Virtual Environments for Pain Alleviation

Joanna Piskorz and Marcin Czub

Abstract
We describe a series of 4 experiments on virtual reality use in pain alleviation. All
studies were part of VR4Health project, realized at the Institute of Psychology,
University of Wroclaw. We tested how certain parameters of virtual environments
(VE) influence pain tolerance and pain sensitivity. All studies were conducted
using induced thermal pain paradigm (heat pain or cold pressor test), and within-
group experimental design. Tested VE parameters (independent variables) were:
game dynamics (slow paced vs fast paced VE), game complexity (amount of the
elements meaningful for the gameplay), type of the interface, memory engagement,
and body/movement engagement. Dependent variables were: temperature of pain
stimulus, the time participants kept their hand in a cold water (pain tolerance), their
subjective rating of pain on a Visual Analog Scale (pain intensity), and presence in
VE. Results of all the studies confirm the analgesic efficacy of virtual reality
interventions, compared to non-VR condition. However, body engagement was the
only variable, which was found to differentiate between VR conditions and
influenced pain tolerance. Game complexity was the only variable which
influenced pain intensity. Partial results of those studies were published previously
in Polish Journal of Applied Psychology and Polish Psychological Bulletin. Here
we present summary description of the results, analyse repetitive patterns in the
results, provide meta-analysis of effect sizes, and reflect on methodological issues
arising from the paradigm we used. We also suggest ways of improving the design
and methodology of further similar experiments.

Key Words: Virtual reality, pain, cold pressor test, analgesia, presence, meta-
analysis.

*****

1. Introduction
Virtual reality (VR) technologies can be an effective tool in pain treatment.
Numerous research studies, published in the last fifteen years confirm its efficacy.1
Majority of those studies used immersive, head-mounted displays (HMD) based
VR where participants are able to interact with a three-dimensional computer
generated environment. We will refer here to VR in the context of such immersive
technology. VR was shown to reduce pain in various clinical populations: children
and adults with cancer,2 or dental pain treatment.3 Majority of the studies are
related to acute pain, but there have been attempts at using VR in chronic pain
treatment.4 Mechanisms of VR were also studied in a laboratory context, using
experimental pain paradigms.5
24 Virtual Environments for Pain Alleviation
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Pain alleviating effect of VR is usually explained by the spotlight model of
attention. The amount of attention paid to painful stimuli is considered to be an
important factor modulating the intensity of experienced pain.6 According to the
spotlight model, there is a limit to the amount of information that can be processed,
so if enough attentional resources are engaged in a VR game, less attention is left
for pain processing. Despite the large body of research, exact mechanisms of VR
analgesia are still not fully understood, as well as parameters of Virtual
Environments (VE) which contribute to pain alleviation. Several studies tested
various properties of VE's but failed to find significant differences in their
effectiveness.7
Active participation in VE was found to be more effective in diminishing pain
than passive observation of someone elses gameplay recording.8 Another factor
contributing to the amount of VR analgesia is experienced presence feeling of
being inside of a virtual world rather than just watching it on the screen.9
In order to better understand why VR analgesia works, and how to make it
more effective it is necessary to conduct experimental studies, where parameters of
VEs are isolated, controlled and manipulated. Here we describe a series of 4 such
experiments investigating how certain aspects of virtual environments influence
pain tolerance and pain sensitivity. Tested VE parameters (independent variables)
were: game dynamics (slow paced vs fast paced VE), game complexity (amount of
the elements meaningful for the gameplay), type of the interface, memory
engagement, and body/movement engagement. All of those studies were conducted
using a within-subject design.

2. Experiment 1: Game Dynamics

In this study we contrasted the analgesic efficacy of slow paced vs. fast paced
game. We hypothesized that fast paced game will lead to greater reduction of pain.

A. Participants
32 undergraduates participated in the study 21 female, 11 male (average age
22.29; SD=1.95, range 20-26). Participants gave their informed consent before the
experimental session. The experimental procedure was approved by the local ethics
committee. Participants were told that they can withdraw from the experiment at
any moment, without justifying their decision.

