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Felix RB, Rao A, Khalid M, Wang Y, Colloca L, Murthi SB, Morris NA. Adjunctive virtual reality pain relief following traumatic injury: protocol for a randomised within-subjects clinical trial. BMJ Open 2021; 11:e056030. [PMID: 34848527 PMCID: PMC8634353 DOI: 10.1136/bmjopen-2021-056030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION The annual mortality and national expense of the opioid crisis continue to rise in the USA (130 deaths/day, $50 billion/year). Opioid use disorder usually starts with the prescription of opioids for a medical condition. Its risk is associated with greater pain intensity and coping strategies characterised by pain catastrophising. Non-pharmacological analgesics in the hospital setting are critical to abate the opioid epidemic. One promising intervention is virtual reality (VR) therapy. It has performed well as a distraction tool and pain modifier during medical procedures; however, little is known about VR in the acute pain setting following traumatic injury. Furthermore, no studies have investigated VR in the setting of traumatic brain injury (TBI). This study aims to establish the safety and effect of VR therapy in the inpatient setting for acute traumatic injuries, including TBI. METHODS AND ANALYSIS In this randomised within-subjects clinical study, immersive VR therapy will be compared with two controls in patients with traumatic injury, including TBI. Affective measures including pain catastrophising, trait anxiety and depression will be captured prior to beginning sessions. Before and after each session, we will capture pain intensity and unpleasantness, additional affective measures and physiological measures associated with pain response, such as heart rate and variability, pupillometry and respiratory rate. The primary outcome is the change in pain intensity of the VR session compared with controls. ETHICS AND DISSEMINATION Dissemination of this protocol will allow researchers and funding bodies to stay abreast in their fields through exposure to research not otherwise widely publicised. Study protocols are compliant with federal regulation and University of Maryland Baltimore's Human Research Protections and Institutional Review Board (protocol number HP-00090603). Study results will be published on completion of enrolment and analysis, and deidentified data can be shared by request to the corresponding author. TRIAL REGISTRATION NUMBER NCT04356963; Pre-results.
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Affiliation(s)
- Ryan B Felix
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aniruddha Rao
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Mazhar Khalid
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yang Wang
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Sarah B Murthi
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicholas A Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Xiang H, Shen J, Wheeler KK, Patterson J, Lever K, Armstrong M, Shi J, Thakkar RK, Groner JI, Noffsinger D, Giles SA, Fabia RB. Efficacy of Smartphone Active and Passive Virtual Reality Distraction vs Standard Care on Burn Pain Among Pediatric Patients: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2112082. [PMID: 34152420 PMCID: PMC8218073 DOI: 10.1001/jamanetworkopen.2021.12082] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE It is unknown whether smartphone-based virtual reality (VR) games are effective in reducing pain among pediatric patients in real-world burn clinics. OBJECTIVE To evaluate the efficacy of a smartphone VR game on dressing pain among pediatric patients with burns. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included children aged 6 to 17 years who seen in the outpatient clinic of a large American Burn Association-verified pediatric burn center and level I pediatric trauma center between December 30, 2016, and January 23, 2019. Speaking English as their primary language was an inclusion criterion. Intention-to-treat data analyses were conducted from December 2019 to March 2020. INTERVENTIONS Active VR participants played a VR game; passive VR participants were immersed in the same VR environment without interactions. Both groups were compared with a standard care group. One researcher administered VR and observed pain while another researcher administered a posttrial survey that measured the child's perceived pain and VR experience. Nurses were asked to report the clinical utility. MAIN OUTCOMES AND MEASURES Patients self-reported pain using a visual analog scale (VAS; range, 0-100). A researcher observed patient pain based on the Face, Legs, Activity, Cry, and Consolability-Revised (FLACC-R) scale. Nurses were asked to report VR helpfulness (range, 0-100; higher scores indicate more helpful) and ease of use (range, 0-100; higher scores indicate easier to use). RESULTS A total of 90 children (45 [50%] girls, mean age, 11.3 years [95% CI, 10.6-12.0 years]; 51 [57%] White children) participated. Most children had second-degree burns (81 [90%]). Participants in the active VR group had significantly lower reported overall pain (VAS score, 24.9 [95% CI, 12.2-37.6]) compared with participants in the standard care control group (VAS score, 47.1 [95% CI, 32.1-62.2]; P = .02). The active VR group also had a lower worst pain score (VAS score, 27.4 [95% CI, 14.7-40.1]) than both the passive VR group (VAS score, 47.9 [95% CI, 31.8-63.9]; P = .04) and the standard care group (VAS score, 48.8 [95% CI, 31.1-64.4]; P = .03). Simulator sickness scores (range, 0-60; lower scores indicate less sickness) were similar for active VR (19.3 [95% CI, 17.5-21.1]) and passive VR groups (19.5 [95% CI, 17.6-21.5]). Nurses also reported that the VR games could be easily implemented in clinics (helpfulness, active VR: 84.2; 95% CI, 74.5-93.8; passive VR: 76.9; 95% CI, 65.2-88.7; ease of use, active VR: 94.8, 95% CI, 91.8-97.8; passive VR: 96.0, 95% CI, 92.9-99.1). CONCLUSIONS AND RELEVANCE In this study, a smartphone VR game was effective in reducing patient self-reported pain during burn dressing changes, suggesting that VR may be an effective method for managing pediatric burn pain. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04544631.
