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Purpose: Non-pharmacologic adjuncts to opioid analgesics for burn wound debridement enhance safety and cost effectiveness in care. The current study explored the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults, and tested whether interactive VR would reduce pain more effectively than nature stimuli viewed in the same VR goggles., Methods: Forty-eight patients with severe burn injuries (44 adults and 4 children) had their burn injuries debrided and dressed in a wet wound care environment on Study Day 1, and 13 also participated in Study Day 2., Intervention: The study used a within-subject design to test two hypotheses (one hypothesis per study day) with the condition order randomized. On Study Day 1, each individual (n = 44 participants) spent 5 min of wound care in an interactive immersive VR environment designed for burn care, and 5 min looking at still nature photos and sounds of nature in the same VR goggles. On Study Day 2 (n = 12 adult participants and one adolescent from Day 1), each participant spent 5 min of burn wound care with no distraction and 5 min of wound care in VR, using a new water-friendly VR system. On both days, during a post-wound care assessment, participants rated and compared the pain they had experienced in each condition. OUTCOME MEASURES ON STUDY DAYS 1 AND 2: Worst pain during burn wound care was the primary dependent variable. Secondary measures were ratings of time spent thinking about pain during wound care, pain unpleasantness, and positive affect during wound care., Results: On Study Day 1, no significant differences in worst pain ratings during wound care were found between the computer-generated world (Mean = 71.06, SD = 26.86) vs. Nature pictures conditions (Mean = 68.19, SD = 29.26; t < 1, NS). On secondary measures, positive affect (fun) was higher, and realism was lower during computer-generated VR. No significant differences in pain unpleasantness or "presence in VR" between the two conditions were found, however. VR VS. NO VR. (STUDY DAY 2): Participants reported significantly less worst pain when distracted with adjunctive computer generated VR than during standard wound care without distraction (Mean = 54.23, SD = 26.13 vs 63.85, SD = 31.50, t(11) = 1.91, p < .05, SD = 17.38). In addition, on Study Day 2, "time spent thinking about pain during wound care" was significantly less during the VR condition, and positive affect was significantly greater during VR, compared to the No VR condition., Conclusion: The current study is innovative in that it is the first to show the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults. However, contrary to predictions, interactive VR did not reduce pain more effectively than nature stimuli viewed in the same VR goggles., (Copyright © 2022 Elsevier Ltd and International Society of Burns Injuries. All rights reserved.)

Objective: To determine the importance of preburn adjustment, injury-related variables, and selection of coping style in various outcome measures using a biopsychosocial model., Design: Longitudinal study., Setting: Outpatient burn clinics., Participants: Burn survivors (N=231) who participated in this study as part of a larger burn model system study of 645 patients with major burn injuries., Interventions: Not applicable., Main Outcome Measures: The 36-Item Short-Form Health Survey was used to assess preburn adjustment. Other outcome measures entered into the model included the Ways of Coping Checklist Revised, the Brief Symptom Inventory, the Beck Depression Inventory-II, and the Davidson Trauma Scale., Results: Correlational and mediational analyses revealed that preburn emotional health predicted better adjustment at year 1 and more posttraumatic stress disorder symptoms at year 2. Better preburn emotional health was also related to less use of avoidance coping strategies, which was found to be a mediator of the effect of preburn emotional health and posttraumatic stress disorder symptoms. Burn injury characteristics were not significantly associated with psychological adjustment at either year 1 or year 2., Conclusions: The results indicate that there is a complex relation between premorbid mental health and the selection of coping strategies that affect long-term adjustment in persons recovering from a burn injury. This relation seems to have greater effect on long-term outcomes than does preburn emotional or physical health alone or the severity of the burn., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: We conducted a randomized controlled study to determine the effects of virtual reality (VR) distraction on pain and range of motion (ROM) in patients hospitalized for burn care during active physical therapy exercises., Method: Thirty-nine participants aged 15 to 66 (M = 36) years with significant burn injuries (mean burn size = 14% TBSA) participated. Under therapist supervision, using a within-subjects design, participants performed unassisted active ROM exercises both with and without VR distraction in a randomized order. Therapists provided participants with instructions but did not physically assist with stretches. Maximum active ROM was measured using a goniometer. A 0-100 Graphic Rating Scale (GRS) was used to assess the cognitive, affective, and sensory components of pain. A GRS rating of the amount of "fun" during stretching served as a measure of positive experience., Results: Participants reported lower mean GRS ratings during VR, relative to No VR, for worst pain, pain unpleasantness, and time spent thinking about pain. They also reported having a more positive experience during VR than during No VR. However, patients did not show greater ROM during VR., Conclusion: Immersive VR reduced pain during ROM exercises that were under the control of the patient. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

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

The current study explored whether immersive virtual reality (VR) continues to reduce pain (via distraction) during more than one wound care session per patient. Thirty-six patients aged 8 to 57 years (mean age, 27.7 years), with an average of 8.4% TBSA burned (range, 0.25-25.5 TBSA) received bandage changes, and wound cleaning. Each patient received one baseline wound cleaning/debridement session with no-VR (control condition) followed by one or more (up to seven) subsequent wound care sessions during VR. After each wound care session (one session per day), worst pain intensity was measured using a visual analog thermometer, the dependent variable. Using a within-subjects design, worst pain intensity during wound care with no-VR (baseline, day 0) was compared with pain during wound care while using immersive VR (up to 7 days of wound care during VR). Compared with pain during no-VR baseline (day 0), pain ratings during wound debridement were statistically lower when patients were in VR on days 1, 2, and 3, and although not significant beyond day 3, the pattern of results from days 4, 5, and 6 are consistent with the notion that VR continues to reduce pain when used repeatedly. Results from the present study suggest that VR continues to be effective when used for three (or possibly more) treatments during severe burn wound debridement.