B. Design and Procedure

Each subject participated in two experimental conditions and a control
condition. The order of experimental conditions was counterbalanced, but the
control condition was always first, and served as a baseline measure of pain
tolerance. While playing the game, the participant's non-dominant hand was put on
a thermode, with temperature gradually raising up to 55 degrees Celsius.
Participants were asked to remove the hand when the pain becomes unbearable.
 Joanna Piskorz and Marcin Czub 25
__________________________________________________________________
For each condition we measured: the temperature at which they removed their
hands (pain tolerance), and their VAS pain ratings administered immediately after
they removed hands from the plate (pain intensity).
The experiment was conducted in a university lab room. Participants were
wearing E-Magin Z-800 HMDs - SVGA resolution, 40 deg diagonal FOV (which
equals looking at a 2.7m diagonal movie screen from 3.7m distance). The weight
of the display set was 227g. Participants were also hearing stereo sound from
HMD's audio output. The game Prince of Persia was used as a slow paced virtual
environment one particular location from the game was chosen, where
participants were walking in the natural landscape, listening to soothing music and
sounds. Split Second game was used as a fast paced VE participants taking part
in a dynamic car race, with many explosions and crashes, and loud dynamic sound
effects. Participants controlled both games with a gamepad (Logitech Rumble
Gamepad F510). In both games participants viewed the environment from the 3rd
person's perspective the point of view was positioned behind a human avatar in
Prince of Persia and behind a car in Split Second. Pain stimuli were applied
with the use of TempTest apparatus (made by EIEWIN Company). The device
consists of a control unit and an aluminium thermode (55x25cm). Minimum
temperature of the thermode was set to 36.6 degrees Celsius, and maximum was
55C.
The participants were informed that the purpose of the experiment is to
investigate how the body is experienced in virtual reality. In each of the two
experimental conditions participants were playing for one minute, before their
hand was put on the thermode. One minute period was chosen on the basis of
previously published literature, where similar or shorter times were used.10

C. Statistical Data Analysis

Due to the lack of normal distribution as well as homogeneity of variances,
non-parametric statistics were used in the analysis (i.e., U -Mann-Whitney Test,
Wilcoxons Signed Rank Test). We computed Hedges g effect sizes and
confidence intervals on them - using adjusted bootstrap method, and BootES R
package.11

D. Results
Pain tolerance was significantly higher in both VR conditions when compared
to the baseline non-VR measure. Fast paced VE (T=60; p<.001; g =.688 [.393-
.967]), Slow paced VE (T=37.5; p<.001; g=.764 [.468-1.029]).
There was also a significant difference in pain intensity ratings between non-
VR and both VR conditions. In VR conditions participants reported more intense
experiences of pain (fast paced VE: T=45; p<.001; g=.923 [.465-1.321]); slow
paced VE: T=71; p<.001; g=.689 [.168 - 1.15]). However, the type of VE (slow vs
fast paced) did not influence any of the two pain measures. There was no
26 Virtual Environments for Pain Alleviation
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significant difference between VE conditions in the pain tolerance ratings (T=25;
p=.81; g=-.008 [-.353-.353]) or pain intensity ratings (T=225; p=.47; g=.123
[-246-.433]).

3. Experiment 2: Game Complexity

In this study we investigated the relationship between game complexity and
pain experience during VR immersion. Game complexity was operationalized as
the number of elements meaningful for the gameplay. We hypothesized that more
complex game will engage more attentional resources, thus leading to stronger
analgesic effect.

A. Participants
31 undergraduate students participated 19 females (average age 21.37;
SD=2.34; range 19-30) and 12 males (average age 22.42; SD=1.51; range 20-24).
Similar ethical procedures were applied as in experiment 1.

