Virtual reality as complementary pain therapy in hospitalized patients with sickle cell disease

Virtual reality used to distract children and young people with long-term conditions from pain or pruritus: A scoping review using PAGER

AIMS AND OBJECTIVES

To map out the primary research studies relating to how virtual reality (VR) has been used to distract children and young people with long-term conditions from pain or pruritus.

BACKGROUND

Pharmacologic treatment of chronic pain and pruritus may have side effects; hence, non-invasive non-pharmacological treatments are being sought.

DESIGN

The scoping review followed the methodology recommended by the Joanna Briggs Institute, PAGER framework and PRISMA-ScR checklist. The protocol was registered with the Open Science Registration on 14 February 2022 https//doi.org/10.17605/OSF.IO/K2R93.

METHODS

Five databases (Medline, CINAHL, PsycINFO, Web of Science and Scopus) were searched. Data were extracted from primary research studies published between 2000 and 2022 involving children and adolescent populations (<21 years) with a long-term condition that had an element of enduring pruritus and/or pain.

RESULTS

Of 464 abstracts screened, 35 full-text papers were assessed with 5 studies meeting the eligibility criteria. Three main themes emerged from the included studies: (1) Improvements in pain and daily functioning; (2) positive perceptions of VR and (3) accessibility and feasibility of VR. No papers were found on the effect of VR on alleviating pruritus.

CONCLUSION

VR is feasible, acceptable, and safe for children and adolescents with chronic pain in a range of long-term conditions and offers promise as an adjunctive treatment for improving chronic pain and quality of life. No studies were identified that targeted pruritis or measured pruritis outcomes; thus, the effects of VR for pruritis are unknown. There is a need for rigorously designed, randomised controlled trials to test the clinical and cost-effectiveness of VR interventions for chronic pain and pruritis in children and adolescents. The use of the PAGER (Patterns, Advances, Gaps, Evidence for Practice and Research Recommendations) framework for scoping reviews helped to structure analysis and findings and identify research gaps.

RELEVANCE TO CLINICAL PRACTICE

VR interventions offer promise in improving chronic pain related to long-term conditions.

Use of Virtual Reality in Physical Therapy as an Intervention and Diagnostic Tool

Within the past decade, the integration of computer-generated virtual realities (VRs) has witnessed a significant rise in the field of healthcare, particularly in diagnosis and treatment applications. These VR systems have found extensive use in physical therapy, rehabilitation, research, and assessment. This narrative review article is aimed at providing a comprehensive overview of the literature regarding the implementation of VR in the physical therapy profession. The primary objective of this review is to provide information to clinicians about the diverse applications of VR and its potential advantages in intervening across various patient populations and diagnoses during rehabilitation therapy. Through in-depth discussions with experts and a thorough review of pertinent literature, several significant aspects of the topic were identified. Subsequently, we carried out an online search to investigate the prevalent utilization of VR systems within healthcare, both as assessment tools and for therapeutic interventions. Our examination encompassed a total of 56 articles, with supplementary references incorporated as required.

Preoperative Virtual Reality to Expose Patients With Breast Cancer to the Operating Room Environment: Feasibility and Pilot Case Series Study

BACKGROUND

Clinically elevated preoperative distress and anxiety are common among patients undergoing cancer surgery. Preoperative interventions have been developed to mitigate this distress and anxiety but are inconsistent in efficacy and feasibility for broad implementation.

OBJECTIVE

This preliminary pilot study aims to assess the feasibility and utility of a newly developed virtual reality (VR) intervention to expose patients awaiting breast cancer surgery to the operating room environment and a simulation of anesthetic induction.

METHODS

Patients undergoing breast cancer surgery (N=7) were assigned to the VR intervention or control (treatment as usual) group and completed self-report measures of distress and anxiety before surgery, on the day of surgery, and after surgery (5 and 30 d postoperatively). Those in the intervention group trialed the VR simulation 1 to 2 weeks preoperatively and provided qualitative and quantitative feedback. We assessed the feasibility of recruitment capability and study design and evaluated participants' impressions of the intervention using self-report rating scales and open-ended questions. We also descriptively examined distress and anxiety levels throughout the duration of the study.

RESULTS

Recruitment occurred between December 2021 and December 2022 and progressed slowly (rate: 1 participant/7 wk on average; some hesitancy because of stress and being overwhelmed). All participants who consented to participate completed the entire study. All participants were female and aged 56 (SD 10.56) years on average. In total, 57% (4/7) of the participants were assigned to the intervention group. On average, intervention participants spent 12 minutes engaged in the VR simulation. In general, the intervention was rated favorably (eg, clear information, enjoyable, and attractive presentation; mean% agreement 95.00-96.25, SD 4.79-10.00) and as helpful (mean% agreement 87.50, SD 25.00). Participants described the intervention as realistic (eg, "It was realistic to my past surgical experiences"), impacting their degree of preparedness and expectations for surgery (eg, "The sounds and sights and procedures give you a test run; they prepare you for the actual day"), and having a calming or relaxing effect (eg, "You feel more relaxed for the surgery").