Introduction: Excessive pain during medical procedures is a widespread problem but is especially problematic during daily wound care of patients with severe burn injuries., Methods: Burn patients report 35-50% reductions in procedural pain while in a distracting immersive virtual reality, and fMRI brain scans show associated reductions in pain-related brain activity during VR. VR distraction appears to be most effective for patients with the highest pain intensity levels. VR is thought to reduce pain by directing patients' attention into the virtual world, leaving less attention available to process incoming neural signals from pain receptors., Conclusions: We review evidence from clinical and laboratory research studies exploring Virtual Reality analgesia, concentrating primarily on the work ongoing within our group. We briefly describe how VR pain distraction systems have been tailored to the unique needs of burn patients to date, and speculate about how VR systems could be tailored to the needs of other patient populations in the future.

This randomized, controlled, within-subjects (crossover design) study examined the effects of immersive virtual reality as an adjunctive analgesic technique for hospitalized pediatric burn inpatients undergoing painful physical therapy. Fifty-four subjects (6-19 years old) performed range-of-motion exercises under a therapist's direction for 1-5 days. During each session, subjects spent equivalent time in both the virtual reality and the control conditions (treatment order randomized and counterbalanced). Graphic rating scale scores assessing the sensory, affective, and cognitive components of pain were obtained for each treatment condition. Secondary outcomes assessed subjects' perception of the virtual reality experience and maximum range-of-motion. Results showed that on study day one, subjects reported significant decreases (27-44%) in pain ratings during virtual reality. They also reported improved affect ("fun") during virtual reality. The analgesia and affect improvements were maintained with repeated virtual reality use over multiple therapy sessions. Maximum range-of-motion was not different between treatment conditions, but was significantly greater after the second treatment condition (regardless of treatment order). These results suggest that immersive virtual reality is an effective nonpharmacologic, adjunctive pain reduction technique in the pediatric burn population undergoing painful rehabilitation therapy. The magnitude of the analgesic effect is clinically meaningful and is maintained with repeated use., (Copyright © 2010 Elsevier Ltd and ISBI. All rights reserved.)

Few studies have empirically investigated the effects of immersive virtual reality (VR) on postburn physical therapy pain control and range of motion (ROM). We performed a prospective, randomized controlled study of the effects of adding VR to standard therapy in adults receiving active-assisted ROM physical therapy, by assessing pain scores and maximal joint ROM immediately before and after therapy on two consecutive days. Thirty-nine inpatients, aged 21 to 57 years (mean 35 years), with a mean TBSA burn of 18% (range, 3-60%) were studied using a within-subject, crossover design. All patients received their regular pretherapy pharmacologic analgesia regimen. During physical therapy sessions on two consecutive days (VR one day and no VR the other day; order randomized), each patient participated in active-assisted ROM exercises with an occupational or physical therapist. At the conclusion of each session, patients provided 0 to 100 Graphic Rating Scale measurements of pain after each 10-minute treatment condition. On the day with VR, patients wore a head-position-tracked, medical care environment-excluding VR helmet with stereophonic sound and interacted in a virtual environment conducive to burn care. ROM measurements for each joint exercised were recorded before and after each therapy session. Because of nonsignificant carryover and order effects, the data were analyzed using simple paired t-tests. VR reduced all Graphic Rating Scale pain scores (worst pain, time spent thinking about the pain, and pain unpleasantness by 27, 37, and 31% respectively), relative to the no VR condition. Average ROM improvement was slightly greater with the VR condition; however, this difference failed to reach clinical or statistical significance (P = .243). Ninety-seven percent of patients reported zero to mild nausea after the VR session. Immersive VR effectively reduced pain and did not impair ROM during postburn physical therapy. VR is easily used in the hospital setting and offers a safe, nonpharmacologic adjunctive analgesic treatment.

Objective: Little is known about how pain and depression after burn injury may influence long-term outcomes such as physical functioning. This prospective study examined associations between pain, depression, and physical functioning in a sample of burn injury survivors., Design and Participants: Questionnaires assessing pain, depression, and physical functioning were completed by 64 (52% of original sample) adult burn survivors shortly after discharge from burn care and at 1- and 2-year follow-ups., Results: Pain and physical functioning improved over the 2 years of the study, whereas depression levels were stable. Pain and depression were associated with poorer physical functioning over time, but associations varied according to the time span under consideration. Also, the association between pain and physical functioning was strongest among persons with higher depression scores., Conclusions: Pain and depression may contribute independently to compromises in physical functioning. The co-occurrence of pain and depression represents even greater risk for reduced physical functioning over time among burn survivors., ((PsycINFO Database Record (c) 2009 APA, all rights reserved).)

