Virtual reality and hypnosis for anxiety and pain management in intensive care units: A prospective randomised trial among cardiac surgery patients

Applications and advances of immersive technology in cardiology

Different forms of immersive technology, such as Virtual Reality (VR) and Augmented Reality (AR), are getting increasingly invested in medicine. Advances in head-mounted display technology, processing, and rendering power have demonstrated the increasing utility of immersive technology in medicine and the healthcare environment. There are a growing number of publications on using immersive technology in cardiology. We reviewed the articles published within the last decade that reported case studies or research that uses or investigates the application of immersive technology in the broad field of cardiology - from education to preoperative planning and intraoperative guidance. We summarized the advantages and disadvantages of using AR and VR for various application categories. Our review highlights the need for a robust assessment of the effectiveness of the methods and discusses the technical limitations that hinder the complete integration of AR and VR in cardiology, including cost-effectiveness and regulatory compliance. Despite the limitations and gaps that have inhibited us from benefiting from immersive technologies' full potential in cardiology settings to date, its promising, impactful future for standard cardiovascular care is undoubted.

Adjunctive use of hypnosis for clinical pain: a systematic review and meta-analysis

Systematic reviews suggest that stand-alone hypnotic suggestions may improve pain outcomes compared with no treatment, waitlist, or usual care. However, in clinical practice, hypnosis is often provided adjunctively with other interventions, which might have different effects than those reported in previous reviews. This systematic review aimed to summarize the analgesic effects of adjunctive hypnosis in adults with clinical pain. Seven databases (MEDLINE, Embase, PsycINFO, Emcare, SCOPUS, CENTRAL, Cochrane) were searched up to January 2024. Randomised controlled trials comparing the analgesic effects of adjunctive hypnosis (hypnosis + primary intervention) with those of the primary intervention alone were included. Meta-analyses (random-effects model) calculated mean differences (MD, [95% confidence intervals]) for pain intensity (0-100). Seventy studies were pooled in meta-analyses (n = 6078). Hypnosis adjunctive to usual care had a small additional analgesic effect (chronic pain: -8.2 [-11.8, -1.9]; medical procedures/surgical pain: -6.9 [-10.4, -3.3]; burn wound care: -8.8 [-13.8, -3.9]). Hypnosis adjunctive to education had a medium additional analgesic effect for chronic pain (-11.5 [-19.7, 3.3]) but not postsurgery pain (-2.0 [-7.8, 3.7]). When paired with psychological interventions, hypnosis slightly increased analgesia in chronic pain only at the three-month follow-up (-2 [-3.7, -0.3]). Hypnosis adjunctive to medicines had a medium additional analgesic effect for chronic pain (-13.2, [-22.5, -3.8]). The overall evidence certainty is very low; therefore, there is still uncertainty about the analgesic effects of adjunctive hypnosis. However, hypnosis adjunct to education may reduce pain intensity for chronic pain. Clarification of proposed therapeutic targets of adjunctive hypnosis to evaluate underlying mechanisms is warranted.

Virtual Reality Combined with Mind-Body Therapies for the Management of Pain: A Scoping Review

When used separately, virtual reality (VR) and mind-body therapies (MBTs) have the potential to reduce pain across various acute and chronic conditions. While their combination is increasingly used, no study offers a consolidated presentation of VR and MBTs. This study aims to propose an overview of the effectiveness of VR combined with MBTs (i.e., meditation, mindfulness, relaxation, and hypnosis) to decrease the pain experienced by healthy volunteers or patients. We conducted a scoping review of the literature using PubMed, Science Direct and Google Scholar and included 43 studies. Findings across studies support that VR combined with MBTs is a feasible, well-tolerated, and potentially useful to reduce pain. Their combination also had a positive effect on anxiety, mood, and relaxation. However, insufficient research on this VR/MBTs combination and the lack of multidimensional studies impede a comprehensive understanding of their full potential. More randomized controlled studies are thus needed, with usability evaluation protocols to better understand the effects of VR/MBTs on patients wellbeing and to incorporate them into routine clinical practice.

