Sustained efficacy of virtual reality distraction

Age and Sex Differences of Virtual Reality Pain Alleviation Therapeutic During Pediatric Burn Care: A Randomized Clinical Trial

Virtual reality (VR) effectively alleviates pain for pediatric patients during many medical procedures, such as venipuncture and burn care. In our previously published randomized clinical trial among 90 pediatric burn patients, participants in the active VR group had significantly lower scores for overall pain compared with participants in the standard care control and for worst pain compared with participants in the passive VR and control group. However, whether VR differs by a patient's age or sex remains unresolved. Thus, we reanalyzed our data by comparing the active and passive VR participants to evaluate how age and sex affect VR pain alleviation during dressing care for pediatric burns. In total, 90 patients aged 6-17 years (inclusive) with burn injuries were recruited from an outpatient burn clinic of an American Burn Association-verified pediatric burn center. Before randomization, VR helpfulness and need expectations were assessed on a visual analog scale (0-100). Participants were randomly assigned to active VR, passive VR, or control for one dressing change. Immediately following the dressing change, active and passive VR participants self-reported pain and the time spent thinking about pain and rated the VR features on the degree of realism, pleasure/fun, and perceived engagement level. Path analyses assessed how these VR features were interrelated and how they affected self-reported pain by age and sex. Patients aged 6-9 years reported higher mean expectations of VR helpfulness and need (mean = 73.6 and 94.5, respectively) than 10-12-year-olds (mean = 55.7 and 84.2, respectively) and 13-17-year-olds (mean = 68.6 and 77.4, respectively). The path analysis indicated VR engagement and fun were significantly correlated (p-value < 0.05). VR engagement significantly negatively impacted overall pain scores (coefficient = -0.45, -0.41; p-value < 0.05) and significantly positively impacted time thinking of pain (coefficient = 0.38, 0.32; p-value < 0.05). Younger patients had the highest expectations of VR helpfulness and need. VR game realism, fun, and engagement features were not statistically different between age groups and sexes. VR engagement and thinking of pain during burn dressing significantly positively affected self-reported pain (p-value < 0.05), suggesting an analgesic mechanism beyond distraction alone. Younger patients benefited more from VR than older patients.

Clinical application of virtual reality in patients with cardiovascular disease: state of the art

Virtual reality offers a multisensory experience to patients, allowing them to hear, watch, and interact in a virtual environment. Immersive virtual reality is particularly suitable for the purpose of completely isolating patients from the external environment to transport them away from the suffering related to the disease. On this state of the art, we summarize the available literature on the effectiveness of virtual reality on various physical and psychological outcomes in patients with atherosclerotic cardiovascular disease. Virtual reality has been employed in the cardiovascular field in various settings such as cardiac rehabilitation, interventional cardiology, and cardiac surgery. This technology offers promising opportunities to improve several outcomes related to cardiovascular disease, but further research is needed to entirely capture its benefits and to standardize the intervention.

Effects of immersive virtual reality for alleviating anxiety, nausea and vomiting among patients with paediatric cancer receiving their first chemotherapy: protocol for a randomised controlled trial

INTRODUCTION

Anxiety, nausea and vomiting are common side effects suffered by paediatric patients receiving chemotherapy. Emerging evidence supports the efficacy of immersive virtual reality (IVR) on improving anxiety and distress symptoms including nausea and vomiting in this vulnerable group. This trial aims to evaluate the effects of IVR intervention on anxiety, chemotherapy-induced nausea and vomiting and anticipatory nausea and vomiting in patients with paediatric cancer receiving first chemotherapy.

METHOD AND ANALYSIS

An assessor-blinded, randomised controlled trial with a mixed methods evaluation approach. On the basis of our pilot results, 128 chemotherapy-naive patients with paediatric cancer scheduled to receive their first intravenous chemotherapy will be recruited from a public hospital and randomly allocated to intervention (n=64) or control groups (n=64). The intervention group will receive the IVR intervention for three sessions: 2 hours before the first chemotherapy, 5 min before and during their first chemotherapy and 5 min before and during their second chemotherapy, respectively. The control group will receive standard care only. A subsample of 30 participants in the intervention group will be invited for a qualitative interview. Study instruments are: (1) short form of the Chinese version of the State Anxiety Scale for Children, (2) visual analogue scale for anticipatory nausea and vomiting, (3) Chinese version of the Multinational Association of Supportive Care in Cancer Antiemesis Tool and (4) individual face-to-face semistructured interviews to explore intervention participants' perceptions of the IVR intervention.