B. Design and Procedure

Design of the study was similar to the one used in Experiment 1. Each
participant was placed in two experimental conditions (high vs. low complexity),
and one control (non-VR) condition. The order of all three conditions was
counterbalanced (Latin square).
Cold pressor test was used as a pain stimulus. This method is a commonly used
paradigm in experimental pain studies and is considered a good approximation of
chronic pain.12 While playing the game, the participants immersed their non-
dominant hands in a container with cold water (temperature 4.5-5.5C). The
apparatus was constructed for the purpose of the study and was equipped with a
water circulator, a separate ice container and a digital thermometer to ensure stable
temperature. Similar devices were used in previous published studies on VR pain
alleviation.13 For each condition we measured: (1) the time participants kept their
hands in cold water (pain tolerance), (2) their VAS pain ratings administered
immediately after they removed hands from water (pain intensity), and (3) feeling
of presence measured by Igroup Presence Questionnaire (IPQ). IPQ consists of
four subscales: Spatial presence the sense of being located inside a VE;
Involvement the level of engagement in a VE; Realism the sense of VE
realism; General an additional item measuring the general sense of being there.
The reliability (Cronbach's Alpha) of IPQ is between .63 and .78.14
The participants were playing a game created by the authors of the study.
During the game participants moved a 3D arrow in a space filled with spheres. In
the low complexity condition virtual scene was filled with white spheres, and
participants task was to hit them with an arrow. For each hit player received a
point. In the high complexity conditions, the players task was also to hit white
spheres with an arrow. Additionally, there were red spheres in the scene, which
 Joanna Piskorz and Marcin Czub 27
__________________________________________________________________
were interfering with completing the task and chasing the player. Each contact with
the red sphere resulted in subtracting a point. Participants were instructed to gather
as many points as possible. The participants were able to look around in the VE
using an orientation tracking device Polhemus Minuteman. They could also rotate
the avatar-arrow using the sensor held in their hands and move forwards/backwards
with pedals from the USB Tracer GTR steering wheel.
At the beginning of the experiment, participants put their hand into the
container with cold water for 5 seconds to get acquainted with the stimulus. Then,
they practiced playing a VR game with the Polhemus Minuteman. The participants
were instructed to remove their hands when the pain becomes unbearable. The
experiment was stopped if they kept their hands in cold water for over 4 minutes.
Then the participants assessed the pain intensity on a VAS and filled in the IPQ.
There was a 15 minute break between conditions in order to warm up the hand.

C. Results
We found main effect with regard to pain tolerance that is significant
differences between three tested conditions one non-VR and two VR conditions
(Friedmans ANOVA=13.15; p=.0014; N=31; df=2). Paired comparisons
(Wilcoxons Signed Rank Test) revealed statistically significant differences
between the low complexity VR condition and the non-VR condition (T=32.5;
Z=3.50; p=.0005; g=.599 [.418-.83]). Participants of the experiment distracted by
the low complexity virtual reality endured pain for a significantly longer time than
in the non-VR conditions. Similar results were found between non-VR and the
high complexity VR experimental conditions (T=41.5; Z=3.10; p=.002; g=.567
[.367-.824]). However, there was no significant difference in pain tolerance
between the two VR conditions participants were keeping their hands in a cold
water for a similar amount of time in high and low complexity condition (T=123.5;
Z=.10; p=.92; g=.036 [-.321-.374]).
Main effect was also found for pain intensity (Friedmans ANOVA=8.30;
p=.016; N=31; df=2). Paired comparisons revealed a significant difference between
the two VR conditions (T=87; Z=2.45; p=.014; g=-.452 [-.745- -.101]). The
participants reported experiencing significantly more pain in the low complexity
virtual reality than in the high complexity virtual reality. There was also a
difference between the non-VR and high complexity conditions (T=79.5; Z=2.81;
p=.005; g=-.547 [-.865- -.214]. The participants reported greater pain during the
non VR trials. However, pain intensity results were not differing between the low
complexity and non-VR conditions (T=163; Z=.91; p=.36; g=-.169 [-.551-.203]).
The correlations between IPQ questionnaire measures and experienced pain
measures were investigated. The only significant (negative) correlation was found
between the general immersion factor (g) and pain intensity (r=-.41, p<.05).
28 Virtual Environments for Pain Alleviation
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4. Experiment 3: Memory Engagement
In this experiment we investigated the influence of memory engagement during
VR intervention on the experience of pain. We hypothesized that memory tasks
will lead to greater involvement in a VR game, and to diminished experience of
pain.