CONCLUSIONS

This preoperative VR intervention demonstrated preliminary feasibility among a sample of patients undergoing breast cancer surgery. Results and participant feedback will inform modifications to the VR intervention and the study design of a large-scale randomized controlled trial to examine the efficacy of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04544618; https://clinicaltrials.gov/study/NCT04544618.

[The prospect of using virtual reality technology in combination with psychotherapeutic methods in children with functional abdominalgia]

OBJECTIVE

The literature review addresses the effectiveness of psychotherapeutic methods in the treatment of functional abdominal pain syndrome and studying the prospects for using virtual reality technology in combination with psychotherapeutic methods according to the available literature.

MATERIAL AND METHODS

A search was conducted for available literature in the eLibrary and PubMed databases, published for the period 2017-2022, using the keywords: abdominalgia, psychotherapeutic methods, gut-brain axis, virtual reality technology.

RESULTS

Currently, the biopsychosocial concept of the etiopathogenesis of abdominal pain syndrome, which is not associated with an organic disease of the gastrointestinal tract, is used. A significant contribution to the formation of the disease is made by genetic, neuropsychological, neurophysiological factors, and disruption of the interaction of the gut-brain axis. Cognitive behavioral therapy, yoga, and hypnotherapy are applicable as effective psychotherapeutic methods in the complex treatment of abdominal pain syndrome in children. A promising direction is the use of virtual reality technology to increase the effectiveness of psychotherapeutic methods and reduce chronic abdominal pain syndrome by influencing the gut-brain axis. Practical research work devoted to this issue is currently rare.

CONCLUSION

In the complex treatment of functional abdominal pain syndrome in children, various psychotherapeutic methods are used, the most effective are cognitive behavioral therapy and hypnotherapy. It is necessary to stimulate domestic research work studying the joint use of virtual reality technology and psychotherapeutic methods in children aged 7 to 18 years.

Psychoneuroimmunological Markers of Psychological Intervention in Pediatric Cancer: A Systematic Review and New Integrative Model

PURPOSE

Pediatric cancer is a serious problem and still becomes a global challenge today. Various complex stressors due to diagnosis, disease symptoms, and various side-effects from the treatment that children with cancer undergo will cause problems in the child's psychoneuroimmunological aspects. Psychological interventions designed to modulate the stress response include psychoneuroimmunological markers. Unfortunately, there is little evidence to support the effect of psychological interventions on psychoneuroimmunological markers. This systematic review aims to assess the effectiveness of psychological interventions on psychoneuroimmunological markers in children with cancer and to provide a new integrative model for further research.

METHODS

This systematic review uses four main databases (Scopus, PubMed, ScienceDirect, and ProQuest). The guideline used Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Selecting articles used the Rayyan application. The quality study was conducted using Joanna Briggs Institute (JBI)'s critical appraisal tools. The data were analyzed using the population, intervention, comparison, outcome, and study design (PICO) Synthesis based on similarities and differences in study characteristics to interpret the results.

RESULTS

The search results in this systematic review found 1653 articles, 21 of which matched the predetermined inclusion and exclusion criteria. Most of the designs used were randomized controlled trials (57.1%). Massage therapy was the most common type of psychological intervention (14.2%). Almost half of the studies measured psychological responses (38.0%), and psycho-physiological responses (42.9%), and only a small proportion assessed the effectiveness of psychological interventions on neuroimmunological markers in pediatric cancer.

CONCLUSIONS

We recommend the use of psychological interventions as an additional intervention in managing psychoneuroimmunological markers of pediatric cancer. This study offers a new integrative model demonstrating the interaction between stress and psychological intervention involving neuroendocrine and immune mechanisms. However, future researchers need to test all domains of these new integrative models. This will reveal the complex interactions among these components and understand their relevance to health outcomes.

Non-pharmacological pain interventions for sickle cell crisis in pediatrics: A scoping review

PROBLEM

Sickle cell crises (SCC) are recurrent, severe pain episodes experienced by people living with sickle cell disease (SCD). Non-pharmacological interventions have been recommended for SCC pain management however, little is known about the impact of these interventions on SCC pain. This scoping review aims to systematically identify evidence on the use and effectiveness of non-pharmacological interventions for pain management during SCC in the pediatric population.