ETHICS AND DISSEMINATION

This study has been approved by the Hong Kong Children's Hospital Research Ethics Committee (HKCH-REC-2021-009). The findings will be disseminated in peer-reviewed journals and through local or interventional conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2100048732.

Virtual Reality for Decreasing Procedural Pain during Botulinum Toxin Injection Related to Spasticity Treatment in Adults: A Pilot Study

BACKGROUND AND OBJECTIVES

Botulinum toxin injections are commonly used for the treatment of spasticity. However, injection procedures are associated with pain and procedural anxiety. While pharmacological approaches are commonly used to reduce these, innovative technology might be considered as a potential non-pharmacological alternative. Given this context, immersive virtual reality (VR) has shown effectiveness in the management of procedural pain. Our retrospective pilot study aimed to assess the potential added value of virtual reality in the management of pain and anxiety during intramuscular injections of botulinum toxin.

MATERIALS AND METHODS

Seventeen adult patients receiving botulinum toxin injections were included. A numerical rating scale was used to assess pain and anxiety during the injection procedure. The patients reported the pain experienced during previous injections without VR before injection and the pain experienced in the current procedure with VR after the end of the procedure. The level of satisfaction of VR experience, whether or not they agreed to reuse VR for the subsequent toxin botulinum injection, and whether or not they would recommend VR to other patients were assessed.

RESULTS

The use of virtual reality led to a decrease of 1.8 pain-related points compared to the procedure without technology. No significant improvement in the level of anxiety was reported. Patients were very satisfied with their VR experiences (7.9 out of 10), and many would agree to reuse VR in their next injection procedure (88%) and to recommend the use of VR in other patients (100%).

CONCLUSION

VR was useful for managing procedural pain related to botulinum toxin injection in adults, with a high level of satisfaction reported by the patients. VR should be considered as a valuable alternative to pharmacological approaches to manage procedural pain during botulinum toxin injection in adults.

Remote cognitive behavioral therapy utilizing an in-home virtual reality toolkit (Vx Therapy) reduces pain, anxiety, and depression in patients with chronic cervical and lumbar spondylytic pain: A potential alternative to opioids in multimodal pain management

Background Context

Virtual reality (VR) reduces pain through visual and auditory distraction without narcotic-related side effects or dependency. Cognitive behavioral therapy (CBT) improves pain-related disability and quality of life, but patient access remains a challenge. We hypothesized that in-home weekly CBT coordinated with daily use of a proprietary VR toolkit will reduce pain, anxiety, and depression for patients with non-operative chronic cervical and lumbar spondylitic pain with and without radiculopathy.

Methods

A total of 145 patients with chronic spondylitic pain (63 cervical, 46 noradicular lumbar, 36 radicular lumbar) were enrolled into a guided 14-week VR+CBT program (Vx Therapy) consisting of weekly encounters with a trained therapist and 50 modules. Pain/anxiety severity scores and time to pain recurrence were recorded prospectively by patients. PROMIS measures of overall daily pain intensity, behavior, interference, anxiety, and depression were recorded at baseline and conclusion of the program.

Results

A total of 52% of the 145 patients were male. The average (SD) age of the cohort was 51 (10.7) years (range: 24-76 years). Mean score for all PROMIS domains were significantly improved after 14 weeks of Vx Therapy (pain intensity 36±24 vs. 28±21, interference 39±25 vs. 24±21, behavior 35±21 vs. 25±16, anxiety 51±28 vs. 41±26, depression 58±32 vs. 48±32) for the entire cohort and each diagnosis group. Virtual reality acutely reduced pain on average by 33% (4.5±2.5 vs. 6.7±2.2, p<.05) across all 14 weeks, lasting a mean 2.8 hours after use. Duration of pain relief increased by the final vs. first month (4.5 hours vs. 2.5 hours, p<.05). Virtual reality acutely reduced anxiety on average by 46% (3.5±3 vs. 6.4±2, p<.05) across all 14 weeks lasting a mean 2.7 hours after use. The effect was similar for all 3 groups.

Conclusions

Fourteen weeks of a remote CBT guided in-home VR toolkit provided effective and sustained pain, anxiety, and depression relief in patients with chronic degenerative neck/back pain with and without radiculopathy. The non-invasive, non-pharmacological nature of Vx Therapy makes it an ideal option for pain management in the post-opioid epidemic era.