A. Participants
Thirty-five undergraduates participated in the study 19 females (average age
22.21; SD=3.03; range 19-33) and 16 males (average age 22.56; SD=2.94; range
19-29).

B. Design and Procedure

Both design and procedure were almost identical to the ones used in
Experiment 2. However, different VR game was used for the memory-VR
condition. In this condition players navigated an avatar-sphere and pointed to
multiple white spheres which then produced different sounds. The participants
task was to memorize elements that made the same sounds, and then hit them in
sequence. At the same time the player had to avoid red spheres. In no-memory-VR
condition we used high complexity game from Experiment 2. In both VR
conditions participants used Microsoft Kinect controller to navigate the game.
They steered avatar-sphere using whole arm movements.

C. Results
We found main effect for pain tolerance (Friedmans ANOVA=14.13; p<.001;
N=32; df=2). Paired comparisons revealed that both VR conditions increased the
participants pain tolerance compared the non-VR condition: no-memory (T=57;
Z=3.61; p<.001; g=.621 [.39-.862]), and memory (T=51.5; Z=3.72; p<.001; g=.59
[.19-.863]). However, there was no significant difference between the two VR
conditions (T=124; Z=.74; p=.46; g=.04 [-.309-.397]).
We did not find main effect for pain intensity (Friedmans ANOVA=2.90;
p=.24; N=32; df=2). The two VR conditions did not differ (T=206; Z=.54; p=.59;
g=.097 [-.257-.444]). IPQ spatial presence subscale positively correlated with pain
intensity, but only in memory-VR condition (r=.37, p<.05).

5. Experiment 4: Body Movement

A. Participants
30 undergraduates participated in the study 20 females (average age 20.55;
SD=1.50; range 19-24) and 10 males (average age 25.60; SD=9.26 ; range 18-50).

B. Design and Procedure

Each subject participated in two experimental conditions and navigated the VR
game using a computer mouse (small movement), or Microsoft Kinect (large
 Joanna Piskorz and Marcin Czub 29
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movement). During the game participants were gliding through 3d space filled with
spheres. They were navigating white avatar-sphere, collecting yellow spheres and
avoiding collision with red spheres. There was no non-VR control condition in this
experiment. The procedure was similar to the one used in experiments 2 and 3. In
the cold pressor test we lowered the temperature of water to 0.5-1.5C.

C. Results
Participants were keeping their hand in cold water significantly longer in the
large movement condition than in the small movement condition (N=26; T=86.5;
Z=2.26; p=.024; g=-.395 [-.645- -.059]). On average, they kept their hand for 25
seconds more. However, we did not observe a significant difference on VAS
results between the two experimental conditions (N=22; T=104; Z=.73; p=.47;
g=.131 [-.241-.527]). The pain tolerance and pain intensity measures were
negatively correlated the longer participants kept their hand in cold water, the
smaller intensity of pain they reported on VAS. Such correlation was present in
both experimental conditions (large movement: r=-.38, p<.05; small movement:
r=-.42, p<.05).
There were no significant correlations between the IPQ results and any of the
two pain measures. Also, IPQ results did not differ between conditions (spatial: t=-
1.96; p =.059; inv: t=-1.21; p=.24; real: t=-.37; p=.72; g: t=.53; p=.60).

