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Distraction Manual

Index Manual Distraction

  1. Distraction and Virtual Reality
  2. Psychological evaluation/intervention protocol proposed by Psious
    1. Pain and Anxiety Evaluation
      1. Evaluation objectives
      2. Some useful tools for the evaluation of Chronic Pain and Anxiety
    2. Intervention on Pain and Anxiety
      1. Intervention with virtual reality proposal to reduce the pain during diagnostic tests
  3. Use Recommendations 
  4. Recommended Bibliography

1. Distraction and Virtual Reality

Pain, despite being an unpleasant sensation, is a vital alarm system of the body since it allows the individual to recognize some stimulus harmful to the body tissue. Acute pain, because of its short duration, ends once the cause is resolved. However, chronic pain loses the alarm function to become an obstacle to achieve the life quality. This pain can be caused by various conditions, and is resistant to standard treatments (Kato, J., Agalave, N. M., and Svensson, C.I., 2016). Some of the causes are burns, cancer, fibromyalgia, among others.

In relation to anxiety, it is a normal reaction to stress. It serves to help a person with a difficult situation and to enable them to deal with it. This type of anxiety is adaptive, but when it becomes excessive it can manifest itself as an anxiety disorder.

The Distraction scene is presented as a good option for patients with chronic pain, acute pain, or anxiety, who have to undergo processes such as hemodialysis, endoscopies, chemotherapy, visits to the dentist, magnetic resonance, etc., in order to decrease the painful sensations or anxiety by focusing the attention on the virtual environment.

There is scientific evidence that when one shifts attention from a noxious stimulus to a more pleasant one, there is a reduction in the perception and experience of pain. Melzack and Wall proposed the gate control theory, which emphasizes the relationship between the central and peripheral nervous systems, according to which only certain painful stimuli would pass to the brain. According to this theory, several CNS activities, especially attention, emotion and memories related to previous experience, play a fundamental role in sensory perception (Gold, JI, Kant, AJ, Kim, SH, and Rizzo, A., 2005)

We have empirical data in favor of the use of virtual reality in these cases (Jones, T., Moore, T., and Choo, J, 2016), since it is a system in which, if one is immersed in the scene, the distraction of painful or anxious sensations can be very high.

2. Psychological evaluation/ intervention protocol

All information in this section is for guidance. Psious environments are therapeutic tools that must be used by the healthcare professional in an evaluation and intervention process designed according to the characteristics and needs of the user

Remember also that you have the General Clinical Guide in which you have more information on how to adapt the techniques of psychological intervention (exposure with response prevention, cognitive restructuring …) to the Psious environments.

2.1 Pain and Anxiety Evaluation 

2.1.1  Evaluation objectives 

  • Determine the presence of emotional disorders
  • Determine the presence of pain behaviors and associated distorted thoughts.
  • Determine the presence of anxiety and associated thoughts.

2.1.2 Some useful tools for the evaluation of Chronic Pain and ç

Anxiety 

Taking into account the evaluation objectives, we will list some tools that may be useful to obtain relevant information about the characteristics of your user. Remember that a good definition of the objectives, a well conducted patient characterization and intervention planning are important for the therapeutic efficiency and effectiveness, as well as for the satisfaction of your user. In the bibliography you will find the articles in which to review the characteristics of the tools proposed below:

  • Open or semi-structured interview.
  • Structured interview: ADIS-IV (Brown, Di Nardo & Barlow, D, 1994)

Regarding Chronic Pain, there are specific scales to measure it:

  1. One-dimensional
  1. VAS (Visual Analogue Scales) (Carlsson, 1983) 
  1. Numeric Scale
  1. Facial Pain Scale 
  1.  Multidimensional
  1. McGill Pain Questionnaire, MPQ (Melzack & Torgerson, 1971)
  1. Lattinen Index, IL (Monsalve, Soriano and De Andrés, 2006) 
  1. Brief Pain Inventory, BPI (Badia et al, 2003)  
  1. Neuropathic Pain Rating Scales 
  1. The LANSS Pain Scale (Bennett, 2001) 
  1. The Neuropathic Pain Questionnaire (NPQ) (Krause & Backonja, 2003)
  1. Douleur neuropathique en 4 questions (DN4) (Bouhassira et al, 2005)
  1. PainDETECT (Freynhagen et al, 2006)