Reasons for distress after burn injuries have not been codified based on any type of acceptable empirical or statistical technique. The unique design methodology proposed in this study can identify the most common reasons cited for causing distress in burn survivors after discharge. A Q-sort task was developed with the assistance of our burn advisory group. After identifying 50 possible reasons for distress after discharge, each reason was placed on a laminated game card. In compliance with Qmethodology, a game board was developed that allowed patients to rank order each reason from "not causing distress" to "causing significant distress." A total of 69 burn survivors were enrolled in the study at four different time points: 1 month, 6 months, 1 year and 2 years postdischarge. After factor analysis, four factors accounted for all of the participants across time points. This indicates that at least four distinct groups of people can be categorized according to themes raised in rating reasons for distress. This Q-sort technique allowed us to capture the complexity of conceptualizing human distress by categorizing clusters of reported problems into similar groups. This methodology shows great promise for developing interventions that target unique needs of burn survivors.

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 repetitive performance - often on a daily basis for weeks to months - of painful and anxiety-provoking procedures that create additional treatment-related pain, such as wound care, dressing changes and rehabilitation activities. Pain management in burn patients is primarily achieved by potent pharmacologic analgesics (e.g., opioids), but is necessarily complemented by nonpharmacologic techniques, including distraction or hypnosis. Immersive virtual reality provides a particularly intense form of cognitive distraction during such brief, painful procedures, and has undergone preliminary study by several research groups treating burn patients over the past decade. Initial reports from these groups are consistent in suggesting that immersive virtual reality is logistically feasible, safe and effective in ameliorating the pain and anxiety experienced in various settings of post-burn pain. Furthermore, the technique appears applicable to a wide age range of patients and may be particularly well-adapted for use in children, one of the most challenging populations of burn victims to treat. However, confirmation and extension of these results in larger numbers of patients in various types of burn-related pain is necessary to more clearly define the specific benefits and limitations of virtual reality analgesia in the burn care setting.

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.

Burn injuries and their subsequent treatment cause one of the most excruciating forms of pain imaginable. Practitioners in the field have been concerned about the suboptimal management of acute pain in this population. Recent studies have shown that greater levels of acute pain are associated with negative long-term psychologic effects such as depression, suicidal ideation, and post-traumatic stress disorder for as long as 2 years after the initial burn injury. Research in other non-burn trauma populations has also pointed to the potential for unmanaged acute pain to delay wound healing and lead to other medical complications, such as infection and extended hospitalization period. The concept of allostatic load is presented as a potential explanation for the relationship between acute pain and subsequent psychologic and physiologic outcomes. A biopsychosocial model is also presented as a means of obtaining better inpatient pain management and helping to mediate this relationship.

The NIDRR burn injury rehabilitation model system program: selected findings. The quality of burn care has improved over the past few decades, and consequently many more survivors with large-area burn injuries have long-term rehabilitation needs. The National Institute on Disability Rehabilitation Research recognized that the rehabilitation of people with burn injuries has been underaddressed and established model systems of care for this population in 1994. This special supplement to the Archives of Physical Medicine and Rehabilitation reports on some of the research that has been generated by the Burn Rehabilitation Model Systems over the past 13 years.

Objective: To determine the extent to which pain contributes to risk for suicidal ideation after burn injury., Design: This longitudinal cohort study evaluated participants at discharge, 6 months, and 1 year after burn injury., Setting: Inpatient rehabilitation units of multiple regional burn centers., Participants: Survivors of major burns (N=128)., Interventions: Not applicable., Main Outcome Measures: Pain severity, assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain subscale, and passive and active suicidal ideation, assessed by self-report., Results: At each time point, approximately one quarter to one third of the sample reported some form of suicidal ideation. In logistic regression analyses, pain severity at discharge was the sole consistent predictor of suicidal ideation at follow-up, with greater pain severity being associated with enhanced risk for both passive and active suicidal ideation. These associations were observed even after controlling for discharge mental health., Conclusions: These are the first findings to suggest an association between acute pain severity and the development and maintenance of suicidal ideation in burn patients. Further research in this area, including the study of improved pain management programs as a prophylaxis against suicidal ideation, may benefit those who are at elevated suicide risk as a consequence of burn injuries.

Objective: To assess the efficacy and side effects of immersive virtual reality (VR) distraction analgesia, as well as patient factors associated with VR analgesic efficacy in burn patients who require passive range-of-motion (ROM) physical therapy (PT)., Design: Prospective, randomized, controlled, within-subject trials., Setting: Regional level I burn center in a university-affiliated urban hospital., Participants: Patients (age range, 6-65y) who required passive ROM PT in sessions lasting 3 to 15 minutes after cutaneous burn injury., Interventions: Standard analgesic (opioid and/or benzodiazepine) care and standard analgesic care plus immersive VR distraction., Main Outcome Measure: Self-reported subjective pain ratings (0 to 100 graphic rating scale)., Results: A total of 146 treatment comparisons were made in 88 subjects, 75% of whom were children ages 6 to 18 years. Compared with standard analgesic treatment alone, the addition of VR distraction resulted in significant reductions in subjective pain ratings for worst pain intensity (20% reduction), pain unpleasantness (26% reduction), and time spent thinking about pain (37% reduction). Subjects' age, sex, ethnicity, size of initial burn injury, or duration of therapy session did not affect the analgesic effects of VR distraction. Nausea with the standard care plus VR distraction condition was infrequent (15%) and mild, with 85% of the subjects reporting no nausea. Children provided higher subjective reports of "presence" in the virtual environment and "realness" of the virtual environment than did adults, but age did not affect the analgesic effects of VR distraction., Conclusions: When added to standard analgesic therapy, VR distraction provides a clinically meaningful degree of pain relief to burn patients undergoing passive ROM PT. Multiple patient factors do not appear to affect the analgesic effect. Immersive VR distraction is a safe and effective nonpharmacologic technique with which to provide adjunctive analgesia to facilitate patient participation in rehabilitation activities.