Assessment of the Objective Effect of Virtual Reality for Preoperative Anxiety in Interventional Cardiology

The management of anxiety because of upcoming invasive coronary angiography (ICA) remains suboptimal. Previously published studies investigating the potential of virtual reality (VR) for the reduction of anxiety in ICA procedures used a subjective evaluation method. The purpose of this study was to determine whether the use of a VR program before ICA objectively decreases anxiety as assessed by the SD of normal to normal (SDNN). Lower SDNN is associated with worse anxiety. A total of 156 patients referred for ICA after a positive noninvasive test for coronary disease were included in the present randomized study. The interventional group benefited from the use of a VR mask in the transfer room before ICA, whereas the control group underwent the procedure as usual. In both groups, SDNN was measured before ICA. No statistical difference in SDNN was observed between the VR and control groups (45.5 ± 17.8 vs 50.6 ± 19.5, p = 0.12). The preoperative use of a VR mask for anxiolytic purposes in the setting of ICA did not result in a decrease in anxiety.

Virtual Reality Applications in Chronic Pain Management: Systematic Review and Meta-analysis

BACKGROUND

Virtual reality (VR) is a computer technology that immerses a user in a completely different reality. The application of VR in acute pain settings is well established. However, in chronic pain, the applications and outcome parameters influenced by VR are less clear.

OBJECTIVE

This review aimed to systematically identify all outcome parameters that are reported in relation to VR in patients with chronic pain.

METHODS

A total of 4 electronic databases (PubMed, Scopus, Web of Science, and Embase) were searched for relevant studies. Multilevel random-effect meta-analyses were performed, whereby the standardized mean difference was chosen as the effect size to denote the difference between measurements before and after a VR intervention.

RESULTS

The initial database search identified 1430 studies, of which 41 (2.87%) were eventually included in the systematic review. Evidence has been found for the effects of VR on pain, functioning, mobility, functional capacity, psychological outcomes, quality of life, neuropsychological outcomes, and physical sensations. The overall effect size (a total of 194 effect sizes from 25 studies) based on a three level meta-analysis was estimated at 1.22 (95% CI 0.55-1.89; z=3.56; P<.001), in favor of improvements after a VR intervention. When categorizing effect sizes, the overall effect sizes were reported as follows: 1.60 (95% CI 0.83-2.36; z=4.09; P<.001) for the effect of VR on pain (n=31), 1.40 (95% CI 0.13-2.67; z=2.17; P=.03) for functioning (n=60), 0.49 (95% CI -0.71 to 1.68; z=0.80; P=.42) for mobility (n=24), and 0.34 (95% CI -1.52 to 2.20; z=0.36; P=.72) for functional capacity (n=21).

CONCLUSIONS

This systematic review revealed a broad range of outcome variables influenced by an intervention of VR technology, with statistically significant pain relief and improvements in functioning. These findings indicate that VR not only has applications in acute pain management but also in chronic pain settings, whereby VR might be able to become a promising first-line intervention as complementary therapy for patients with chronic pain.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021227016; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227016.

Virtual Reality and the Mediation of Acute and Chronic Pain in Adult and Pediatric Populations: Research Developments

The use of virtual reality (VR) in the mediation of acute pain in adults has shown real benefit to patients for the past 20 years. This review of the literature provides a descriptive synthesis of the types of VR technology, the mechanisms by which VR mediates pain, and a history of early research in the area. A review of the use of VR to mediate chronic pain in adults, and both acute and chronic pain in pediatric populations follows. The studies reviewed provide mixed results and it is noted that many studies have small sample sizes, are case studies, and do not control for extraneous variables such as the dosage and type of VR technology used. Although VR is an exciting area of inquiry that promises to yield multiple applications, there is a necessity to conduct larger random controlled trials to better understand the use cases for which VR is most effective.

Implementation of virtual reality for patient distraction during diagnostic cardiac catheterisation

Until now, the application of virtual reality as a distraction model has been widely described in the medical field, showing different benefits offered on patient's perception, particularly related to pain and anxiety. Previous clinical experience of virtual reality applications on surgical intervention has shown how during procedures with local anaesthesia, this modality improves patients' experience without changing times, costs, and clinical outcomes. Herein, we report our experience with three patients during diagnostic cardiac catheterisation, showing the effect of this technology on patients' perception and metrics during the procedure.

A virtual reality-based mind-body approach to downregulate psychophysiological arousal in adolescent insomnia

Objective

In this study, we describe the rationale, supported by preliminary data, for a novel, digital, immersive virtual reality (VR)-based mind-body approach, designed to reduce bedtime arousal in adolescents with insomnia.

Methods

Fifty-two high-school students (16-20 years; 32 female) with (N = 18) and without (N = 34) DSM-5 insomnia symptoms engaged with 20 min of immersive VR-guided meditation and paced breathing (0.1 Hz) (intervention condition) and 20 min of quiet activity (control condition), right before bedtime, on two separate evenings.