Kinesiophobia in patients after cardiac surgery: a scoping review

BACKGROUND

This paper reviews the scope of research on kinesiophobia in patients after cardiac surgery. Further, it reviews the current situation, evaluation tools, risk factors, adverse effects, and intervention methods of kinesiophobia to provide a reference for promoting early rehabilitation of patients after cardiac surgery.

METHODS

Guided by the scoping methodology, the Web of Science, PubMed, CINAHL, Cochrane Library, China Biomedical Literature Database, VIP Database, Wanfang Database, CNKI, and other databases were searched from database inception until July 31, 2024. The studies obtained were screened, summarised and systematically analysed by two researchers.

RESULTS

Eighteen studies (16 cross-sectional studies, one qualitative study, and one randomised controlled trial) were included. The incidence of kinesiophobia in patients after cardiac surgery was 39.20-82.57%, and the Tampa Scale for Kinesiophobia Heart (TSK-SV Heart) was used to evaluate this incidence. The influencing factors of kinesiophobia in patients after cardiac surgery included demographic characteristics, pain severity, frailty, exercise self-efficacy, disease-related factors, and psychosocial factors. Kinesiophobia led to adverse health outcomes such as reduced recovery, prolonged hospital stays, and decreased quality of life in patients after cardiac surgery, and there were few studies on intervention methods for postoperative kinesiophobia.

CONCLUSION

The kinesiophobia assessment tools suitable for patients after cardiac surgery should be improved, and intervention methods to promote the early recovery of patients after major clinical surgery and those with difficult and critical diseases should be actively researched.

Virtual reality for postsurgical pain management: An explorative randomized controlled study

BACKGROUND

Virtual reality (VR) is a promising tool in a multimodal analgesic approach; however, evidence regarding virtual reality for postsurgical pain is limited. This study investigates the initial effectiveness and feasibility of self-administered virtual reality in postsurgical pain management.

METHODS

Patients reporting a postsurgical pain score ≥4 were randomized for control or VR, stratified for 3 interventions with varying levels of immersion and interaction. Subjects were instructed to use virtual reality as add-on treatment at least 3 times a day for 10 minutes on days 2 till 4 postoperatively. Primary outcome was the mean daily pain intensity. Results of pain scores were related to patient and intervention characteristics, to explore which characteristics interact with virtual reality effects. Secondary outcomes were analgesic use, anxiety, stress, and feasibility.

RESULTS

One hundred patients were included in the analyses: 37 in the control group and 63 for VR. VR did not demonstrate a significant effect on self-reported pain scores (P = .43), nor were specific patient or intervention characteristics associated with greater VR effects. Analgesic usage did not differ between groups. However, there was a trend toward greater cumulative percentages of patients achieving a 30% pain reduction, and significantly lower daily experienced stress (P = .01) and anxiety (P = .03) levels in VR intervention groups. VR was used less than prescribed, mainly because of illness and pain. Adverse events included disorientation, nausea, and fatigue.

CONCLUSIONS

This explorative study did not demonstrate initial effectiveness of VR as add-on pain treatment regarding pain and analgesic use; however, VR positively affected stress and anxiety. VR is safe and suitable for a wide target audience, and feasibility differed between interventions. Personalizing and improving VR technology may enhance its effectiveness.

Psychological intervention based on social cognitive theory: Treating pain, anxiety, and depression in perioperative patients

BACKGROUND

Surgery is an effective method for treating certain diseases. Factors such as disease, preoperative fear and tension, surgical stress, postoperative pain, and related complications directly affect the smooth progression and outcome of surgery. Patients may experience a series of psychological and physiological changes during the perioperative period, resulting in anxiety and depression, which may reduce the pain threshold and worsen their prognosis.

AIM

To investigate the effects of a psychological intervention among perioperative patients, based on social cognitive theory (SCT).