Background: The adverse consequences of burn injuries include pain and psychological distress, which show bidirectional associations. However, much of the existing research has relied on global measures of distress that do not separate distinct symptoms of anxiety and depression., Purpose: The purpose is to assess the prospective effects of anxiety and depression on pain and functional outcomes following burn injury., Methods: This article describes a 2-year cohort study in patients hospitalized for serious burn injuries (assessments at discharge and 6-month, 1-year, and 2-year follow-up). Linear mixed effects analyses were conducted to model anxiety and depression's unique longitudinal effects; at each time point, depressive and anxiety symptoms were studied as predictors of subsequent changes in pain, fatigue, and physical function., Results: When studied in separate prediction models, both depression and anxiety were strong prospective predictors of greater pain, more fatigue, and physical dysfunction at the subsequent time point (ps < .01). However, when both were included in a single model to study their unique effects, depressive symptoms (but not anxiety) emerged as a significant predictor of subsequent increases in pain and reductions in physical functioning, whereas anxiety (but not depression) predicted subsequent elevations in fatigue., Conclusions: These findings suggest potentially distinct effects of depression and anxiety and imply that assessment and early treatment of both depressive and anxiety symptoms may help improve a broad range of long-term pain-related outcomes following burn injury.

Objective: To track the prevalence and stability of clinically significant psychological distress and to identify potentially modifiable in-hospital symptoms predictive of long-term distress (physical, psychological, and social impairment)., Method: We obtained data from the Burn Model Systems project, a prospective, multisite, cohort study of major burn injury survivors. The Brief Symptom Inventory (BSI) was used to assess symptoms in-hospital (n = 1232) and at 6 (n = 790), 12 (n = 645), and 24 (n = 433) months post burn. Distress was examined dimensionally (BSI's Global Severity Index (GSI)) and categorically (groups formed by dichotomizing GSI: T score > or =63). Attrition was unrelated to in-hospital GSI score., Results: Significant in-hospital psychological distress occurred in 34% of the patients, and clinically significant and reliable change in symptom severity by follow-up visits occurred infrequently. Principal components analysis of in-hospital distress symptoms demonstrated "alienation" and "anxiety" factors that robustly predicted distress at 6, 12, and 24 months, controlling for correlates of baseline distress., Conclusions: This is the largest prospective, multisite, cohort study of patients with major burn injury. We found that clinically significant in-hospital psychological distress was common and tends to persist. Two structural components of in-hospital distress seemed particularly predictive of long-term distress. Research is needed to determine if early recognition and treatment of patients with in-hospital psychological distress can improve long-term outcomes.

The purpose of this investigation was to examine the amount of anxiety patients believed tolerable and the amount of anxiety experienced during routine burn wound care. Participants included 47 hospitalized adults who provided data for four consecutive assessment periods. Patients (mean TBSA, 16%; range, 2-70%) were primarily Caucasian (87%) and had an average hospital stays of 23 days (range, 11-130). Reports of what level of anxiety they would be able to tolerate and what level of anxiety had been experienced were assessed using 10-point Graphic Rating Scales. The use of anxiolytic was recorded, and patient suggestions for reducing anxiety were obtained. The single most commonly endorsed anxiety treatment goal was 0, although 53% consistently chose a treatment goal other than 0 (range, 1-6). Two repeated-measure analyses of variance indicated that the amount of anxiety patients could tolerate and the amount they reported experiencing did not change over the course of time. Paired t-tests revealed that patients routinely reported more anxiety than they considered tolerable. Analyses of anxiety reports of patients treated with anxiolytics (n = 6) vs patients receiving no anxiolytics (n = 41) revealed inconsistent differences in actual anxiety and treatment goals across time. In general, patient suggestions for lessening anxiety included requests for education, communication, additional medications, and manipulation of the hospital environment. Anxiety for burn-injured, hospitalized adults remains a concern. Our findings are consistent with the literature indicating that adult patients hospitalized for burn wound care report appreciable anxiety, over and above what they consider "tolerable." Continued research is needed and should include investigations into the relationship between pain and anxiety during routine wound care.

Acute pain after medical procedures is often undertreated, opioid analgesics are used far too sparingly, and patients are forced to suffer needlessly as a result. Attempts to change health care practitioner behavior in the area of pain control are often futile. The purpose of the current study was to provide empirical evidence that supports the deleterious impact of acute pain. A prospective, longitudinal study was designed to assess the impact of pain during burn hospitalization on postdischarge follow-up of 122 patients. A composite score of patient ratings of procedural pain during hospitalization was composed. Regression analyses were used to compare the extent to which pain predicted long-term adjustment relative to potential competing variables such as the length of hospitalization, preinjury adjustment, and coping style. Pain during hospitalization was significantly associated with psychological adjustment at 1-month (53% return), 1-year (46% return) and 2-year (33% return) follow-up. Regression analyses indicate that pain was a stronger predictor than the size of the burn or length of hospitalization, and that this correlation could not be attributed to the patients' preinjury mental health history or coping style (for the 1-month and 1-year follow-up periods). Pain during hospitalization had a significant and enduring relationship with adjustment after burn injuries. Although causality cannot be definitively determined, the study findings provided compelling evidence for the value of controlling acute pain during hospitalization.

