraumatic stress disorder in pediatric burn down survivors? J. Clin. Psychiatry 76, 1564–1568. doi: 10.4088/JCP.14m09365

PubMed Abstract | CrossRef Total Text | Google Scholar

Rosenberg, Fifty., Rosenberg, M., Precipitous, South., Thomas, C. R., Humphries, H. F., Holzer Three, C. Due east., et al. (2018). Does astute propranolol treatment prevent posttraumatic stress disorder, feet, and low in children with burns? J. Child Adolesc. Psychopharmacol. 28, 117–123. doi: ten.1089/cap.2017.0073

PubMed Abstract | CrossRef Total Text | Google Scholar

Scheffler, M., Koranyi, Southward., Meissner, W., Strau,ß, B., and Rosendahl, J. (2017). Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: a systematic review and meta-analysis of randomized controlled trials. Burns 44, 1709–1720. doi: 10.1016/j.burns.2017.eleven.019

PubMed Abstruse | CrossRef Full Text | Google Scholar

Schwaller, F., and Fitzgerald, M. (2014). The consequences of hurting in early life: injury-induced plasticity in developing hurting pathways. Eur. J. Neurosci. 39, 344–352. doi: 10.1111/ejn.12414

PubMed Abstract | CrossRef Full Text | Google Scholar

Slater, M., Usoh, M., and Steed, A. (1994). Depth of presence in immersive virtual environments. Presence Teleoper Virtual Environ. three, 130–144. doi: x.1162/pres.1994.iii.2.130

CrossRef Total Text | Google Scholar

Slater, Chiliad., and Wilbur, S. (1997). A framework for immersive virtual environments (FIVE): speculations on the part of presence in virtual environments. Presence Teleoper Virtual Environ. 6, 603–616. doi: ten.1162/pres.1997.vi.6.603

CrossRef Full Text | Google Scholar

Sullivan, M. J. L., Bishop, S. R., and Pivik, J. (1995). The pain catastrophizing calibration: development and validation. Psychol. Assess. 7, 524–532. doi: 10.1037//1040-3590.7.4.524

CrossRef Full Text | Google Scholar

Tesler, M. D., Savedra, M. C., Holzemer, W. L., Wilkie, D. J., Ward, J. A., and Paul, Due south. Grand. (1991). The word-graphic rating calibration as a measure of children'due south and adolescents' hurting intensity. Res. Nurs. Wellness xiv, 361–371. doi: 10.1002/nur.4770140507

PubMed Abstruse | CrossRef Total Text | Google Scholar

van der Heijden, Thou. J. E., Jeekel, J., Rode, H., Cox, S., van Rosmalen, J., Hunink, Yard. Yard. G., et al. (2018). Tin live music therapy reduce distress and pain in children with burns subsequently wound care procedures? a randomized controlled trial. Burns 44, 823–833. doi: 10.1016/j.burns.2017.12.013

PubMed Abstract | CrossRef Total Text | Google Scholar

Van Loey, N. E., Klein-König, I., de Jong, A. E. E., Hofland, H. W. C., Vandermeulen, E., and Engelhard, I. Grand. (2018). Catastrophizing, pain and traumatic stress symptoms following burns: A prospective study. Eur. J. Pain 22, 1151–1159. doi: x.1002/ejp.1203

PubMed Abstract | CrossRef Total Text | Google Scholar

van Twillert, B., Bremer, M., and Faber, A. Westward. (2007). Calculator-generated virtual reality to control pain and feet in pediatric and developed burn patients during wound dressing changes. J. Burn down Care Res. 28, 694–702. doi: 10.1097/BCR.0B013E318148C96F

PubMed Abstract | CrossRef Full Text | Google Scholar

Verhoeven, K., Goubert, L., Jaaniste, T., Van Ryckeghem, D. K., and Crombez, Yard. (2012). Hurting catastrophizing influences the employ and the effectiveness of distraction in schoolchildren. Eur. J. Pain 16, 256–267. doi: 10.1016/j.ejpain.2011.06.015

PubMed Abstract | CrossRef Full Text | Google Scholar

Vijayan, R. (2011). Managing acute pain the developing world. Pain Clin Updates. 19. 1–seven.

Google Scholar

Wender, R., Hoffman, H. G., Hunner, H. H., Seibel, E. J., Patterson, D. R., and Sharar, S. R. (2009). Interactivity influences the magnitude of virtual reality analgesia. J. Cyber Ther. Rehabil. two, 27–33.

PubMed Abstract | Google Scholar

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