6. Discussion
Several patterns and conclusions arise when results from all four experiments
are analysed together. One conclusion that can be drawn from this data is that pain
tolerance and pain intensity yield differing, sometimes contrasting results. Certain
parameters of VR intervention may selectively influence either pain tolerance or
pain sensitivity. Game complexity seems to influence pain sensitivity but not pain
tolerance (experiment 2), while opposite pattern was found for body movement
(experiment 4). Those two measures may thus reflect separate aspects of pain
processing. This may be important when interpreting results from published VR
analgesia studies, where often only one measure of pain was used. We especially
recommend that in meta-analyses the type of pain measure should be always coded
and included as a variable in the analysis. Averaging over all pain measures (as
sometimes practiced in meta-analyses on VR analgesia) may hide important
differences.
Another conclusion which arises from reported here results is that one should
expect small effect sizes when contrasting two VR interventions. This should be
taken into account when estimating sample size needed for such studies.
Unfortunately, none of the experiments reported by us here had enough power to
reach statistical significance for effects of this size. Expecting small effect sizes
may be especially valid for studies, where two VR interventions are similar to each
other, and differ only with regard to one selected parameter. But those are exactly
30 Virtual Environments for Pain Alleviation
__________________________________________________________________
the studies which are most needed in order to better understand the mechanisms of
VR analgesia.
Average effect size for pain tolerance was .638 mean effect size for both VR
vs control conditions was first computed for each study, and then weighted by
sample size. This was computed for Experiments 1,2 and 3, as there was no control
group in Experiment 4. This effect size is smaller than average effect size reported
in recent meta-analysis,15 which was obtained from 7 studies. In this meta-analysis,
authors averaged all pain measures reported in each study, while we analysed pain
tolerance. Effect size obtained by us was higher than in 2 of 7 studies reported in
that meta-analysis. The effect size from our studies may be also explained by
relatively low tech HMDs we used.16
Potentially useful conclusions may also arise from the interpretation of VAS
results opposite pattern was obtained in Experiment 1 and Experiments 2, 3. In
Experiment 1 higher pain tolerance data was correlated with higher pain intensity.
In the VR condition participants endured higher temperature, but also reported
stronger pain. However in Experiments 2 and 3 pain tolerance was negatively
related to pain intensity those participants who kept their hand longer in a cold
water reported less pain on VAS. This means that details of the paradigm can
drastically influence pain intensity ratings, and the effects obtained. In turn, effect
sizes for pain tolerance were similar in all three experiments, even though different
pain stimulus (and pain tolerance measure) was used in the Experiment 1 than in
Experiments 2 and 3.
Lastly, non-normal (actually, bimodal) distribution of pain tolerance data was
found in all our CPT studies. This is consistent with the literature on CPT and this
suggests, that in studies using this paradigm it may be useful to analyse separately
pain sensitive and pain tolerant participants.

Notes
1
For review see: Cristina Botella, et al., Virtual Reality in the Treatment of Pain,
Journal of CyberTherapy & Rehabilitation 1.1 (2008): 94-98; Mark D. Wiederhold
and Brenda K. Wiederhold, Virtual Reality and Interactive Simulation for Pain
Distraction, Pain Medicine 8.3 (2007): 183-186; Kevin M. Malloy and Leonard S.
Milling, The Effectiveness of Virtual Reality Distraction for Pain Reduction: A
Systematic Review, Clinical Psychology Review 30.8 (2010): 1016.
2
Debashish A. Das, et al., The Efficacy of Playing a Virtual Reality Game in
Modulating Pain for Children with Acute Burn Injuries: A Randomized Controlled
Trial (ISRCTN87413556), BMC Pediatrics 5.1 (2005): 3-7, doi: 10.1186/1471-
2431-5-1; Jonathan Gershon, et al., A Pilot and Feasibility Study of Virtual
Reality as a Distraction for Children with Cancer, Journal of the American
Academy of Child Adolescent Psychiatry 43.10 (2004): 12451247.
 Joanna Piskorz and Marcin Czub 31
__________________________________________________________________