METHODS

We enrolled 200 patients who underwent surgical care at The First People's Hospital of Lin'an District, Hangzhou between January and December 2023. They were categorized into a routine intervention group (n = 103) and a psychological intervention group (n = 97), based on the intervention strategies used. Various assessment tools, including the self-rating anxiety scale (SAS), the self-rating depression scale (SDS), and the Connor-Davidson Resilience scale, were used to measure patients' negative states and emotions. The pre- and post-intervention scores for these metrics in the two groups were then analyzed.

RESULTS

In the psychological intervention group, the SAS and SDS scores (31.56 ± 5.18 and 31.46 ± 4.57, respectively) were significantly reduced compared to the routine intervention group (P < 0.05). The visual analog scale pain scores at 12 and 24 hours after intervention (6.85 ± 1.21, 4.24 ± 0.72) were notably higher than those in the routine intervention group (P < 0.05). The psychological intervention group also demonstrated superior scores in perseverance (36.08 ± 3.29), self-reliance (22.63 ± 2.91), optimism (11.42 ± 1.98), and resilience (70.13 ± 5.37), compared to the routine intervention group (P < 0.05). Additionally, the psychological intervention group's confrontation score (23.16 ± 4.29) was higher (P < 0.05). This group also reported lower scores in avoidance (9.28 ± 1.94) and yielding (6.19 ± 1.92) (P < 0.05). Lastly, the Short Form 36 Health Survey scores were significantly higher in the psychological intervention group, indicating a better quality of life (P < 0.05).

CONCLUSION

Psychological intervention measures based on SCT can effectively alleviate pain, anxiety, and depression in perioperative patients.

Virtual reality as a treatment for chronic musculoskeletal pain syndromes

Chronic musculoskeletal pain syndromes, including fibromyalgia, are often resistant to conventional medications and invasive therapies. Central hypersensitization, neurotransmitter dysregulation, and autonomic nervous system abnormalities are key pathomechanisms, frequently resulting in widespread pain and a variety of psychosomatic symptoms. Virtual Reality (VR) applications have demonstrated effectiveness in reducing pain, both during and after interventions, and in chronic conditions such as fibromyalgia and back pain. The proposed mechanisms behind VR's effectiveness include distraction and immersion, coupled with cognitive behavioral therapy, which promote neuroplasticity and alter pain perceptions. Functional MRI studies have shown the impact of VR interventions on specific brain regions. Advances in hardware and software, potentially combined with treatments like biofeedback, could enhance VR's role in managing chronic pain. Currently, VR for musculoskeletal pain syndromes is primarily used within multimodal programs, but it is also available for home use as a standalone health application. Future research should focus on the 'drug-like' effects of VR, requiring controlled trials with comparable study populations and appropriate sham interventions.

Virtual Reality as a Pain Control Adjunct in Orthopedics: A Narrative Review

Orthopedic surgeons typically prescribe opioids for postoperative pain management as they are effective in managing pain. However, opioid use can lead to issues such as overdose, prescription excess, inadequate pain management, and addiction. Virtual reality (VR) therapy is an alternative route for postoperative pain management that has grown in popularity over the years. VR therapy involves immersing patients in a virtual 3D experience that is anticipated to alleviate pain. In this review article, we summarized the findings of numerous PubMed studies on the effectiveness of VR therapy for postoperative pain control. VR therapy is beneficial for reducing anxiety, pain, and opioid use after surgical procedures across various specialties. Further studies should explore VR therapy in orthopedic procedures.

The Effectiveness of Virtual and Augmented Reality in Surgical Pain Management: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Satisfactory management of postoperative pain remains challenging. Nonpharmacological modalities such as virtual and augmented reality (VR/AR) offer potential benefits and are becoming increasingly popular. This systematic review evaluates the effectiveness and safety of VR/AR interventions on postoperative pain and recovery.

