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Virtual Reality and Mobius Floe: Cognitive Distraction as Non-Pharmacological Analgesic for Pain Management

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This paper outlines the intentions and current design behind the production of Mobius Floe, an immersive virtual reality game catered to acute and chronic pain patients. Researchers have shown that immersive virtual reality (VR) can serve as a non-pharmacological analgesic by inducing cognitive distraction in acute pain patients [Hoffman 2000]. Mobius Floe experiments with virtual reality as well as auditory immersion, a more experimental approach to cognitive distraction for pain relief; the results will be tested by acute as well as chronic pain patients to determine if chronic sufferers can benefit from similar VR practices as their acute counterparts. Mobius Floe’s game design is informed by contemporary game design theory and cognitive psychology in order to improve its distractive properties.
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Virtual Reality and Mobius Floe: Cognitive Distraction as
Non-Pharmacological Analgesic for Pain Management
Amber Choo1, Xin Tong1, Diane Gromala1 and Ari Hollander2
1School of Interactive Arts and Technology, Simon Fraser University, Surrey, B.C, Canada
{achoo, tongxint, dgromala}
2Firsthand Technology Inc., Seattle, W.A, USA
Abstract. This paper outlines the intentions and current design behind the pro-
duction of Mobius Floe, an immersive virtual reality game catered to acute and
chronic pain patients. Researchers have shown that immersive virtual reality
(VR) can serve as a non-pharmacological analgesic by inducing cognitive dis-
traction in acute pain patients [Hoffman 2000]. Mobius Floe experiments with
virtual reality as well as auditory immersion, a more experimental approach to
cognitive distraction for pain relief; the results will be tested by acute as well as
chronic pain patients to determine if chronic sufferers can benefit from similar
VR practices as their acute counterparts. Mobius Floe’s game design is in-
formed by contemporary game design theory and cognitive psychology in order
to improve its distractive properties.
Keywords. Chronic pain, acute pain, pain management, serious game design,
health games, analgesia, virtual reality, cognitive load
1 Introduction
Virtual reality (VR) applications have yet to become a widely accepted complemen-
tary method to analgesics to reduce the perception of pain despite documented instances
of its success. SnowWorld, a VR game with accompanying head mounted display
(HMD) has demonstrated that VR treatments can work in tandem with pain medications
to further reduce perceived instances of pain in patients with combat-related burn inju-
ries [8]. Virtual reality has also been used to help combat other types of discomfort such
as acute pain from dental procedures [6]. There is already evidence to suggest that
chronic pain patients can benefit from immersive virtual reality applications [10].
Chronic pain patients, although requiring long-term pain reduction strategies, also suf-
fer from shorter-term spikes in pain intensity [1] of which they may also benefit from
non-pharmacological treatment practices suiting acute pain patients. Mobius Floe, the
immersive VR discussed in this paper aims to expand upon non-pharmacological anal-
gesic research for acute and chronic pain patients by improving the quality and varia-
bility of the distractive gameplay of its predecessors while introducing new forms of
gameplay to examine, evaluate and compare to the field. Tasks involving cognitive
B. Schouten et al. (Eds.), Games for Health 2014,
DOI 10.1007/978-3-658-07141-7_2, © Springer Fachmedien Wiesbaden 2014
Virtual Reality and Mobius Floe
distraction and heightened cognitive load are discussed for usage in Mobius Floe in
order to attract and maintain the attention of pain patients.
2 Related Work
Virtual reality treatments for the reduction of acute pain have seen promising results
in multiple studies. A VR titled SnowWorld, which draws patient’s attention away from
their embodied experience of pain and toward the virtual 3D environment was used to
curb the wound care pain of U.S. soldiers injured with significant burns at the U.S.
Army Institute of Surgical Research (USAISR). SnowWorld featured a snowy land-
scape where the patient could throw snowballs and be hit by snowballs in the virtual
space. This experience combined with analgesic medications served to improve the sol-
dier’s pain experiences in regards to “time spent thinking about pain” and experienced
“pain unpleasantness”, both of which declined significantly with the introduction of
VR to their standard wound care routine [8].