ELIGIBILITY CRITERIA

Studies were eligible if they are published in English and focusing on the use of any non-pharmacological interventions on pain during SCC in pediatric patients. Nine databases were searched including Medline, CINAHL and PsychInfo. Also, the reference lists of relevant studies were searched.

SAMPLE

The database searching yielded 1517 studies. After the title and abstract screening, 1348 studies were excluded, and 169 full texts were retrieved and screened. One study was identified through handsearching. Finally, 27 articles were included in this scoping review.

RESULTS

Across all studies, 27 different non-pharmacological interventions were identified. There were inconsistent results regarding the effectiveness of virtual reality, guided imagery, and cognitive-behavioral interventions in experimental studies. The most common interventions used at home were prayer, massage, and distraction. The main interventions used in hospitals were prayer and fluid intake, but this was explored by a few studies.

CONCLUSION

Pediatric SCD patients use numerous non-pharmacological interventions to manage pain during SCC. However, the impact of many interventions on SCC pain has not been empirically investigated.

IMPLICATIONS

Further research is necessary to establish the effectiveness of non-pharmacological interventions on SCC pain.

Interventions to Reduce Pediatric Anxiety During Orthopaedic Cast Room Procedures: A Systematic and Critical Analysis Review

BACKGROUND

Cast room procedures can be a source of considerable distress for pediatric patients. High levels of anxiety can make it difficult to perform procedures effectively and may negatively affect the doctor-patient relationship. We sought to evaluate available interventions to reduce anxiety in pediatric patients undergoing orthopaedic cast room procedures.

METHODS

Following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, we performed a systematic review to answer our study question (PROSPERO registration of the study protocol: CRD42022333001, May 28, 2022). PubMed, EBSCO host, MEDLINE, Cochrane, and Google Scholar electronic databases were used to identify all studies evaluating interventions to reduce pediatric anxiety during orthopaedic cast room procedures between January 1, 1975, and June 1, 2022. The quality of included studies was assessed using the Jadad scale.

RESULTS

Our initial search yielded 1,490 publications, which were then screened for appropriate studies that aligned with the purpose of our review. Fourteen studies comprising 8 prospective cohort and 6 randomized controlled trials were included. The total sample size of included studies consisted of 1,158 patients with participant age ranging from 1 to 21 years. The interventions investigated included noise reduction headphones, musical therapy, inclusion of a certified child life specialist, casting shears, virtual reality, Bedside Entertainment and Relaxation Theater (BERT), children's and instructional videos, and video games. Most of the included interventions were effective at reducing anxiety during cast room procedures. However, there was variation in anxiety reduction across cast room procedure and treatment modality.

CONCLUSION

The use of physical or technology-based distraction tools can play an important interventional role in improving patient satisfaction during cast room procedures. The majority were inexpensive, readily applicable to the clinical setting, and of negligible risk to the patient.

LEVEL OF EVIDENCE

Level II. See Instructions for Authors for a complete description of levels of evidence.

Complementary and alternative medicine for children with sickle cell disease: A systematic review

BACKGROUND

Complementary and alternative medicine (CAM) is a popular alternative to opioid and other analgesics in sickle cell disease (SCD). We review the effectiveness, prevalence, and factors associated with CAM use in the pediatric SCD population.

METHODS

The review protocol was created based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search was conducted in MEDLINE, Embase, Cochrane Library, PubMed, and Web of Science.

RESULTS

Twenty-four studies were examined. The prevalence of CAM use in pediatric patients with SCD ranged from 36 to 84.5%. Common inpatient CAM interventions were yoga, virtual reality, and acupuncture, which decreased pain scale scores. Outpatient CAMs were consisted of cognitive behavioral therapy, massage therapy, and guided-imagery, which increased pain tolerability and decreased pain scale scores.

CONCLUSIONS

CAM modalities can decrease pain scale scores. However, the impact of specific CAM modalities on emergency department visits, hospitalizations, and school absences were inconclusive.

Virtual Reality as Anxiolysis During Laceration Repair in the Pediatric Emergency Department

BACKGROUND

Although procedural pain is effectively treated with analgesics, managing anxiety during laceration repair is more challenging.

OBJECTIVES

We examined the feasibility of using immersive virtual reality (VR) as anxiolysis during laceration repair in the pediatric emergency department (ED).

METHODS

We conducted a non-blinded, observational, pilot study in an urban pediatric ED that enrolled a convenience sample of children aged 5-13 years undergoing sutured repair of non-facial lacerations. Subjects played an immersive VR game while undergoing laceration repair. Parents assessed their child's anxiety on a 100-mm visual analogue scale at enrollment and during laceration repair. The primary outcome measure was the percentage of children whose anxiety score did not increase by ≥ 20 mm from enrollment to the first stitch.