Results

The intervention resulted in acute autonomic and cortical modulation (p < 0.05), leading to reduced physiological arousal (↓heart rate, ↓cortisol) compared with the control condition, with similar effects in adolescents with and without insomnia. No significant changes were detected for cognitive arousal levels. During the intervention, all participants were able to achieve the targeted 0.1 Hz breathing rate, and the majority experienced no discomfort associated with the VR exposure. However, 30-40% of the participants experienced some trouble slowing down their breathing.

Conclusions

The study provides supporting preliminary evidence for the mechanism behind a novel VR-based digital approach, designed to regulate psychophysiological arousal levels by acting on neurocognitive and autonomic pathways. Further studies (e.g. randomized clinical trials) are needed to evaluate the isolated and synergistic effects of its components (e.g. VR vs. VR + paced breathing), and its efficacy, acceptance, and feasibility in alleviating insomnia symptoms in adolescents.

Electrical Muscle Stimulation to Develop and Implement Menstrual Simulator System

Menstrual symptoms and cycles are complex, and the associated discomfort is difficult to quantify. Therefore, men, and some women, do not completely understand them. Here, we propose a system that simulates menstruation-like cramps through electrical muscle stimulation (EMS). We conducted an experiment to compare and evaluate the natural and electrically stimulated menstrual cramps. The results show that menstrual cramps using EMS can reproduce the nature of periodic dull pain. However, in this study, the position where the pain occurred was shallow. Furthermore, we constructed a demonstration system based on the proposed method. From the exhibition, we confirmed that this experience can help verbalize menstrual-related discomfort and allow people to better understand menstrual symptoms. In other words, this experience will help eliminate negative perception of menstruation.

Combining Virtual Reality and Behavioral Health to Promote Pain Resiliency: Analysis of a Novel BioPsychoSocial Modality for Solving Pain in the Workplace

Background

The use of virtual reality in treating pain symptoms is a new and emerging modality that has gained more traction, especially in light of the COVID-19 pandemic, which has led to a rise in the remote care of patients. Our study tested the effectiveness of a home-based pain relief program that utilized virtual reality and behavioral health for treating acute and chronic pain.

Study Design

Retrospective Cohort Study.

Methods

Due to the remote nature of the pain clinic during the COVID-19 pandemic, patients with work-related injuries were considered for inclusion in a 90-day Harvard MedTech Vx Pain Relief Program, which consisted of home-based virtual reality therapy (VRT) and tailored behavioral therapy that was conducted through phone consultations. Both the VRT and behavioral therapy focused on the specific workplace injury and centered around setting three personal goals for each patient that were considered meaningful to them. The progress towards achieving these goals was then tracked. The primary outcome of the retrospective analysis was pain scores after completion of home-based VRT. Secondary outcomes included: change in opioid therapy (opioid consumption), psychological awareness/perception of pain, level of immersion, and overall improvement/achievement in patient goals.

Results

A total of 36 patients (16 male and 20 female) with acute and chronic pain secondary to workplace injuries were included; these injuries severely limited their activities of daily living and reduced their quality of life. During the course of VRT and after completion of the 90-day program, patients experienced a substantial immediate and legacy pain relief. Specifically, patients reported an average 40% reduction in pain while utilizing the program and an additional 2.8 h of continued pain relief at the conclusion of 90 days. Further, 69% of patients also reported either a decrease in opioid use or complete cessation after VRT. The majority of patients also reported reduced depression, fatigue, and sleep disturbance.

Conclusions

The Harvard MedTech Vx Therapy appears to be an effective tool in the treatment of pain and the psycho-social issues associated with pain. This translates into a greater degree of pain resiliency and an overall improvement in general wellness and improved workplace functionality.

Effects of immersive virtual reality for preventing and managing anxiety, nausea and vomiting among paediatric cancer patients receiving their first chemotherapy: A study protocol for an exploratory trial

BACKGROUND

Anxiety, nausea and vomiting are common side effects suffered by paediatric patients receiving chemotherapy. Emerging evidence supports the efficacy of immersive virtual reality (IVR) on improving anxiety and distress symptoms including nausea and vomiting among this vulnerable group. This trial aims to assess the feasibility and acceptability of IVR for preventing and managing anxiety, nausea and vomiting among paediatric cancer patients receiving their first chemotherapy.