This study is the first to use virtual-reality technology on a series of clinical patients to make hypnotic analgesia less effortful for patients and to increase the efficiency of hypnosis by eliminating the need for the presence of a trained clinician. This technologically based hypnotic induction was used to deliver hypnotic analgesia to burn-injury patients undergoing painful wound-care procedures. Pre- and postprocedure measures were collected on 13 patients with burn injuries across 3 days. In an uncontrolled series of cases, there was a decrease in reported pain and anxiety, and the need for opioid medication was cut in half. The results support additional research on the utility and efficacy of hypnotic analgesia provided by virtual reality hypnosis.

This prospective, longitudinal study examined the influence of baseline physical and psychological burden on serial assessments of health-related quality of life among adults with major burns from three regional burn centers (n = 162). Physical burden groups were defined by % TBSA burned: <10%, 10% to 30%, or >30%. Psychological burden groups were defined by in-hospital distress using the Brief Symptom Inventory Global Severity Index T-score with scores of < 63 or > or = 63. Analyses compared groups across level of burden and with published normative data. Assessments reflected health and function (Short Form 36) during the month before burn, at discharge, and at 6 and 12 months after burn. Physical functioning was significantly more impaired and the rate of physical recovery slower among those with either large physical burden or large psychological burden. Notably, psychosocial functioning also was more impaired and the rate of psychosocial recovery slower among those with greater psychological burden. These results suggest that, in addition to aggressive wound closure, interventions that reduce in-hospital distress may accelerate both physical and psychosocial recovery.

Sleep disorders are a frequent but under-addressed complication of burn injuries. Burn injuries can potentially disrupt sleep for a variety of reasons, including the physiological effects of trauma as well as ramifications of treatment (ie, intensive care unit environment, pain, itching, medications). The literature on sleep disorders and burn injuries is reviewed, and suggestions for treatment are provided. Treatment is divided into two major types: nonpharmacologic and pharmacologic. Nonpharmacologic treatment, also referred to as behavioral techniques, may include any one or combination of the following: sleep hygiene, stimulus control, sleep restriction, relaxation techniques, cognitive, and light therapy. Pharmacologic therapies may include hypnotics (benzodiazepine, nonbenzodiazepine, or benzodiazepine receptor agonists), antidepressants, over-the-counter preparations, hormone replacement therapy, herbs, and melatonin.

Recent research suggests that entering an immersive virtual environment can serve as a powerful nonpharmacologic analgesic for severe burn pain. The present case study describes an attempt to use water-friendly virtual reality (VR) technology with a burn patient undergoing wound care in a hydrotherapy tub. The patient was a 40-year-old male with 19% total body surface area deep flame/flash burns to his legs, neck, back, and buttocks. The virtual reality treatment decreased the patient's sensory and affective pain ratings and decreased the amount of time spent thinking about his pain during wound care. We believe that VR analgesia works by drawing attention away from the wound care, leaving less attention available to process incoming pain signals. The water-friendly VR helmet dramatically increases the number of patients with severe burns that could potentially be treated with VR (see http://www.vrpain.com)., (Copyright 2003 Wiley Periodicals, Inc.)

This preliminary case report explored the use of hypnosis induced through a 3-dimensional, immersive, computer-generated virtual reality (VR) world as a means to control pain and anxiety in a patient with a severe burn injury. On hospitalization Day 40, after reports of uncontrollable pain and anxiety, the patient underwent hypnotic induction while immersed in a virtual world and received posthypnotic suggestions for decreased pain and anxiety during subsequent wound-care sessions. The patient's pain and anxiety each dropped 40% after VR hypnosis on a Graphic Rating Scale for his Day 41 wound care. Pain dropped similar levels on Day 42 with an audio-only version of the intervention and then returned to baseline without intervention on Day 43.

Impairment rating is regularly reported for trauma and other conditions but rarely for burns. The purposes of this study were: (1) to report impairment collected prospectively at our burn center, (2) to relate this impairment to measures of psychosocial and functional outcome, and (3) to compare these data to similar data from another burn center to verify that rating impairment is standardized and that the impairments are similar. We studied 139 patients from the University of Washington (UW) Burn Center and 100 patients from the University of Texas (UT) Southwestern Burn Center. The average whole person impairment (WPI) ratings at the University of Washington were 17% and this correlated with total body surface area burned and days off work. It did not correlate with Brief Symptom Inventory (BSI), Functional Independence Measure (FIM), Short-Form 36-Item Health Survey (SF-36), Satisfaction With Life Scale (SWLS), and the Community Integration Questionnaire (CIQ). Average whole person impairment ratings at UT Southwestern were similar at 19%. Several components of the impairment rating, however, differed at the two institutions. To minimize this variation, we recommend: (1) use the skin impairment definitions of the fifth edition of the Guides to the Evaluation of Permanent Impairment (or the most recent published versions of the Guide), and (2) include sensory impairment in healed burns and skin grafts in the skin impairment.