RESULTS

Forty patients completed the study. Mean initial anxiety score was 54 mm (standard deviation 33 mm). Thirty-seven of forty patients (93%; 95% confidence interval [CI] 83-99%) had anxiety scores that did not increase by 20 mm or more from enrollment to the first stitch. Eighty percent (95% CI 64-91%) of patients' anxiety scores decreased between enrollment and first stitch. The mean change in anxiety score at first stitch was -39 mm (95% CI -51 mm to -27 mm; p < 0.001). Similar downward trends in anxiety scores were noted throughout the procedure. All laceration repairs were successfully completed without sedation or restraints. There were no adverse events noted, and the main barriers identified with VR use involved easily correctable technical difficulties with the equipment.

CONCLUSION

Immersive VR is a safe and effective distractive technique to reduce procedural anxiety during laceration repair in the pediatric ED.

The State of Science in the Use of Virtual Reality in the Treatment of Acute and Chronic Pain: A Systematic Scoping Review

Previous reviews have reported virtual reality (VR) to be an effective method to treat pain. This scoping review examines the state of the science for VR and pain both generally and by pain type (acute and chronic) related to types of mechanisms, dosage, effectiveness, and adverse events (AEs). We searched online databases PubMed, Web of Science, PsychInfo, and CINAHL from 2010 to 2020 and included studies from peer reviewed journals that examined people with pain, (excluding pain-free participants) with a primary outcome measuring pain. We assessed studies for risk of bias using PEDro criteria. We described data through counts and percentages. Significant results were determined through P-values. We found 70 studies representing 4105 people; 46 acute pain studies (65.7%), 22 chronic pain studies (31.4%), and 2 (2.9%) "both." The most common VR mechanism was distraction (78.6%) then embodiment (17.1%). However, distraction was the mechanism for 97.8% acute pain studies while embodiment was more common for chronic pain (54.5%). Dosage of VR was inconsistently reported and varied considerably. VR treatment groups showed significant improvements in pain, particularly for intensity of pain (72.1%) and quality of pain (75.0%). Few studies examined AEs. Limitations of this review include only examining last 10 years of articles and that many studies were missing data. VR appears to be an effective intervention to address both acute and chronic pain. Research evaluating VR mechanisms, dosage, and AEs is warranted, as is further work in under-served populations (children for chronic pain and older adults) as the current evidence is largely limited to adult populations with pain.

Virtual Reality for Distraction and Relaxation in a Pediatric Hospital Setting: An Interventional Study With a Mixed-Methods Design

Accumulating evidence supports the use of virtual reality (VR) as an effective pain and anxiety management tool for pediatric patients during specific medical procedures in dedicated patient groups. However, VR is still not widely adopted in everyday clinical practice. Feasibility and acceptability measures of clinicians' experiences are often missing in studies, thereby omitting an important stakeholder in VR use in a clinical setting. Therefore, the aim of this mixed-methods study was to investigate the feasibility, acceptability, tolerability (primary outcomes), and preliminary effectiveness (secondary outcome) of Relaxation-VR in both pediatric patients aged 4–16 years and clinicians. Relaxation-VR is a VR application prototype aimed to provide distraction and relaxation for a variety of patient populations and procedures and is used to reduce anxiety, stress (tension) and pain for children in hospital. Multiple measures of acceptability, feasibility and tolerability, and pre-to-post changes in measures of pain, anxiety, stress and happiness were assessed in pediatric patients. At the end of the study, acceptability and feasibility of VR use was assessed in clinicians. Results indicate that VR use (in particular, the Relaxation-VR prototype) for both distraction and relaxation is acceptable, feasible and tolerable for a variety of pediatric patients aged 4–16 years, as assessed in both patients and clinicians, and can reduce anxiety, pain and tension (stress), and increase happiness in a hospital setting.

Virtual Reality in the Pediatric Intensive Care Unit: Patient Emotional and Physiologic Responses

Context

Patients in the Pediatric Intensive Care Unit (PICU) are limited in their ability to engage in developmentally typical activity. Long-term hospitalization, especially with minimal interpersonal engagement, is associated with risk for delirium and delayed recovery. Virtual reality (VR) has growing evidence as a safe, efficacious, and acceptable intervention for pain and distress management in the context of uncomfortable healthcare procedures, and for enhancing engagement in, and improving outcomes of rehabilitation therapy.

Hypothesis

Critically ill children may experience high levels of engagement and physiologic effects while engaging with VR.

Methods and Models

This cross-sectional study of 3–17-year-old children admitted to a PICU used a VR headset to deliver 360-degree immersive experiences. This study had a mixed-method approach, including standardized behavioral coding, participant and parent surveys, and participant physiologic responses. Investigators noted comments the child made about VR, observed emotional responses, and documented an engagement score. To determine physiologic response to VR, integer heart rate variability (HRVi) was collected 30 min before, during, and 30 min after VR.

