FORT SAM HOUSTON, Texas -- Military members who have combat burn injuries can suffer through some of the most intense and prolonged types of pain imaginable. Patients need daily care to clean the wound and daily physical therapy to stretch the newly healed skin.

Despite the use of strong painkillers, the majority of burn patients report severe to excruciating pain during wound care. Even knowing the pain from wound treatment is coming can bring on a high level of anxiety and stress for these patients, according to Maj. (Dr.) Peter DeSocio, an anesthesiologist with the burn center at Brooke Army Medical Center.

"Burn pain is generalized and not easy to treat," DeSocio said. "We can't just give the patient a shot to make it stop."

The 40-bed burn center - the only one of its kind for the nation's military - is located in a fourth-floor wing of the massive hospital located on Fort Sam Houston. The center, part of the Army Institute of Surgical Research, has treated more than 800 military personnel injured in war.

Research is now showing that an interactive video game can be one effective prescription for easing the pain and stress during burn wound treatment.

For the past two years, a group of military patients have taken part in a study using "SnowWorld," a three-dimensional video game that employs high-tech goggles and earphones, allowing patients to immerse themselves in the game experience.

While in the game, they are drawn into the action as they glide through an icy world of frozen canyons and mountains, and loft snowballs at snowmen, igloos, mammoths, and penguins. It's this frosty experience that allows the wounded warrior to focus on something other than their injuries and the treatment that goes along with it.

The game was designed by Dr. Hunter Hoffman, director of the University of Washington's Virtual Reality Analgesia Research Center, with psychologist David Patterson, the chief of rehabilitation medicine at Harborview Burn Center. It was designed by Imprint Interactive Technology, based in Seattle, Wash., using NVIDIA graphics and Virtools™ 3D software. The game was originally used with children during their rehabilitation, but the testing with wounded warriors has been a success.

"Not having to see the burn wounds helps keep them from thinking about it so much, or thinking about where and when the injuries happened to them," DeSocio said. "Used as a complementary treatment, the VR game helps them relieve the stress of knowing the treatment is coming and gets them through their treatment better. It makes it a more tolerable experience."

Patients often report re-living their original burn experience during wound care, DeSocio said, and SnowWorld has shown to help put out the fire.

"Once I was using this system, I wasn't expecting the pain (from the dressing changes)," said Sgt. Oscar Liberato, a 23-year-old tanker from Ferndale, Wash. "I wouldn't be focusing on it so much and it kept my mind off what was going on."

The sergeant was injured two years ago while with his unit in Iraq when an improvised explosive device detonated near the Humvee he was riding in. Liberato suffered severe burns on his left arm and hand. He was also the only survivor from his unit.

The sergeant said it used to take longer to change the dressings and do any kind of debridement to remove any blisters or dead skin.

"I would constantly complain about the pain, and therefore need more medication," Liberato said. "Using the virtual reality during the treatment, it takes less time to change the dressings and I didn't feel like I needed as much of the drugs."

Burn patients are usually treated with large amounts of opioids (morphine and morphine-related chemicals) to alleviate the pain, but the side effect of these potent drugs leaves the patients feeling groggy and disconnected.

Being able to reduce patients' pain medication with the help of VR improves other psychological aspects of their care, DeSocio said. The high doses of opioids given to burn victims sometimes sedates them so much they're unaware of what's going on in terms of other support from caregivers and family members.

"The side effects of these drugs make patients feel like they are not the same person," said DeSocio, who has been with the burn center for two-and-a-half years. "The Soldiers with burn injuries have frequent acute pain episodes and have had them for a very long time. After a while, they start building up a tolerance for the drugs."

By reducing the medication, Liberato said was able to think clearer and not feel so out of it.
"My wife really appreciated that, because I was able to stay awake and talk and interact while she was visiting," the Soldier said.

However, when the VR treatment was first offered, Liberato was skeptical.

"At first, I didn't think the game would work, but I was willing to try anything," said Liberato, who said he was a big gamer before his injuries, owning both the PS3 and Wii gaming systems. "But once I was using it, I wasn't expecting the pain. I wasn't focusing on it. The environment makes you feel like you're at peace."

The game also got a boost from an unexpected source: world-famous singer-songwriter Paul Simon. When Simon was on tour in 2005, one of his friends invited him to come to meet Hoffman at the Human Interface Technology Lab in Seattle.

"Out of all the things Paul saw at HITLab, he was very smitten by SnowWorld," said Hoffman, who is a big fan of the music legend.

Simon has a children's health charity based in New York, so it seemed like a natural fit. "Paul offered to let us use his music free of charge," Hoffman said. "Paul Simon said, 'You need to use some music in SnowWorld' - and the truth is I think the Paul Simon music really enhances the effectiveness of the treatment of SnowWorld for pain distraction."

For more comfortable use with the combat veterans, who may have burns on their heads and faces, an articulated arm was created to position the VR goggles the patients use, instead of having to wear a helmet, DeSocio said. The goggle holder is important because of the sensitivity of the skin when patients have burns. The entire unit costs about $40,000 to $50,000, with $30,000 just for the goggles. Patients manipulate a computer mouse to interact with the environment, allowing them to pick up and throw snowballs, for example.

"There is a limit to what we can do," DeSocio said, "but the study will show there is a benefit to this treatment, that it's worth investing in. I believe that it is moving toward having as part of the standard care for burn patients."

Another benefit is that a doctor doesn't have to be present during the treatment, since a nurse can operate the VR game and provide the wound treatment. This frees the doctors up to treat other patients in the burn center or perform surgeries.

"I think this will benefit more Soldiers if they get a chance to use it," Liberato said. "It'll make their time spent here less traumatic."