METHOD AND ANALYSIS

An exploratory trial supplemented by qualitative methods will be conducted. We will recruit 20 paediatric patients who are aged between 6 and 12 years, chemotherapy naïve, scheduled to receive their first intravenous chemotherapy and able to understand Chinese. Participants will be randomly allocated to intervention or control groups. The intervention group will receive the IVR intervention for three sessions as follows: 4 hours before chemotherapy, 5 minutes before and during their first course chemotherapy and 5 minutes before and during their second course chemotherapy. The control group will receive standard care only. Main outcome measures included (1) key parameters for the design of a definitive trial (i.e. screening, eligibility, consent and withdrawal rates); (2) anxiety, anticipatory and acute chemotherapy-induced nausea and vomiting for collection of preliminary data; (3) feasibility and acceptability of the intervention. Semi-structured interviews will be conducted with patients, parents and oncology nurses. Generalized estimating equations model will be used to compare each of the outcome measures across the time points between the two groups. Qualitative data will be analysed by conventional content analysis.

EXPECTED RESULTS

The results of this exploratory trial will inform the design and conduct of future definitive trial.

TRIAL REGISTRATION NUMBER

ChiCTR1900021694; Pre-results.

The effects of exergaming on pain, postural control, technology acceptance and flow experience in older people with chronic musculoskeletal pain: a randomised controlled trial

BACKGROUND

Older people with chronic musculoskeletal pain are at risk of falls. This study aimed to investigate the effects of exergaming on pain and postural control in older people with chronic musculoskeletal pain. Secondary outcomes were technology acceptance, flow experience, perceived physical exertion, expended mental effort and heart rate.

METHODS

Fifty four older adults (age: 71 ± 5 years) with chronic musculoskeletal pain were randomised into 2 groups. Group 1 received exergaming training using the Interactive Rehabilitation and Exercise System (IREX®). Group 2 undertook traditional gym-based exercise (TGB). Both groups completed twice weekly 40-min exercise sessions for 6 weeks. Perceived pain was measured using a numeric pain rating scale and the Multidimensional Affect and Pain Survey questionnaire. Postural control was measured as sway using a Kistler™ force platform. Technology acceptance was measured with the Unified Theory of Acceptance and Use of Technology questionnaire and flow experience with the Flow State Scale. Physiological measures of perceived physical exertion, expended mental effort and heart rate were recorded during all sessions.

RESULTS

The exergaming group demonstrated significant reductions in pain intensity and thermal pain including a near significant approach in physical engagement in comparison to TGB group. Although no intervention effects on postural control were found, the exergaming group showed significant improvements in three sway measures (AP SD, ML SD and AP range) over time whereas significant improvements in ML range were found in the TGB group. Relating to technology acceptance, significant intervention effects on social influence and behavioural intention were found in the TGB group instead, although both groups demonstrated increases of acceptance over time. Regarding flow experience, concentration at task was significantly influenced in the TGB group and significant increases in flow variables over time were observed in both groups. Significant increases over time in perceived physical exertion and expended mental effort were found in both groups.

CONCLUSION

Our findings support the potential of exergaming to alleviate pain and improve balance in older people with chronic musculoskeletal pain. Both forms of exercise are acceptable, intrinsically motivating and show evidence of benefit to older people with chronic musculoskeletal pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04029285 (retrospectively registered, July 23, 2019).

Virtual Reality as Distraction Analgesia and Anxiolysis for Pediatric Otolaryngology Procedures

OBJECTIVES/HYPOTHESIS

While virtual reality (VR) has been used as analgesia and anxiolysis for invasive procedures, no literature exists on the use of VR in the pediatric otolaryngology setting. The purpose of this study was to determine the efficacy of VR in reducing pain and anxiety for pediatric otolaryngology patients.

STUDY DESIGN

Randomized controlled trial.

METHODS

A total of 53 patients aged 7-17 undergoing in-office nasal endoscopies were included. Patients were randomized to receive VR or standard of care. Procedural pain, anxiety, and satisfaction scores were recorded from patients and caregivers. The physician filled out a childhood emotional manifestation scale (CEMS).

RESULTS

Patients in VR group reported a significant decrease in pain (0.80 ± 1.06 vs. 2.26 ± 2.38, P = .018) and anxiety (9.50 ± 12.48 vs. 38.48 ± 29.83, P = .0002) and increase in procedural satisfaction (6.40 ± 0.77 vs. 4.74 ± 1.74, P = .0002) compared to patients in control group. CEMS scores were significantly reduced in VR group (5.15 ± 0.46 vs. 9.64 ± 5.66, P = .0001) and caregiver anxiety levels were significantly reduced in VR group (11.50 ± 17.67 vs. 27.39 ± 30.48, P = .041) compared to control group. There were no reported side effects. Procedural time did not significantly differ between groups.