Results

One hundred fifteen participants were enrolled from 6/18 to 10/19, and they interacted with VR for a median of 10 min (interquartile range 7–17). Most children enjoyed the experience; 83% of participants smiled and 36% laughed while using VR. Seventy-two percent made positive comments while using VR. The strongest age-related pattern regarding comments was that the youngest children were more likely to share the experience with others. Seventy-nine percent of participants were highly engaged with VR. Ninety-two percent of parents reported that VR calmed their child, and 78% of participants felt that VR was calming. HRVi Minimum scores were significantly higher during VR than pre- (p < 0.001) or post-VR (p < 0.001). There was no significant difference between pre-and post-VR (p = 0.387); therefore, children returned to their pre-intervention state following VR.

Interpretations and Conclusions

Children admitted to the PICU are highly engaged with and consistently enjoyed using VR. Both participants and parents found VR to be calming, consistent with intra-intervention physiologic improvements in HRVi. VR is an immersive tool that can augment the hospital environment for children.

Biopsychosocial Predictors of Quality of Life in Paediatric Patients With Sickle Cell Disease

Sickle cell disease (SCD) refers to a group of inherited blood disorders with considerable morbidity that causes severe pain, reduces life expectancy, and requires significant self-management. Acute painful episodes are the hallmark of SCD, but persistent daily pain is also highly prevalent in this population. Characterising the impact and experience of SCD-related morbidity (i.e., sleep disruption, frequent emergency department visits, cognitive dysfunction) on health-related quality of life (HRQOL) requires multiple assessment methods to best capture the underlying mechanisms. To gain a greater understanding of the effect of common symptom categories on HRQOL and to determine potential pain coping targets, the present study investigated whether demographic, socioeconomic, sleepiness, pain burden, frequency of emergency department (ED) visits, and cognition predicted HRQOL in a paediatric sample of patients with SCD. Our study was a secondary analysis of baseline assessment data of children with SCD aged 8-15 years (n = 30) in the Prevention of Morbidity in Sickle Cell Anaemia Phase 2b (POMSb2) randomised controlled clinical trial of auto-adjusting continuous positive airways pressure. Patients completed cognitive testing (IQ, Processing Speed Index, Delis-Kaplan Executive Function Scale (DKEFS) Tower, Conner's Continuous Performance Test), sleepiness (Epworth Sleepiness Scale), and HRQOL (PedsQL Sickle Cell Module) at baseline. Patients reported pain burden (Sickle Cell Pain Burden Inventory-Youth) each month over 8 visits. Caregivers provided demographic information and reported their child's executive function (Behavioural Rating Inventory of Executive Function) at baseline. Data from our analysis demonstrated that demographic factors (i.e., age, gender, level of neighbourhood deprivation) and treatment variables (i.e., hydroxyurea use) did not independently predict HRQOL, and laboratory values (i.e., haemoglobin, haematocrit, mean oxygen saturation) were not significantly correlated with HRQOL (ps > 0.05). However, sleepiness, pain burden, ED visits, and executive dysfunction independently predicted HRQOL (R ² = 0.66) with large effects (η² = 0.16 to 0.32). These findings identify specific, measurable symptom categories that may serve as targets to improve HRQOL that are responsive to change. This knowledge will be useful for multimodal interventions for paediatric patients with SCD that include sleep management, pain coping strategies, and executive function training.

Pain in sickle cell disease: current and potential translational therapies

Pain is a major comorbidity of sickle cell disease (SCD). Patients with SCD may suffer from both acute and chronic pain. Acute pain is caused by recurrent and unpredictable episodes of vaso-occlusive crises (VOC), whereas the exact etiology of chronic pain is still unknown. Opioids are the mainstay for pain treatment, but the opioid epidemic has significantly altered access to prescription opioids and has brought concerns over their long-term use into the forefront, which have negatively impacted the treatment of sickle pain. Opioids remain potent analgesics but growing opioid-phobia has led to the realization of an unmet need to develop nonopioid therapies that can provide relief for severe sickle pain. This realization has contributed to the approval of 3 different drugs by the Food and Drug Administration (FDA) for the treatment of SCD, particularly to reduce VOC and/or have an impact on the pathobiology of SCD. In this review, we outline the challenges and need for validation of side-effects of opioids and provide an update on the development of mechanism-based translational therapies, specifically targeting pain in SCD.