METHODS

MEDLINE, Embase, CINAHL, Web of Science, and CENTRAL databases were searched from inception to July 27, 2023, for randomized controlled trials (RCTs), published in English, evaluating the use of VR/AR interventions for surgical pain relief. Study selection and data extraction were performed by pairs of reviewers independently and in duplicate, and potential risk of bias was determined using the Risk of Bias-version 2 (RoB 2) tool. Our outcomes included pain relief, reduction of anxiety, satisfaction, and adverse effects. Due to substantial heterogeneity, a narrative synthesis without meta-analysis was performed.

RESULTS

We included 35 trials among 2257 citations, categorized as surgery (n = 12), minor procedures (n = 15), and postoperative physiotherapy (n = 8). Surgical group included various surgeries, with 11 using immersive VR predominantly in the postoperative period, and most reporting no differences in pain, but potential for reduced anxiety and sedation requirements. In the minor procedures group, most studies reported decreased pain and anxiety during the procedural performance. Two studies reported increased heart rate, while 2 others reported better hemodynamic stability. Home-based AR physiotherapy achieved (n = 6) similar pain and functional outcomes after knee replacement, with 1 large study (n = 306) reporting reduction of mean costs by $2745 for provision of 12 weeks physiotherapy. There were some concerns around potential bias for most studies, as the nature of interventions make it challenging to blind assessors and participants. No important adverse effects were noted using VR/AR technology.

CONCLUSIONS

Evidence from RCTs indicates that the use of immersive VR during minor procedures may reduce procedural pain, decrease anxiety, and improve satisfaction. However, small studies, inconsistent effect, and variation in the application of interventions are important limitations. Evidence to support the application of AR/VR for major surgeries is limited and needs to be further investigated. Use of home-based physiotherapy with AR likely has economic advantages, and facilitates virtual care for appropriate patients who can access and use the technology safely.

Pain Management Strategies in Intensive Care Unit: Challenges and Best Practice

Pain management in the ICU (intensive care unit) is a very complex problem which involves a wide variety of conditions, lack of sufficient tools for use, and high personnel to patient ratio. In the last three decades, pain as a clinical issue has become well analyzed, and treatment protocols based on scientific evidence have been established. Besides medication, some non-pharmacological methods such as music therapy, relaxation, and massage have been proven to be very much practical and manageable in pain management of ICU. The main opioids are utilized predominantly due to their power but NSAIDs and local anesthesia are combined with opioids with the aim to reduce the pain as much as possible. Yet more research now has to prove that pain evaluation and management is effective. This article discusses on the issues and the best approaches to solving them when managing pain in ICU patients.

Improving immersive experiences in virtual natural setting for public health and environmental design: A systematic review and meta-analysis of randomized controlled trials

In recent years, virtual reality (VR) technology has emerged as a powerful tool in the field of therapeutic landscapes. For hospitalized patients or individuals with limited mobility, VR provides highly personalized therapy by simulating authentic natural environments within a safe, convenient, and engaging setting. This study investigated the effectiveness of immersing patients in virtual natural environments for health recovery and compared the varying impacts of different types of landscapes on patients' recovery levels. The aim was to complement traditional medical approaches and enhance environmental design in the field of public health. Researchers systematically reviewed databases (January 2018 to August 2, 2023) to identify randomized controlled trials comparing the efficacy of virtual nature immersion with other treatments. The inclusion/exclusion criteria were established based on the population, intervention, comparison, outcomes, study design, and other aspects (expanded PICO) framework. The Cochrane tool was employed to assess the risk of bias. Meta-analysis was conducted by pooling the mean differences with a 95% confidence interval. Among 30 trials, a total of 2123 patients met the inclusion criteria, with 15 studies included in the meta-analysis. 30 trials met the criteria. Results show significant improvements in pain, anxiety, fear, and some physiological indicators with virtual nature-based treatments. On the other hand, natural scenes incorporating blue and green elements have been applied more extensively and have shown more significant effects. In comparison to conventional methods, this study strongly advocates that virtual reality environments are a crucial tool in bridging the gap between patients and nature, demonstrating their potential to reshape medical interventions and improve environmental design in the field of public health.