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Affiliation(s)
- Henry Xiang
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Injury Research and Policy, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University, Columbus
| | - Jiabin Shen
- Department of Psychology, University of Massachusetts, Lowell
| | - Krista K. Wheeler
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Injury Research and Policy, Nationwide Children’s Hospital, Columbus, Ohio
| | - Jeremy Patterson
- Research Information Solutions and Innovation, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University, Columbus
| | - Kimberly Lever
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Injury Research and Policy, Nationwide Children’s Hospital, Columbus, Ohio
| | - Megan Armstrong
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Injury Research and Policy, Nationwide Children’s Hospital, Columbus, Ohio
| | - Junxin Shi
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Injury Research and Policy, Nationwide Children’s Hospital, Columbus, Ohio
| | - Rajan K. Thakkar
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University, Columbus
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Surgery, The Ohio State University, Columbus
| | - Jonathan I. Groner
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Injury Research and Policy, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Surgery, The Ohio State University, Columbus
| | - Dana Noffsinger
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Sheila A. Giles
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Renata B. Fabia
- Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University, Columbus
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Surgery, The Ohio State University, Columbus
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Delshad SD, Almario CV, Fuller G, Luong D, Spiegel BMR. Economic analysis of implementing virtual reality therapy for pain among hospitalized patients. NPJ Digit Med 2018; 1:22. [PMID: 31304304 PMCID: PMC6550142 DOI: 10.1038/s41746-018-0026-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/08/2018] [Accepted: 03/09/2018] [Indexed: 01/08/2023] Open
Abstract
Virtual reality (VR) has emerged as a novel and effective non-pharmacologic therapy for pain, and there is growing interest to use VR in the acute hospital setting. We sought to explore the cost and effectiveness thresholds VR therapy must meet to be cost-saving as an inpatient pain management program. The result is a framework for hospital administrators to evaluate the return on investment of implementing inpatient VR programs of varying effectiveness and cost. Utilizing decision analysis software, we compared adjuvant VR therapy for pain management vs. usual care among hospitalized patients. In the VR strategy, we analyzed potential cost-savings from reductions in opioid utilization and hospital length of stay (LOS), as well as increased reimbursements from higher patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The average overall hospitalization cost-savings per patient for the VR program vs. usual care was $5.39 (95% confidence interval –$11.00 to $156.17). In a probabilistic sensitivity analysis across 1000 hypothetical hospitals of varying size and staffing, VR remained cost-saving in 89.2% of trials. The VR program was cost-saving so long as it reduced LOS by ≥14.6%; the model was not sensitive to differences in opioid use or HCAHPS. We conclude that inpatient VR therapy may be cost-saving for a hospital system primarily if it reduces LOS. In isolation, cost-savings from reductions in opioid utilization and increased HCAHPS-related reimbursements are not sufficient to overcome the costs of VR. Implementing virtual reality (VR) programs for inpatient pain management can potentially save hospitals money. Recent studies have highlighted VR as an effective alternative to traditional opioid treatments for the management of pain. Brennan Spiegel, at Cedars-Sinai Medical Center in Los Angeles, and colleagues carried out an economic analysis to determine the cost implications of implementing inpatient VR therapy programs for acute pain management in different US hospital settings. They found that such programs are cost-saving when they reduce patients’ length of stay in the hospital. However, the projected costs for inpatient VR programs are higher than the savings that can be made from decreases in opioid use or additional income from Hospital Consumer Assessment of Healthcare Providers and Systems-related reimbursements through increased patient satisfaction alone.
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Affiliation(s)
- Sean D Delshad
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA.,2Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Christopher V Almario
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA.,3Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA USA.,4Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Garth Fuller
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA
| | - Duong Luong
- 5Department of Pharmacy, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Brennan M R Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA.,3Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA USA.,4Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, CA USA.,6Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA USA
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