Addressing virtual reality misclassification: A hardware-based qualification matrix for virtual reality technology

Through its unique sensory synchronized design, virtual reality (VR) provides a convincing, user-centred experience of highly controllable scenarios. Importantly, VR is a promising modality for healthcare, where treatment efficacy has been recognized for a range of conditions. It is equally valuable across wider research disciplines. However, there is a lack of suitable criteria and consistent terminology with which to define VR technology. A considerable number of studies have misclassified VR hardware (e.g. defining laptops as VR), hindering validity and research comparisons. This review addresses these limitations and establishes a standardized VR qualification framework. As a result of a comprehensive theoretical and literature review, the hardware-based VR qualification matrix is proposed. The matrix criteria consist of (1) three-dimensional (3D) synchronized sensory stimulation; (2) degrees of freedom tracking; and (3) visual suppression of physical stimuli. To validate the model and quantify the current scale/diversity of VR misclassification, a 2019 sectional review of health-related studies was conducted. Of the 115 studies examined against standardized criteria, 35.7% utilized VR, 31.3% misclassified VR, 18.3% were considered quasi-VR, and 14.8% omitted critical specifications. The proposed model demonstrates good validity and reliability for qualifying and classifying VR. Key Practitioner Messages Virtual reality (VR) therapy has gained rapid empirical support, although many practitioners do not understand the difference between genuine and less-realistic VR variations. That has resulted from an evident lack of suitable criteria to define VR across a range of studies and protocols. Our proposed hardware-based virtual reality qualification matrix addresses issues to do with misclassification, via the introduction of standardised criteria. Applying the matrix to existing literature has revealed that more than 30% of VR studies use hardware that does not fit the high standards of rigour required for immersion in a simulated space. The model is a practical tool researchers and practitioners can use to quality and verify VR standards across research studies.

Resource Use During Pediatric Venipuncture With Virtual Reality: Secondary Analysis of a Randomized Controlled Pilot Trial

OBJECTIVES

Virtual reality (VR) therapy is growing in use and popularity during pediatric medical procedures. Currently, data that describe the hospital resources used during pediatric procedures with off-the-shelf VR games that are not tailored to medical procedures are lacking. In this study, we aimed to characterize procedural resources associated with VR use during venipuncture in a pediatric emergency department.

METHODS

This was a secondary analysis of a 2-arm randomized, controlled pilot trial with an external group. Resource use was evaluated in 3 groups: child life (CL)-supported VR engagement, CL support without VR, and a reference group that received no intervention (ie, no CL and no VR).

RESULTS

The study sample (N = 55) included the following: 15 patients randomly assigned to VR, 20 patients randomly assigned to CL, and 20 patients in the reference group. There was a significant difference in procedure duration, with the VR group exhibiting the longest duration compared with the CL and reference groups (P = .01).

CONCLUSIONS

Longer procedure times associated with VR use during venipunctures (4-6 minutes on average) may be attributed to pauses to troubleshoot VR games not tailored for medical procedures. Although they are inexpensive and accessible, nontailored VR games may warrant the need for dedicated staff to provide restraint and/or assistance to navigate the VR application. In this study, we offer a protocol on the application of nontailored VR games for pediatric procedures. For those considering a VR program in an inpatient setting, the benefits of pain/anxiety reduction must be weighed against the resources needed, including device costs, staff availability, and increased procedure duration.

Pain management in children during invasive procedures: A randomized clinical trial

AIMS

This study was performed to determine the effect of distraction technique that was applied to 4-6-year-old children during blood drawal for decreasing the pain of the child during the procedure.

MATERIAL AND METHODS

The study was carried out as randomized controlled trial. Data were collected by individual information form, Faces Pain Scale-Revised (FPS-R), and a timer. Virtual reality glasses were used for distraction in the study.

RESULTS

Pain intensity and duration of crying significantly differed between the control and experimental groups. During the procedure, mean score of the children in the experimental group from "faces pain scale" was found to be 3.82 ± 1.20; the control group from "faces pain scale" was found to be 6.96 ± 2.08; and statistically significant differences were detected between both groups (p = 0.0001 and p = 0.001, respectively). When their duration of crying was examined, it was determined that mean crying time among the children in the experimental group was 8.43 ± 12.42 s and it was 33.65 ± 24.02 s among the children in control group; and the difference between groups was found to be statistically significant.

CONCLUSION

It was detected that using virtual reality glasses was an effective method in decreasing pain of the children during blood drawal procedure.

American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain

BACKGROUND

The management of acute and chronic pain for individuals living with sickle cell disease (SCD) is a clinical challenge. This reflects the paucity of clinical SCD pain research and limited understanding of the complex biological differences between acute and chronic pain. These issues collectively create barriers to effective, targeted interventions. Optimal pain management requires interdisciplinary care.

OBJECTIVE

These evidence-based guidelines developed by the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in pain management decisions for children and adults with SCD.