Regarding Anxiety, there are specific measurement scales:

  • Hamilton Anxiety Rating Scale (HAM-A) (Hamilton, 1959)
  • The State-trait Anxiety Inventory (STAI) (Spielberger et al, 1999)
  • Beck Anxiety Inventory (BAI) (Beck et al, 1998)
  • Hospital Anxiety And Depression ScaleAnxiety (HADS-A) (Zigmond & Snaith, 1983)

2.2 Intervention on Pain and Anxiety

2.2.1 Intervention with virtual reality proposal to reduce the 

pain during diagnostic tests 

In order to achieve a better result, it would be advisable to perform different relaxation techniques both before and after the painful diagnostic test. It is also recommended to evaluate the levels of pain and anxiety at the previous and final moments of the process, in order to analyze the changes in these levels (Cabas Hoyos, Cárdenas López, Gutiérrez Maldonado, Ruiz Esquivel, Torres Villalobos, 2015).

  1.  Before the diagnostic test
  1. Assessment of the level of pain and anxiety (baseline). Tools such as visual analogue scales (VAS) for pain and anxiety questionnaires (eg BAI)
  1. Application of relaxation techniques:
  1. Abdominal breathing through Psious virtual environments for this task (eg, diaphragmatic breathing in a meadow, diaphragmatic breathing under the sea).
  1. Abdominal breathing through 360º videos of relaxation (for ex.: cove), with abdominal breathing audio.
  1.  During the diagnostic test
  1. Distraction Task using the Psious virtual environment.
  1.  After the diagnostic test is done
  1. Assessment of the level of pain and anxiety using the same instruments as in the beginning.
  1. Imagery task through the Beach scene and/or 360º videos of Psious to consolidate the results achieved

3. Use Recommendations

It is recommended to be used on patients with chronic pain, who have to go through a painful intervention or have to undergo a therapeutic process that causes them mild anxiety (not a psychopathological type of phobia) such as an intervention at the dentist, removal of a cast… Managing the focus of attention can actually decrease the painful feeling and help in the management of mild anxiety. The therapist should explain to the patient that the environment consists of a game and encourage him to be immersed in the environment of tranquility, without thinking of anything else. Disconnecting from reality to try to achieve the goals required in the game, progress and earn rewards.

4. Recommended Bibliography

Badia X, Muriel C, Gracia A, Núñez-Olarte J, Perulero N, Gálvez R, et al. (2003). Validación española del cuestionario Brief Pain Inventory en pacientes con dolor de causa neoplásica. Med Clin, 120, 52-9.

Beck, AT, Brown, G, Epstein, N, Steer, RA (1988). An Inventory for Measuring Clinical Anxiety: Psychometric Properties. Journal of Consulting and Clinical Psychology, 56, 893-897.

Bennett, M. (2001). The LANSS Pain Scale: The Leeds assessment of neuropathic symptoms and sign, Pain, 92, 147-157

Bouhassira, D., Attal, N., Alchaar, H., Boureau, F., Brochet, B., Bruxelle, J., Cunin, G., Fermanian, J., Ginies, P., Grun-Overdyking, A., JafariSchluep, H., Lantéri-Minet, L., Laurent, B., Mick, G., Serrie, A., Valade, D., Vicaut, E. (2005). Comparison of pain syndromes associated with nervous or somatic lesions and development of a new Neuropathic pain diagnostic questionnaire (DN4). Pain, 114, 29–36. 10.1016/j. Pain.2004.12.010

Brown, T.A., Di Nardo, P.A. & Barlow, D.H. (1994). Anxity Disorders Interview Schedule for DSM-IV (ADIS-IV). San Antonio: The Psychological Corporation.