Hoffman et al. reported significantly reduced levels of pain in dental patients under-
going scaling and root planing in those who were immersed in cognitive distraction via
a virtual reality simulation over patients who were asked to watch a movie and those
who had no distraction present during their procedures [6]. Their results imply that
immersive virtual reality applications may serve as an effective non-pharmacologic
analgesic which could to be used in tandem with existing prescribed pain medications
for dental pain; this conclusion by extension may also be applicable to other pain demo-
graphics, especially considering the surrounding literature. For example, in a random-
ized control trial study by Das et al., a virtual reality game was added to the proce-
dural care schedule of children with acute burn injuries. The introduction of VR to
their normally prescribed pharmacological analgesics decreased the average of the
children’s self-reported Faces Scale pain ratings from 4.1 (SD 2.9) to 1.3 (SD 1.8) [3].
The introduction of meaningful game design strategies can improve the gameplay
of Mobius Floe to become more engaging than its previous counterparts, improving
the quality of patient immersion. The examination of the potency of effects such as
Csikszentmihalyi’s ‘flow’ are important to maintaining virtual immersion, for flow
“can be positively associated with degrees of the cognitive phenomenon of immersion
and telepresence” [4]. SnowWorld has some degree of flow and is discussed widely in
virtual reality literature. However, there is no perceivable consequence to inaction in
SnowWorld when clear reactions from the game world in response to the player are
necessary to create a more engaging design [2]. The SnowWorld patients also had
minimal player agency in regards to their potential actions in the space, which is un-
usual considering player agency is an extremely useful tool for user engagement [9].
Mobius Floe aims to learn from and improve upon previous attempts such as Snow-
World by extending the software’s ability to become immersive and cognitively dis-
tract in a more reliable fashion.
Mobius Floe also incorporates techniques from the cognitive sciences by introducing
n-back tasks, attentional switching and dual-task paradigms which work in tandem to
invoke strong immersion, cognitive load, continuous action and heighten arousal
Choo · Tong · Gromala · Hollander
[5][11]. Patients are rewarded with ‘health packs’ to increase their player’s health
points (HP) when memorizing short visual patterns within the Mobius Floe space,
recalling them later using a throwing mechanic to interact with the correct sequence
of colors. Attentional switching and dual-task paradigm examples are discussed in the
following section.
3 Virtual Reality Design and Development for Mobius Floe
Mobius Floe is currently being constructed in the Unity game engine and sports vari-
ous distraction-based gameplay strategies in different areas of the virtual space. It can
be played with the Oculus Rift head-mounted display (HMD) or a stereoscopic HMD
provided by Firsthand Technologies, which sits in front of the eyes without touching
the patient; the intent of using this hardware is to provide greater depth of cognitive
Mobius Floe appears as a sprawling snowy landscape, and the player is automatically
moved forward through the space. The patient can look around the virtual space using
the Oculus Rift or with a mouse as they are brought to their next destination.
The patient quickly finds themselves under threat from monsters which appear to be
half neuron, half tree (see Fig. 1). These ‘neuron trees’ have menacing expressions and
require sedation to escape from successfully. They chase the player and will damage
their Health Points (HP) on contact. The neuron trees represent the neurological sys-
tems in the human body which are causing the pain experience; patients are able to calm
them down by throwing abstracted particle systems representing analgesics with the
left mouse button. The neuron trees serve as a key mode of cognitive distraction as they
coerce the player into taking defensive actions against them in a strategic and time sen-
sitive manner. Overuse of drugs against the neuron trees results in negative conse-
quences, some of which manifest as detrimental behaviors in the neuron trees, while
others affect the visual rendering of the virtual space in a negative fashion. For example,
Fig. 1. A production still of Mobius Floe which shows an idling neuron tree.
Virtual Reality and Mobius Floe
overuse of morphine slows the neuron trees down considerably, but they become
more aggressive once the effect wears off.
Sea otters also wander the virtual space and are able to interact with the patient
(Fig. 2). They are friendly entities always approaching the player on sight, serving as
metaphors for the patient’s friends and family. Sea otters wag their tails and smile up at
the patient when nearby. The patient can toss sea urchins at the otters in the same way
they toss analgesics to the neuron trees. Otters who receive sea urchins will drop health
packs for the player.
Occasionally the n-back tasks discussed in the previous section, sea otters and neu-
ron trees will be in the proximity of the player at the same time, encouraging attentional
switching and dual-task paradigms. The player must switch their attention between the
neuron trees’ location, the n-back task memorization, their health points, and the otters,
fully engaging their cognitive load. For example, the player may find themselves fend-
ing off neuron trees, trying to memorize the n-back task hint and trying to feed the otters
4 Future Work
The retention of pain experience metaphors and how they translate to new patients
would help distinguish Mobius Floe from ordinary games. For example, do the helpful
sea otters naturally correlate to feelings of comfort, friends or family? How does the
health point mechanic translate to patient’s experiences? Do the depictions of drugs and
how they operate in the virtual space realistically represent pain patient’s affective ex-
periences? We will conduct several case studies with patients from Greater Vancouver
to help evaluate the existing pain experience metaphors as well as the effectiveness of
cognitive distraction and perceived pain reduction within Mobius Floe. To do so will
help situate the position of Mobius Floe within the research field and provide further
context as to where the development of Mobius Floe should gravitate toward.