METHODS

ASH formed a multidisciplinary panel, including 2 patient representatives, that was thoroughly vetted to minimize bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic reviews. Clinical questions and outcomes were prioritized according to importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery.

CONCLUSIONS

Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions.

Pain Experience, Physical Function, Pain Coping, and Catastrophizing in Children With Sickle Cell Disease Who Had Normal and Abnormal Sensory Patterns

CONTEXT

Sickle cell disease (SCD) is associated with recurrent pain that could lead to abnormal sensory patterns (ASPs).

OBJECTIVES

The purpose of this study is to compare children with SCD who had normal sensory patterns (NSPs) and ASPs in pain experience, physical function, pain coping, and pain catastrophizing.

METHODS

Children with quantitative sensory testing data were selected from a larger study that examined pain and symptoms in children with SCD. Comparisons were made between children with NSP (n = 35; 13.9 ± 1.9 years) and ASP (n = 13; 12.8 ± 1.9 years). Children completed the Adolescent Pediatric Pain Tool, Functional Disability Inventory, Pain Coping Questionnaire, and Pain Catastrophizing Scale.

RESULTS

No significant differences were found in pain intensity (2.9 ± 3.0 vs. 2.6 ± 2.8 on 0-10 Visual Analogue Scale) between the NSP and ASP, respectively. The most common marked pain sites for both groups were lower extremities (22.9%), head and neck (20.8%), and upper extremities (20.8%). Functional Disability Inventory scores were significantly worse in ASP (38.5%) compared with NSP (11.4%). The ASP group had significantly worse scores in emotion-focused pain coping subscales.

CONCLUSION

Children with SCD with ASP had worse functional disability, were expressing more affective pain quality, and had emotion-focused pain coping compared with NSP. Future studies are needed to examine the effectiveness of physical activities on the physical function as well as psychosocial interventions such as peer support and creative arts expression to minimize development of ASP in children with SCD.

Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study

Background

In the field of pain, virtual reality (VR) technology has been increasingly common in the context of procedural pain management. As an interactive technology tool, VR has the potential to be extended beyond acute pain management to chronic pain rehabilitation with a focus on increasing engagement with painful or avoided movements.

Objective

We outline the development and initial implementation of a VR program in pain rehabilitation intervention to enhance function in youth with chronic pain.

Methods

We present the development, acceptability, feasibility, and utility of an innovative VR program (Fruity Feet) for pediatric pain rehabilitation to facilitate increased upper and lower extremity engagement. The development team was an interdisciplinary group of pediatric experts, including physical therapists, occupational therapists, pain psychologists, anesthesiologists, pain researchers, and a VR software developer. We used a 4-phase iterative development process that engaged clinicians, parents, and patients via interviews and standardized questionnaires.

Results

This study included 17 pediatric patients (13 female, 4 male) enrolled in an intensive interdisciplinary pain treatment (IIPT) program, with mean age of 13.24 (range 7-17) years, completing a total of 63 VR sessions. Overall reports of presence were high (mean 28.98; max 40; SD 4.02), suggestive of a high level of immersion. Among those with multisession data (n=8), reports of pain (P<.001), fear (P=.003), avoidance (P=.004), and functional limitations (P=.01) significantly decreased. Qualitative analysis revealed (1) a positive experience with VR (eg, enjoyed VR, would like to utilize the VR program again, felt VR was a helpful tool); (2) feeling distracted from pain while engaged in VR; (3) greater perceived mobility; and (4) fewer clinician-observed pain behaviors during VR. Movement data support the targeted impact of the Fruity Feet compared to other available VR programs.

Conclusions

The iterative development process yielded a highly engaging and feasible VR program based on qualitative feedback, questionnaires, and movement data. We discuss next steps for the refinement, implementation, and assessment of impact of VR on chronic pain rehabilitation. VR holds great promise as a tool to facilitate therapeutic gains in chronic pain rehabilitation in a manner that is highly reinforcing and fun.

Outpatient pain clinic and intranasal fentanyl to improve sickle cell disease outcomes

BACKGROUND

Acute pain events are a leading complication for sickle cell patients. In an attempt to improve pain outcomes, we developed an outpatient pain clinic, and included intranasal fentanyl in the opioid emergency department (ED) pain order set. We evaluated admission rates and opioid administration for patients that attended both the outpatient pain clinic and ED within a 3-month period.

METHODS

We recorded the admission rate, IV morphine equivalents, and time from triage for each opioid order and administration from both an outpatient pain clinic and ED visit within a 3-month period for an individual pediatric patient with sickle cell disease.