3
Hunter G. Hoffman, et al., The Effectiveness of Virtual Reality for Dental Pain
Control: A Case Study, CyberPsychology & Behavior 4.5 (2001): 529531.
4
Francis J. Keefe, et al., Virtual Reality for Persistent Pain: A New Direction for
Behavioral Pain Management, Pain 153.11 (2012): 2164.
5
Andreas Mhlberger, et al., Pain Modulation During Drives Through Cold and
Hot Virtual Environments, CyberPsychology & Behavior 10.4 (2007): 517;
Lynnda M. Dahlquist, et al., Virtual-Reality Distraction and Cold-Pressor Pain
Tolerance: Does Avatar Point of View Matter?, Cyberpsychology, Behavior and
Social Networking 13.5 (2010): 588.
6
Chantal Villemure and Catherine Bushnell, Cognitive Modulation of Pain: How
Do Attention and Emotion Influence Pain Processing?, Pain 95. 3 (2002): 196-
198.
7
Mhlberger, et al., Pain Modulation, 520-521; Dahlquist,et al., Does Avatar
Point of View Matter?, 589; Marcin Czub and Joanna Piskorz, The Effectiveness
of Different Virtual Reality Environments for Thermal Pain Distraction. How Does
the Level of Stimulation Influence the Amount of Experienced Pain?, Polish
Journal of Applied Psychology 10.2 (2012): 14-15; Marcin Czub, et al., Influence
of Memory Engagement on the Level of Experienced Pain During Virtual Reality
Analgesia, Polish Journal of Applied Psychology 12.4 (2014): 48-49; Joanna
Piskorz, et al., How Does Interface Influence the Level of Analgesia with the Use
of Virtual Reality Distraction?, Polish Journal of Applied Psychology 12.1 (2014):
50-51.
8
Lynnda M. Dahlquist, et al., Active and Passive Distraction Using a Head-
Mounted Display Helmet: Effects on Cold Pressor Pain in Children, Health
Psychology: Official Journal of the Division of Health Psychology. American
Psychological Association 26.6 (2007): 798-799.
9
Maria V. Sanchez-Vives and Mel Slater, From Presence to Consciousness
Through Virtual Reality, Nature Reviews Neuroscience 6.4 (2005): 333-335;
Martijn J. Schuemie, et al., Research on Presence in Virtual Reality: A
Survey, CyberPsychology & Behavior 4.2 (2001): 187-188; Hunter G. Hoffman,
et al., Manipulating Presence Influences the Magnitude of Virtual Reality
Analgesia, Pain 111.1 (2004): 165-166.
10
Dahlquist, Active and Passive Distraction, 797; Dahlquist, Does Avatar Point
of View Matter?, 588.
11
Kris Kirby and Daniel Gerlanc, BootES: An R Package for Bootstrap
Confidence Intervals on Effect Sizes, Behavior Research Methods 45.4 (2013):
915-925.
12
Dahlquist, Active and Passive Distraction, 796; Dahlquist, Does Avatar Point
of View Matter?, 588; Charles E. Rutter and Lynnda M. Dahlquist, Sustained
Efficacy of Virtual Reality Distraction, The Journal of Pain 10.4 (2009): 393;
32 Virtual Environments for Pain Alleviation
__________________________________________________________________

Laura A. Mitchell, Raymond A. MacDonald and Eric E. Brodie, Temperature and

the Cold Pressor Test, The Journal of Pain 5.4 (2004): 234-235.
13
Dahlquist, Active and Passive Distraction, 796-797; Kelly L. Forys and
Lynnda M. Dahlquist, The Influence of Preferred Coping Style and Cognitive
Strategy on Laboratory-Induced Pain, Health Psychology 26.1 (2007): 24-25.
14
Thomas W. Schubert, The Sense of Presence in Virtual Environments: A Three-
Component Scale Measuring Spatial Presence, Involvement and Realness,
Zeitschrift fr Medienpsychologie15.3 (2003): 69-71.
15
Malloy and Milling, The Effectiveness of Virtual Reality Distraction for Pain
Reduction, 1016.
16
Hunter G. Hoffman, et al., Virtual Reality Helmet Display Inuences the
Magnitude of Virtual Reality Analgesia, Journal of Pain 7.11 (2006): 846-847.

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 Joanna Piskorz and Marcin Czub 33
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34 Virtual Environments for Pain Alleviation
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Simulation for Pain Distraction, Pain Medicine 8.3 (2007): 182-188.

Joanna Piskorz Institute of Psychology, University of Wroclaw, Poland.

Researcher in VR4Health project, studying applications of VR in pain treatment; e-
mail: joanna.piskorz@uni.edu.pl

Marcin Czub Principal Investigator in VR4Health a research project on

Virtual Reality use in Pain alleviation. Assistant Professor of Cognitive
Psychology, University of Wroclaw. e-mail: marcin.czub@uni.edu.pl