Fig. 2. Two otters greeting the player. ‘HP’ is visually represented as a red icicle in the top left.
Choo · Tong · Gromala · Hollander
5 References
[1] Baliki, Marwan et al. “Chronic Pain and the Emotional Brain: Specific Brain
Activity Associated with Spontaneous Fluctuations of Intensity of Chronic Back
Pain.” The Journal of Neuroscience 26.47 (2006): 12165–12173.
[2] Church, Doug. “Formal Abstract Design Tools.” Game Developer 6.8 (1999):
[3] Das, Debashish et al. “The Efficacy of Playing a Virtual Reality Game in Mod-
ulating Pain for Children with Acute Burn Injuries: A Randomized Controlled
Trial.” BMC Pediatrics 5.1 (2005): n. pag.
[4] Faiola, Anthony et al. “Correlating the Effects of Flow and Telepresence in Vir-
tual Worlds: Enhancing Our Understanding of User Behavior in Game-Based
Learning.” Computers in Human Behavior 29.3 (2003): 1113–1121.
[5] Herff, Christian et al. “Mental Workload during N-Back Task—quantified in
the Prefrontal Cortex Using fNIRS.” Frontiers in Human Neuroscience 7
(2013): 935.
[6] Hoffman, Hunter et al. “The Effectiveness of Virtual Reality for Dental Pain
Control: A Case Study.” Cyberpsychology & Behavior 4.4 (2001): 527–535.
[7] Hoffman, Hunter, David Patterson, and Gretchen Carrougher. “Use of Virtual
Reality for Adjunctive Treatment of Adult Burn Pain During Physical Therapy:
A Controlled Study.” The Clinical Journal of Pain 16.3 (2000): 244–250.
[8] Maani, Christopher et al. “Pain Control During Wound Care for Combat-Re-
lated Burn Injuries Using Custom Articulated Arm Mounted Virtual Reality
Goggles.” Journal of CyberTherapy & Rehabilitation 1.2 (2008): 193–198.
[9] Schubert, Damion. “Narrative and Player Agency.” Game Developer 18.2
(2011): 58.
[10] Shahrbanian, Shahnaz et al. “Scientific Evidence for the Effectiveness of Virtual
Reality for Pain Reduction in Adults with Acute or Chronic Pain.” 7 (2009):
[11] Wickens, Christopher. “Multiple Resources and Performance Prediction.” The-
oretical Issues in Ergonomics Science 3.2 (2002): 159–177.
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The present study explored whether immersive virtual reality can serve as an effective non-pharmacologic analgesic for dental pain. Two patients (aged 51 and 56 years old) with adult periodontitis, a chronic, progressive inflammatory disease that affects gums, ligaments, and bones around the teeth, were studied in the treatment room of a periodontist. Each patient received periodontal scaling and root planing (scraping off/removing plaque deposits below the gum line, hereafter referred to as scaling) under three treatment conditions: (1) virtual reality distraction, (2) movie distraction, and (3) a no-distraction control condition. Condition order was randomized and counterbalanced. For each of the three treatment conditions, five visual analog pain scores for each treatment condition served as the dependent variables. On 0-10 labeled scales, both patients provided sensory and affective pain ratings, and subjective estimates of time spent thinking about his pain during the procedure. For patient 1, mean pain ratings were in the severe range while watching a movie (7.2), or no distraction (7.2) but in the mild pain range (1.2) during the VR condition. Patient 2 reported mild to moderate pain with no distraction (mean = 4.4), mild pain while watching the movie (3.3), and essentially no pain while in VR (0.6) during his periodontal scaling. Although the small sample size limits generalizability, we contend that virtual reality is a uniquely attention-grabbing medium capable of maximizing the amount of attention drawn away from the "real world," allowing patients to tolerate painful dental procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable adjunctive nonpharmacologic analgesia for procedural dental/periodontal pain. Virtual reality may also have analgesic potential for other painful procedures or pain populations. Practical implications are discussed.