Variations of the Relative Parasympathetic Tone Assessed by ANI During Oocyte Retrieval Under Local Anaesthesia with Virtual Reality : A Randomized, Controlled, Monocentric, Open Study

Transvaginal oocyte retrieval is an outpatient procedure performed under local anaesthesia. Hypno-analgesia could be effective in managing comfort during this procedure. This study aimed to assess the effectiveness of a virtual reality headset as an adjunct to local anaesthesia in managing nociception during oocyte retrieval. This was a prospective, randomized single-centre study including patients undergoing oocyte retrieval under local anaesthesia. Patients were randomly assigned to the intervention group (virtual reality headset + local anaesthesia) or the control group (local anaesthesia). The primary outcome was the efficacy on the ANI®, which reflects the relative parasympathetic tone. Secondary outcomes included pain, anxiety, conversion to general anaesthesia rate, procedural duration, patient's and gynaecologist's satisfaction and virtual reality headset tolerance. ANI was significantly lower in the virtual reality group during the whole procedure (mean ANI: 79 95 CI [77; 81] vs 74 95 CI [72; 76]; p < 0.001; effect size Cohen's d -0.53 [-0.83, -0.23]), and during the two most painful moments: infiltration (mean ANI: 81 +/- 11 vs 74 +/- 13; p < 0.001; effect size Cohen's d -0.54[-0.85, -0.24]) and oocytes retrieval (mean ANI: 78 +/- 11 vs 74.40 +/- 11; p = 0.020; effect size Cohen's d -0.37 [-0.67, -0.07]).There was no significant difference in pain measured by VAS. No serious adverse events related were reported. The integration of virtual reality as an hypnotic tool during oocyte retrieval under local anaesthesia in assisted reproductive techniques could improve patient's comfort and experience.

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.

Nonpharmacologic Therapies for Postoperative Pain in Cardiac Surgery: A Systematic Review

OBJECTIVES

To search for studies that address the efficacy of nonpharmacologic methods for pain relief in adults undergoing cardiac surgeries.

DESIGN

A systematic review registered in the International Prospective Register of Systematic Reviews (PROSPERO) under number CRD42020168681.

DATA SOURCE

PubMed, LILACS, CINAHL, the Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials.

REVIEW/ANALYSIS METHODS

The review used a PRISMA guideline that selected primary randomized controlled trials on the efficacy of nonpharmacologic pain relief therapies in patients undergoing cardiac surgery, with no time or language restrictions. The Joanna Briggs Institute Critical Appraisal Checklist for Randomized Clinical Trials was used to assess methodological rigor.

RESULTS

After screening, 23 of the 140 studies found in the databases were selected. The studies examined the efficacy of 13 different nonpharmacologic therapies, as well as a combination of therapies, with massage therapy being the most commonly examined, followed by musical intervention and hypnosis.

CONCLUSIONS

Some interventions, when combined with pharmacologic therapy, were effective in relieving postoperative pain after cardiac surgeries, according to the studies analyzed. However, most studies had significant methodological flaws, and further studies with high methodological quality are needed.

The Effectiveness of Virtual Reality on Anxiety and Pain Management in Patients Undergoing Cardiac Procedures: A Systematic Review and Meta-Analysis

Cardiac procedure-related anxiety and pain can adversely affect outcomes and lead to patient dissatisfaction. Virtual reality (VR) offers a promising alternative to traditional therapies for improving patient experience. Our objective is to synthesize evidence and assess the effectiveness of VR in reducing cardiac procedure-related anxiety and pain compared to standard of care. We conducted a comprehensive search across various online databases, including MEDLINE, EMBASE, CINAHL, Web of Sciences, and COCHRANE, to identify relevant randomized controlled trials (RCTs) focusing on VR, cardiac procedures, anxiety, and pain. We utilized a random-effect model to generate effect estimates reported as standardized mean differences (SMD) with a 95% confidence interval. Our review comprised 10 studies with a total of 621 participants (intervention arm: 301, control arm: 320). Overall, among the seven studies evaluating anxiety outcomes, no significant difference in anxiety reduction was observed between the intervention and control groups (standardized mean difference (SMD) -0.62, 95% CI -1.61, 0.37, p=0.22). However, studies using the same anxiety assessment tool demonstrated a significant improvement in the VR arm (SMD -1.01, 95% CI -1.98, -0.04, p=0.04). Conversely, the narrative synthesis of four studies examining pain revealed mixed results. Our findings suggest no significant difference in anxiety reduction between the VR and control groups. Future studies should employ standardized tools for assessing and reporting anxiety and pain to better understand the potential of VR in enhancing patient experience during cardiac procedures.