CONCLUSIONS

For pediatric otolaryngology patients undergoing in-office nasal endoscopies, VR is a safe and effective form of distraction analgesia and anxiolysis, significantly reducing pain and increasing procedural satisfaction for patients. In addition, VR significantly reduces anxiety for both patients and caregivers without disrupting procedural efficiency and workflow.

LEVEL OF EVIDENCE

2. Laryngoscope, 131:E1714-E1721, 2021.

Low-Cost Virtual Reality Headsets Reduce Perceived Pain in Healthy Adults: A Multicenter Randomized Crossover Trial

Objectives: Recent studies have established the usage of virtual reality (VR) to help alleviate acute and chronic pain. VR technology can be cost prohibitive and cheaper alternatives are desired. In this study, a Google Cardboard headset ($15) combined with a smartphone was used as a low-cost VR device to assess efficacy in altering the perception of pain. Materials and Methods: The cold pressor test, a minimal-risk method, was used to simulate pain. Participants immersed their hands into ice water, with and without VR, in a crossover manner, and their pain perception data were recorded. Results: Forty-eight healthy volunteer participants completed the study between 2017 and 2018. Participants were randomized to right hand control, left control, right experimental, and left experimental groups, respectively, before the crossover. Data collected included pain threshold (time at which participants first reported pain), pain tolerance (time at which participants removed their hand), and pain intensity (highest reported pain level on a [1-10] scale). Approximately two-thirds of participants had improvements in pain threshold and pain tolerance with a mean improvement of +13.0 seconds (P = 0.0045) for pain threshold and +29.8 seconds (P = 0.0003) for pain tolerance. Pain intensity had a reduction of 0.43 points (P = 0.0371). Conclusion: Our results demonstrate that inexpensive VR devices, such as the Google Cardboard headset used in this study, may be a safe, portable, and cost-effective way to alter the perception and improve tolerance of pain.

The Soothing Sea: A Virtual Coastal Walk Can Reduce Experienced and Recollected Pain

Virtual reality (VR) distraction has become increasingly available in health care contexts and is used in acute pain management. However, there has been no systematic exploration of the importance of the content of VR environments. Two studies tested how interacting with nature VR influenced experienced and recollected pain after 1 week. Study 1 (n = 85) used a laboratory pain task (cold pressor), whereas Study 2 (n = 70) was a randomized controlled trial with patients undergoing dental treatment. In Study 1, nature (coastal) VR reduced both experienced and recollected pain compared with no VR. In Study 2, nature (coastal) VR reduced experienced and recalled pain in dental patients, compared with urban VR and standard care. Together, these data show that nature can improve experience of health care procedures through the use of VR, and that the content of the VR matters: Coastal nature is better than urban.

Application of virtual reality technology in clinical medicine

The present review discusses the application of virtual reality (VR) technology in clinical medicine, especially in surgical training, pain management and therapeutic treatment of mental illness. We introduce the common types of VR simulators and their operational principles in aforementioned fields. The clinical effects are also discussed. In almost every study that dealt with VR simulators, researchers have arrived at the same conclusion that both doctors and patients could benefit from this novel technology. Moreover, advantages and disadvantages of the utilization of VR technology in each field were discussed, and the future research directions were proposed.

A feasibility study to determine the benefits of upper extremity virtual rehabilitation therapy for coping with chronic pain post-cancer surgery

BACKGROUND

Persistent pain in shoulder and arm following post-surgical breast cancer treatment can lead to cognitive and physical deficits. Depression is also common in breast cancer survivors. Virtual reality therapy with integrative cognitive and physical rehabilitation has not been clinically trialed for this population. The novel BrightArm Duo technology improved cognition and upper extremity (UE) function for other diagnoses and has great potential to benefit individuals coping with post-surgical breast cancer pain.

OBJECTIVES

The aim of this study was to explore the feasibility of BrightArm Duo therapy for coping with post-surgical chronic pain and associated disability in breast cancer survivors with depression.

METHODS

BrightArm Duo is a robotic rehabilitation table modulating gravity loading on supported forearms. It tracks arm position and grasping strength while patients play three-dimensional (3D) custom integrative rehabilitation games. Community-dwelling women (N = 6) with post-surgical breast cancer pain in the upper arm trained on the system twice a week for 8 weeks. Training difficulty increased progressively in game complexity, table tilt and session length (20-50 minutes). Standardized assessments were performed before and after therapy for pain, cognition, emotion, UE function and activities of daily living.