The presence of psychiatric problems in burn patients has been found to have an impact on their burn care and long-term adjustment. This study investigated rates of previous mental health symptoms in a sample of 199 hospitalized burn patients screened for previous psychiatric diagnoses. Patients were instructed to fill out a questionnaire about their mental health functioning on the Rand Inventory for the month preceding their burn injury. Scores compared with a national normative sample on the Rand Mental Health Inventory revealed that burn patients scored higher on psychological distress, anxiety, depression, and loss of behavioral and emotional control. These results reflect other studies in the literature, indicating that burn patients are premorbidly more psychologically vulnerable than the general population, a factor that likely contributes to many of them sustaining their injuries.

Procedural and background pain scores were assessed prospectively and compared with treatment goals and satisfaction scores in 84 adult (67 men and 17 women) burn-injured patients treated at a single, tertiary care medical center. We hypothesized that patient satisfaction with pain management plans would be highest among those patients who were experiencing the least pain and also among patients whose experiences most closely matched their treatment analgesic goals. Twice-weekly patient self-reports of worst and average procedural pain, background pain, treatment goals (the level of procedural pain and background pain patients reported that they would be satisfied as experiencing), and overall satisfaction with pain management plans were assessed using 10-point Graphic Rating Scales. Data concerning adjunctive treatments were also obtained. Opioid equivalents, representing pain medications administered, were compared. The majority of patients perceived that "no pain" during burn wound care was an unrealistic goal, a perception that was consistent throughout hospitalization. As hypothesized, average procedural pain levels demonstrated a negative association with patient satisfaction, indicating that patients with the highest levels of procedural pain also reported the lowest level of satisfaction. Opioid analgesic dosing was not significantly associated with ratings of procedural pain or treatment goals. Our findings support the hypothesis that patient satisfaction with pain management is highest in those who experience the least amount of burn care pain and do not support the hypothesis that satisfaction is highest in those whose pain experiences most closely match treatment analgesic goals.

This study investigated pediatric pain control practices in North American Burn Centers using a mail-in survey. Questions were asked regarding pain control practices, pain assessment methods, and perceived treatment efficacy for inpatients and outpatients in four age groups. Eighty-two centers responded with 111 surveys. Intravenous morphine was the most frequently used analgesic for wound care pain. The most common background pain medications were intravenous morphine, acetaminophen with codeine, and acetaminophen alone. The use of long-acting medications increased with increasing age. Additional areas reported in the text include nonpharmacologic and pharmacologic adjuvants, treatment of itching, pain assessment, outpatient pain management, and efficacy of pain control and assessment practices. There have been great advances in pediatric burn pain control and assessment in recent years, but room for improvement remains. This study provides a basis for evaluation and comparison among burn centers. It further highlights areas that may warrant additional study and intervention.

Very little has been published on treating acute pain in children younger than the age of 3 for burns or any other trauma etiology. This study prospectively monitored the pain behavior and opioid analgesic intake of 31 pediatric burn patients (mean age = 23.71 months; SD = 15.75). Twelve of those children were randomized to conditions in which they either received opioid analgesics pro re nata (ie, as needed, pain contingent) or on a regular basis. The two groups did not show differences in demonstrable pain but, interestingly, they received equivalent does of opioid analgesics. As such, the pro re nata group was likely medicated largely on a regularly scheduled basis. For most of the remaining (nonrandomized) subjects, physicians ordered regularly scheduled opioid analgesics, suggesting that this practice has become largely institutionalized in the study setting. Information on pediatric opioid analgesic dosing and pain measurement strategies for nonverbal subjects can be derived from the findings.

A burn survivor may provide unique psychological support to patients who have been burned more recently and enhance their adjustment to burn injury. The purpose of this study was to describe the peer consultation/burn survivor support program at a large regional burn center in the Northwest United States. Over the course of 17 months, three specially trained peer consultants who had survived their own burn injuries in the past made 167 visits to 108 patients, who, in turn, completed evaluation forms for each visit. Findings indicated that patients reported that the peer consultants approached them in an appropriate manner, answered their questions, and provided useful support and information.

In this investigation the authors collected data regarding trait anxiety, well-being, and depression from 209 men and women who had been screened for prior psychiatric diagnosis and treated in an acute-care setting for burn injuries. Well-being was measured in reference to the month before the burn injury, whereas level of depression was self-rated by patients within 2 days of hospitalization, 5 days later, and 5 days after that. Ratings of depression were also obtained 1 month after hospital discharge. Results indicated that few patients rated their depression as severe at any point in time. Depression scores decreased significantly across the hospitalization period and were correlated with burn size, trait anxiety, and well-being. Depression ratings after discharge were significantly related to depression scores obtained at the end of the inpatient phase of the study. Although most patients did not report experiencing severe levels of depression, the stability of scores across time suggests the usefulness of early screening procedures. Catching such problems early may head off longer-term difficulties.

This study describes sleep disturbance and related factors in a group of 74 patients at 1 week after discharge using a sleep problems questionnaire developed by the authors. Results indicated that a significant proportion of patients reported a problem with their sleep (73%). Several items were identified as highly prevalent, including frequent nighttime awakenings (87%), napping during the daytime (65%), sleeping alone (64%), experiencing pain during the night (62%), and difficulties with sleep onset (62%). Results suggest numerous possible interventions to improve patients' sleep quality. The usefulness of a more extensive questionnaire was also indicated.