Cabas Hoyos, Kattia; Cárdenas López, Georgina; Gutiérrez Maldonado, José; Ruiz Esquivel, Fernanda; Torres Villalobos, Gonzalo; (2015). Uso clínico de la realidad virtual para la distracción y reducción del dolor postoperatorio en pacientes adultos. Tesis Psicológica, JulioDiciembre, 38-50. 

Carlsson, A.M. (1983). Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain, 16, 87-101.

Cid, J., Acuña, J. P., Andrés, J., Díaz, J., y Gómer-Caro, L. (2014). ¿Qué y cómo evaluar al paciente con dolor crónico? Evaluación del paciente con dolor crónico. REV. MED. CLIN. CONDES, 25(4), 687-697

Freynhagen, R., Baron, R., Gockel, U., & Tölle, T. R. (2006). Pain DETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Current medical research and opinion, 22(10), 1911-1920.

García-Palacios, A., Hoffman, H. G., Richards, T. R., Siebel, E. J., y Sharar, S. R. (2007). Use of Virtual Reality Distraction to Reduce Claustrophobia Symptoms during a Mock Magnetic Resonance Imaging Brain Scan: A Case Report. CyberPsychology & Behavior, 10(3), 485-488. doi:10.1089/cpb.2006.9926

Gold, J. I., Kant, A. J., Kim, S. H., y Rizzo, A. S. (2005). Virtual anesthesia: The use of virtual reality for pain distraction during acute medical interventions. Seminars in Anesthesia, Perioperative Medicine and Pain, 24(4), 203-210. https://doi-org.sire.ub.edu/10.1053/j.sane.2005.10.005

Hamilton M. (1959). The assessment of anxiety states by rating. Br J Med Psychology; 32, 50–55. http://dcf.psychiatry.ufl.edu/files/2011/05/HAMILTON-ANXIETY.pdf

Jones, T., Moore, T., y Choo, J. (2016). The Impact of Virtual Reality on Chronic Pain. PLoS ONE, 11(12), 1-10

Julian, L. J. (2011) Measures of Anxiety. Arthritis Care Res (Hoboken), 63 (11). doi:10.1002/acr.20561 

Kato, J., Agalave, N. M., y Svensson, C. I. (2016). Pattern recognition receptors in chronic pain: Mechanisms and therapeutic implications. European Journal of Pharmacology, 788, 261-273. http://doi.org.sire.ub.edu/10.1016/j.ejphar.2016.06.039

Krause, S.J. & Backonja, M. (2003). Development of a neuropathic pain questionnaire. Clin J Pain,19, 306–14.

Melzack R & Torgerson WS. (1971). On the language of pain. Anesthesiology, 34(1), 50–59.

Melzack, R. y Wall, P.D. (1965). Pain mechanisms: a new theory. Science, 150 (3699), 971–979. 

Monsalve V, Soriano J y De Andrés J. (2006). Utilidad del Índice de Lattinen (IL) en la evaluación del dolor crónico: relaciones con afrontamiento y calidad de vida. Rev Soc Esp Dolor ,13, 216-29.

Ríos, E. M., Herrera, R. A., y Rojas A. G. (2014). Ansiedad dental: Evaluación y tratamiento. Avances en Odontoestomatología, 30(1), 39-46.

Spielberger, C. D., Gorsuch, R. L., Lushene, R. E., & Cubero, N. S. (1999). STAI: Cuestionario de Aansiedad Estado-Rasgo: Manual. Madrid: TEA Ediciones.

Tanja-Dijkstra, K., Pahl, S., White, M. P., Andrade, J., Qian, C., Bruce, M., …Moles, D. R. (2014). Improving Dental Experiences by Using Virtual Reality 

Zigmond, A.S. & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand, 67, 361–70. (Primary reference)