RESULTS

Subjects averaged upwards of 1300 arm repetitions and 850 hand grasps per session. Pain intensity showed a 20% downward trend (p = 0.1) that was corroborated by therapist observations and participant feedback. A total of 10 out of 11 cognitive metrics improved post-training (p = 0.01) with a significant 8.3-point reduction in depression severity (p = 0.04). A total of 17 of 18 range of motion metrics increased (p < 0.01), with five affected-side shoulder improvements above the Minimal Clinically Important Difference (8°). In all, 13 out of 15 strength and function metrics improved (p = 0.02) with lateral deltoid strength increasing 7.4 N on the affected side (p = 0.05).

CONCLUSION

This pilot study demonstrated feasibility of using the BrightArm Duo Rehabilitation System to treat cancer survivors coping with upper body chronic pain. Outcomes indicate improvement in cognition, shoulder range, strength, function and depression.

AULA-Advanced Virtual Reality Tool for the Assessment of Attention: Normative Study in Spain

OBJECTIVE

The present study describes the obtention of normative data for the AULA test, a virtual reality tool designed to evaluate attention problems, especially in children and adolescents.

METHOD

The normative sample comprised 1,272 participants (48.2% female) with an age range from 6 to 16 years (M = 10.25, SD = 2.83). The AULA test administered to them shows both visual and auditory stimuli, while randomized distractors of ecological nature appear progressively.

RESULTS

Variables provided by AULA were clustered in different categories for their posterior analysis. Differences by age and gender were analyzed, resulting in 14 groups, 7 per sex group. Differences between visual and auditory attention were also obtained.

CONCLUSION

Obtained normative data are relevant for the use of AULA for evaluating attention in Spanish children and adolescents in a more ecological way. Further studies will be needed to determine sensitivity and specificity of AULA to measure attention in different clinical populations. (J. of Att. Dis. 2016; 20(6) 542-568).

Videogames and Health Improvement: A Literature Review of Randomized Controlled Trials

OBJECTIVE

There are potential benefits of playing videogames for health improvement such as increasing knowledge about health-related issues by playing educational games and fighting a sedentary lifestyle by playing exergames. The number of systematic review articles about "videogames" and "health improvement" is limited. Therefore, the purpose of this study is to review those randomized controlled trials (RCTs) with the topic of "videogames" and "health improvement."

MATERIALS AND METHODS

Several electronic databases were searched for RCTs testing videogames on health outcomes that were published in English between January 2000 and April 2012.

RESULTS

Forty-five articles met the eligibility criteria and were categorized into five groups: (1) videogames and patient pain and stress reduction (nine articles), (2) videogames and patient behavioral change (19 articles), (3) videogames and patient rehabilitation (eight articles), (4) videogames as diagnostic tools (three articles), and (5) videogames and cognitive ability (six articles).

CONCLUSIONS

Most of the articles have shown promising results in using videogames within various fields of healthcare. Although exergames are the most prominent choice regarding health improvement, videogames have the potential to be used as a pain management tool, diagnostic tool, or educational tool. They also can be used as a facilitator in physical rehabilitation or cognitive loss prevention. More RCTs are needed to fully uncover the benefits of using videogames for improving patients' health.

Distraction of attention with the use of virtual reality. Influence of the level of game complexity on the level of experienced pain

: Research done in recent years shows that Virtual Reality (VR) can be an effective tool for distracting attention from pain. The purpose of this study was to test how the complexity of Virtual Environment (VE) influences the experienced intensity of thermal pain stimuli.

A within-subjects design experiment was conducted, using cold pressor test for pain stimulation. Research was done on 31 students of Wroclaw Universities. Participants played games created for the purpose of the study, using head mounted displays and movement sensors. Two Virtual Environments differing in the level of complexity and non-VR control condition were used. The order of all conditions was counterbalanced.

Participants reported significantly lower pain intensity (Visual Analogue Scale) after playing the high complexity game, compared to the low complexity game. There were also significant differences between non-VR control condition and high complexity game, but not between non-VR and low complexity game. The pain tolerance (measured by time of keeping the hand in cold water) was significantly higher in both VR conditions comparing to non-VR conditions. However, no significant differences between VE’s were found in pain tolerance ratings. Results of this study provide preliminary evidence that game complexity can be related to pain experience during VR interventions.