It is commonly assumed that patients hospitalized for burn treatment will experience some level of depression. However, little is known about the trends in severity of depression over time. The purpose of this study was to determine the rates and severity of depression over a 2-year period. The Beck Depression Inventory was administered at 1 month (N = 151), 1 year (N = 130), and 2 years (N = 125) after discharge. At 1 month, 54% of patients showed symptoms of moderate to severe depression, and at 2 years, 43% of the patients responding still reported moderate to severe depression. The average correlation between scores over time was high. Women had higher depression scores than men at each time period. An interaction between gender and having a head or neck injury was also observed at 1 month and 1 year after discharge. Results suggest that routine outpatient screening for depression is warranted.

Patients treated for burn injuries commonly experience high levels of acute pain and anxiety during hospitalization, particularly as it relates to their dressing changes and other medical procedures. A new instrument, the burn specific pain anxiety scale (BSPAS), was designed to characterize patient's anxiety in this setting, but its predictive validity in relation to other measures of anxiety has yet to be demonstrated. In this study, 27 patients with acute burn injuries completed three measures of anxiety upon admission to a major medical burn trauma center. Scores on the anxiety measures were compared with regard to their ability to predict subsequent ratings of procedural and background pain levels, pain medication usage, and physical and emotional functioning upon discharge. In support of criterion-related validity, the BSPAS was the best predictor of procedural pain levels as rated later the same day relative to the other global anxiety measures; moreover, the BSPAS did not predict later-day background pain levels as hypothesized. Both the BSPAS and the global anxiety measures were found to significantly predict total number of pain medications over a 24-h period. Finally, the BSPAS was the only significant predictor of decreased physical role functioning at discharge whereas the other more global measures of anxiety were better predictors of emotional functioning. These results provide preliminary evidence that the BSPAS is a unique and valid indicator of pain-related anxiety surrounding burn care in hospitalized patients and may be useful in identifying those patients at risk for decreased functional capacity at the time of discharge.

We investigated ratings of emotional distress and satisfaction with life at discharge from the hospital and at a 6-month follow-up in a multisite sample of 295 adults hospitalized for the care of a major burn injury. Several psychosocial variables (history of alcohol abuse, marital status, and previous mental health) and some medical variables (days of intensive care, pulmonary complications, and hand burns) accounted for significant variance in the prediction of outcomes. Brief Symptom Inventory (distress) scores were higher and Satisfaction With Life Scale scores were significantly lower than those of a normative population at both measurement points. The results show the utility of biosocial models in which psychological and physical variables interact to influence adjustment and quality of life.

The pain involved in acute burn care can be excruciating and intractable. Even the best pharmacologic pain control efforts often fail to adequately control pain, especially procedure-related pain, in pediatric patients with burn injuries. Nonpharmacologic interventions have been found to be effective in reducing pain in both children and adults and can be extremely important adjuvants to standard pharmacologic analgesia in the burn care setting. In the first article in this series, we outlined psychological factors that influence the emotions, cognitions, and behaviors of children during wound care. Building on this theoretical framework, we now present a detailed discussion of the implementation of nonpharmacologic intervention strategies in the burn care setting. Because accurate measurement of discomfort is imperative for the development of interventions and for the evaluation of their efficacy, we begin with a brief review of pain measurement techniques. We follow this with suggestions for tailoring interventions to meet specific patient needs and conclude with a detailed and practical discussion of specific intervention techniques and the implementation of those techniques.

Objective: The pain experienced by burn patients during physical therapy range of motion exercises can be extreme and can discourage patients from complying with their physical therapy. We explored the novel use of immersive virtual reality (VR) to distract patients from pain during physical therapy., Setting: This study was conducted at the burn care unit of a regional trauma center., Patients: Twelve patients aged 19 to 47 years (average of 21% total body surface area burned) performed range of motion exercises of their injured extremity under an occupational therapist's direction., Intervention: Each patient spent 3 minutes of physical therapy with no distraction and 3 minutes of physical therapy in VR (condition order randomized and counter-balanced)., Outcome Measures: Five visual analogue scale pain scores for each treatment condition served as the dependent variables., Results: All patients reported less pain when distracted with VR, and the magnitude of pain reduction by VR was statistically significant (e.g., time spent thinking about pain during physical therapy dropped from 60 to 14 mm on a 100-mm scale). The results of this study may be examined in more detail at www.hitL.washington.edu/projects/burn/., Conclusions: Results provided preliminary evidence that VR can function as a strong nonpharmacologic pain reduction technique for adult burn patients during physical therapy and potentially for other painful procedures or pain populations.

A prerequisite for studying and treating burn-related pain is the establishment of a good understanding of the nature of burn-related pain. However, in most investigations of pain, researchers have failed to examine pain over time or to create summary scores that capture differences in the nature of the pain experiences of individual patients. For 10 consecutive days, 47 patients treated for burn injuries reported on three aspects of procedural pain: worst pain, sensory pain, and affective pain. Three summary pain scores were constructed for each pain dimension: average pain, variability in pain, and linear change in pain. The authors found considerable variability in pain reports from the same patient and from different patients. Analyses indicated that pain reports decreased over time and that patients who had more trait anxiety reported more pain. Patients with larger burn injuries tended to report more affective pain and tended to have a pattern of high and low pain reports that differed from patients with less severe burn injuries. These findings suggest that adequate assessment of burn pain must occur frequently over the course of a single day, as well as for the duration of each patient's care.