RESULTS

Thirty patients received acute pain management in both settings. We identified a significant reduction in hospital admission when patients received care in the pain clinic as compared to the ED (17% vs 43%, P = .02). Additionally, outpatient pain clinic patients received significantly less IV morphine equivalents than patients received in the ED (5.6 vs 10.6 IV morphine equivalents, P < .0001). In the ED, intranasal fentanyl was administered in a significantly shorter time than patients ordered intravenous opioid (43 vs 75 min, P = .02). The mean time to receiving an opioid in the outpatient pain clinic was 57 min.

CONCLUSION

The use of an outpatient pain clinic can reduce admission rates as compared to the ED. The use of intranasal fentanyl reduced the time to first opioid administration in the ED. Patient-centered research or quality improvement projects should continue to focus on novel approaches to acute pain event management.

Integrative approaches to treating pain in sickle cell disease: Pre-clinical and clinical evidence

Sickle cell disease (SCD) is a genetic disorder characterized by hemolysis, end-organ damage, inflammation, and pain. Recurrent and unpredictable episodes of acute pain due to vaso-occlusive crises are a unique feature of SCD. Many patients also develop lifelong chronic pain. Opioids are the primary method of pain treatment in SCD; however, continued use is associated with several adverse effects. Integrative approaches to treating pain in SCD are increasingly being explored to prevent the side effects associated with opioids. In this review, we highlight the mechanisms of pain in SCD and describe mechanism-based integrative approaches for treating pain.

A Comprehensive Review of the Treatment and Management of Pain in Sickle Cell Disease

PURPOSE OF REVIEW

Sickle cell disease (SCD) is a hematological disorder which leads to serious complications in multiple organ systems. While significant research has addressed many of the effects of acute pain episodes and end-organ damage connected to this disease, little has approached the chronic pain state associated with this condition.

RECENT FINDINGS

Associated chronic pain represents a significant detractor from the quality of life experienced by these patients, affecting over half of those with SCD on more days than not. Current treatment typically is centered upon preventing and responding to acute vasoocclusive crises, presumably because this is the most common reason for hospitalization in these patients. The lack of management of chronic pain symptoms leaves many with SCD in a state of suffering. In this review, the treatment methodologies of SCD patients are examined including alternative treatments, both pharmaceutical and non-pharmaceutical, as well as procedural approaches specifically aimed at reducing chronic pain in these patients.

Use of virtual reality for epidural placement in an adolescent with ischemic priapism

In children with chronic pain conditions, the acute pain and anxiety induced by routine procedures such as dressing changes, phlebotomy, and lumbar punctures may be amplified compared to that experienced by healthy children. However, sedatives and opiates may be contraindicated if respiratory depression is a concern. In this case report, we describe a 17‐year‐old male with ischemic priapism secondary to sickle cell disease in whom we used virtual reality immersion as a distraction method during epidural catheter placement. No sedation or analgesia was needed, and the patient reported no pain or distress.

Does virtual reality reduce pain in pediatric patients? A systematic review

Virtual Reality (VR) as a tool for pain reduction is the research topic of several clinical trial for Randomized Controlled Trials despite its wide use in the daily clinical practice for non- pharmacological reduction of pain in some countries. At present, there are no published reviews of VR-efficacy of pain reduction in pediatric patients. That is why we made a systematic review of the efficacy of VR as a tool for pain reduction in children and adolescents. Electronic databases and gray literature published between 2014 and 2019 were analyzed. A total of 9 studies were eligible according to the established inclusion criteria. Results show that virtual reality is a valid tool for non-pharmacological pain reduction and that this approach is to be preferred to the standard reduction techniques currently in use. However, more studies using standardized experimental methodologies are needed to provide more systematic comparison and quantitative synthesis.

An Innovative Virtual Reality Experience in the PICU: A Pilot Study

OBJECTIVES

Patients in the PICU frequently have limitations that impede independent interactions with their environment. Virtual reality is an immersive experience that may improve outcomes in critically ill children. The objective of this study was to assess feasibility and satisfaction with virtual reality.

DESIGN

Cross-sectional, single-arm pilot study.

SETTING

PICU.

PATIENTS

Convenience sample of 3- to 17-year-old patients.

INTERVENTIONS

Three-hundred sixty degree immersions were delivered using a simple virtual reality headset and smartphone videos. Each participant was given a choice of developmentally appropriate virtual reality experiences. Following the short (< 15 min) virtual reality experience, participants, and parents completed a brief survey.

MEASUREMENTS AND MAIN RESULTS

One-hundred percent of participants enjoyed using virtual reality, and 84% reported preference to use virtual reality for a longer duration. One-hundred percent of parents agreed that their child enjoyed using virtual reality, and 100% enjoyed watching their child use virtual reality. Eighty-two percent of parents reported that virtual reality calmed their child.

CONCLUSIONS

Virtual reality is an innovative, easily administered, and enjoyable tool that subjectively calms PICU patients in an otherwise chaotic environment.