Differential effects of two virtual reality interventions: distraction versus pain control

There is evidence that virtual reality (VR) pain distraction is effective at improving pain-related outcomes. However, more research is needed to investigate VR environments with other pain-related goals. The main aim of this study was to compare the differential effects of two VR environments on a set of pain-related and cognitive variables during a cold pressor experiment. One of these environments aimed to distract attention away from pain (VRD), whereas the other was designed to enhance pain control (VRC). Participants were 77 psychology students, who were randomly assigned to one of the following three conditions during the cold pressor experiment: (a) VRD, (b) VRC, or (c) Non-VR (control condition). Data were collected regarding both pain-related variables (intensity, tolerance, threshold, time perception, and pain sensitivity range) and cognitive variables (self-efficacy and catastrophizing). Results showed that in comparison with the control condition, the VRC intervention significantly increased pain tolerance, the pain sensitivity range, and the degree of time underestimation. It also increased self-efficacy in tolerating pain and led to a reduction in reported helplessness. The VRD intervention significantly increased the pain threshold and pain tolerance in comparison with the control condition, but it did not affect any of the cognitive variables. Overall, the intervention designed to enhance control seems to have a greater effect on the cognitive variables assessed. Although these results need to be replicated in further studies, the findings suggest that the VRC intervention has considerable potential in terms of increasing self-efficacy and modifying the negative thoughts that commonly accompany pain problems.

Case study: videogame distraction reduces behavioral distress in a preschool-aged child undergoing repeated burn dressing changes: a single-subject design

OBJECTIVE

This single-subject design study evaluated the feasibility and efficacy of passive and interactive videogame distraction on behavioral distress for a preschool-aged child receiving repeated burn dressing changes.

METHOD

A 4-year-old girl underwent 3 baseline and 10 videogame distraction sessions (5 passive and 5 interactive) using a restricted alternating treatments design. Observed behavioral distress was coded, and parents and nurses rated the child's distress and cooperative behavior.

RESULTS

Relative to baseline, behavioral distress decreased and cooperative behavior increased immediately after the onset of videogame distraction. Single Case Randomization Tests revealed significantly lower behavioral distress and greater cooperation during interactive videogame distraction relative to passive videogame distraction.

CONCLUSIONS

Interactive videogame distraction appears to be a feasible and effective pain management strategy for a preschool-aged child undergoing repeated painful medical procedures.

Virtual reality and pain management: current trends and future directions

Virtual reality (VR) has been used to manage pain and distress associated with a wide variety of known painful medical procedures. In clinical settings and experimental studies, participants immersed in VR experience reduced levels of pain, general distress/unpleasantness and report a desire to use VR again during painful medical procedures. Investigators hypothesize that VR acts as a nonpharmacologic form of analgesia by exerting an array of emotional affective, emotion-based cognitive and attentional processes on the body's intricate pain modulation system. While the exact neurobiological mechanisms behind VR's action remain unclear, investigations are currently underway to examine the complex interplay of cortical activity associated with immersive VR. Recently, new applications, including VR, have been developed to augment evidenced-based interventions, such as hypnosis and biofeedback, for the treatment of chronic pain. This article provides a comprehensive review of the literature, exploring clinical and experimental applications of VR for acute and chronic pain management, focusing specifically on current trends and recent developments. In addition, we propose mechanistic theories highlighting VR distraction and neurobiological explanations, and conclude with new directions in VR research, implications and clinical significance.

Baroreceptor activation attenuates attentional effects on pain-evoked potentials

Focused attention typically enhances neural nociceptive responses, reflected electroencephalographically as increased amplitude of pain-evoked event-related potentials (ERPs). Additionally, pain-evoked ERPs are attenuated by hypertension and baroreceptor activity, through as yet unclear mechanisms. There is indirect evidence that these two effects may interact, suggesting that baroreceptor-related modulation of nociception is more than a low-level gating phenomenon. To address this hypothesis, we explored in a group of healthy participants the combined effects of cue-induced expectancy and baroreceptor activity on the amplitude of pain-evoked ERPs. Brief nociceptive skin stimuli were delivered during a simple visual task; half were preceded by a visual forewarning cue, and half were unpredictable. Nociceptive stimuli were timed to coincide either with systole (maximum activation of cardiac baroreceptors) or with diastole (minimum baroreceptor activation). We observed a strong interaction between expectancy and cardiac timing for the amplitude of the P2 ERP component; no effects were observed for the N2 component. Cued stimuli were associated with larger P2 amplitude, but this effect was abolished for stimuli presented during baroreceptor activation. No cardiac timing effect was observed for un-cued stimuli. Taken together, these findings suggest a close integration of cognitive-affective aspects of expectancy and baroreceptor influences on pain, and as such may cast further light on mechanisms underlying mental and physiological contributions to clinical pain.