Burn injuries and the care of burn injuries are punishing experiences for hospitalized children. Pain, novelty, and altered reinforcement schedules elicit instinctive escape and avoidance behaviors that complicate wound care. An understanding of the psychological principles that underlie these complex, complicating behaviors paves the way for effective cognitive and behavioral interventions. In this first article of a two-part series, we use the principles of classical conditioning, operant conditioning, and control coping to describe the developmentally normal emergence of avoidance behaviors that are incompatible with burn wound care. Then, using brief case examples, we outline how classical conditioning transforms neutral stimuli into anxiety-producing, fearful stimuli, how operant behaviors are intentionally or unintentionally reinforced, and how the umbrella of reduced control in the novel hospital environment makes coping difficult for children. We conclude by discussing obstacles to effective application of cognitive and behavioral strategies for the enhancement of control and of compliance with wound care.

For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16-year-old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17-year-old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care). We contend that VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.

The occurrence and predictors of post-traumatic stress symptoms 1 year after a burn injury were assessed in a large prospective sample (N = 172). Participants completed a self-report post-traumatic stress symptom checklist at 3 time points: within 24 hours of admission to a burn center, 1 month after the injury, and 1 year after the injury. A notable number of participants had a range of post-traumatic stress symptoms both at 1 month and at 1 year after the burn injury. More than half of the sample reported recurrent intrusive recollections of the burn injury at 1 month and at 1 year. Other commonly endorsed symptoms were sleep disturbance, avoidance of thoughts or feelings associated with the burn, and distress at reminders of the burn. The number of post-traumatic stress symptoms endorsed at 1 month was the only significant predictor of post-traumatic stress symptoms at 1 year. These results suggest that it is common for patients to have some post-traumatic symptoms 1 year after a burn injury and that early experiences of post-traumatic stress symptoms may be associated with the development or maintenance of post-traumatic stress disorder. We recommend that burn care professionals identify and intervene with patients who have clinically significant distress as a result of their burn injuries.

The occurrence and predictors of acute post-traumatic stress symptoms were assessed in a large, prospective sample of persons with new burn injuries (N = 172). Participants completed a self-report post-traumatic stress symptom checklist, pain ratings, and a premorbid mental health inventory within 24 h of admission to a burn center (Day 1). Over half of the sample reported sleep disturbance and recurrent, intrusive recollections of the burn injury on Day 1. Other commonly endorsed symptoms were difficulties concentrating, avoidance of thoughts/feelings associated with the burn, flashbacks, and exaggerated startle response. Persons with less favorable premorbid mental health and larger burns reported a greater number of stress symptoms on Day 1. These results suggest that experiencing some post-traumatic stress symptoms immediately following a burn trauma is normal. It is recommended that burn care professionals identify and intervene with patients who are suffering clinically significant distress early in the hospitalization.

The purpose of the current study was to examine the rates of family and child dysfunction in a prospectively, consecutively admitted sample of children. One hundred eleven parents of children consecutively admitted for burn treatment were interviewed using a demographic questionnaire during their child's stay. Results of the questionnaire indicated that in 36% of the families, at least one parent reported significant dysfunction (history of substance abuse, involvement with Child Protective Services, incarceration, or psychiatric history). Results also indicated that 29% of the children over the age of 4 years had significant dysfunction (physical or sexual abuse, or both, psychiatric disorder, behavior problems, or learning disability. It was concluded that (1) parents of children with burns had a substantially high rate of dysfunction, (2) psychologic and preventive interventions should be focused on parents as well as children, and (3) burn injuries often should be regarded as a symptom rather than a cause of psychosocial problems in the family.

Three children younger than 5 with minor burns (< 5% total body surface area) experienced opiate-induced respiratory depression early in hospitalization. This prompted a decrease in the recommended opiate analgesic-dose ranges on our pediatric worksheet. In reviewing 57 admissions, 31 pre- and 26 post-dose change, the amount of opioid equivalents/kg received on admission day did not differ significantly. However, the incidence of respiratory depressive events decreased. Lower opiate-dose guidelines might improve the safe administration of these medications to young children. Other factors- such as concomitant sedative medications, previously administered opiate analgesics, and underlying medical conditions-also must be considered when giving initial doses of opiate analgesics in the burn center.

Little is known concerning health outcome for patients who survive burn injuries, and how their health outcome compares with that of other medical populations. Such information is important given that the current direction of health care policy decision making is toward outcomes-driven decision models. We compared the health status of 91 patients 1 month after severe burn injury with the published reports of the health status of 39 medical comparison samples, and two reports of health status for the general population. Additionally, we collected longitudinal data on a subsample of our surviving patients with burn injuries at 1 year. Our findings suggest that people who survive a severe burn experience a stable and relatively good health status after their injury compared with other medical samples. However, their health status remains worse than that of the general population over time. Further, people who survive a major burn indicate that the areas of vocational and psychosocial functioning are often the most troublesome for them.