Hypnosis in psychotherapy, psychosomatics and medicine. A brief overview

Aspects of hypnosis and its application in psychotherapy, psychosomatics and medicine are examined and contextualized in the 250-year history of hypnosis. Imagination as an essential element of hypnotic treatments appeared as early as 1784 as an argument rejecting the theory of animal magnetism of Franz Anton Mesmer. In somnambulism of German romanticism, another proto-form of hypnosis after 1800, concepts of the mind-body problem were dealt with, which still characterize the understanding of unconscious mental processes today. Hypnosis was at the beginning of psychoanalysis, but was not pursued further by Sigmund Freud from 1900 onwards. Nevertheless, there were some hypnoanalytical approaches in the 20th century, as well as attempts to integrate hypnosis into behavior therapy. Techniques of imagination and relaxation combine both; in particular findings from cognitive psychology explain processes of both hypnosis and cognitive behavioral therapy. The influence of social psychology brought a new perspective to the debate about the nature of hypnosis, which continues to this day: is hypnosis to be understood as a special state of consciousness or is it a completely normal, mundane interaction? The experiments that were carried out to support one side or the other were also dependent on the hypnotizability of the subjects involved, as the more difficult hypnotic phenomena such as paralysis, hallucinations or identity delusions can only be demonstrated by highly hypnotizable subjects. The fact that these are not mere compliance reactions has now been proven by many studies using imaging techniques. But even those who are moderately hypnotizable benefit from hypnosis rituals. Variables postulated by socio-cognitive hypnosis researchers, such as motivation and expectation, are relevant, as is a good "hypnotic rapport." Practical application of hypnotherapy today is characterized by the innovative techniques and strategies developed by Milton H. Erickson. Research into the effectiveness of hypnosis in the field of psychotherapy and psychosomatics still leaves much to be done. The situation is different in the field of medical hypnosis, where there are considerably more studies with a satisfactory design and verifiable effects. However, the impact in practical application in everyday medical practice is still low. Newer developments such as virtual reality and artificial intelligence are being looked at with critical interest.

Virtual reality hypnosis prior to radiofrequency thermocoagulation for patients with chronic pain: an exploratory clinical trial

Background

The management of chronic pain may involve an array of tools, including radiofrequency thermocoagulation (Rf-Tc) of sensory nerve terminals. Like many other invasive procedures, Rf-Tc can generate anxiety in a lot of patients, either during the expectation of the procedure or in the course of it. Virtual reality hypnosis (VRH) is a promising tool for managing anxiety and pain in several situations, but its anxiolytic property has not been investigated in participants with chronic pain and going through a Rf-Tc procedure.

Objectives

The goal of this study was to evaluate the effectiveness of VRH for reducing self-assessed anxiety in participants with chronic pain, when received in preparation for Rf-Tc.

Materials and methods

This prospective, controlled trial was conducted in the Interdisciplinary Algology Centre of the University Hospital of Liège (Belgium). Participants were assigned to two groups: VRH or control (usual care). Assessment was carried-out at 4 time points: T0 (one week before Rf-Tc); T1 (pre-intervention, on the day of Rf-Tc); T2 (immediately after the VRH intervention outside of the Rf-Tc room); and T3 (right after Rf-Tc). Medical, sociodemographic data, anxiety trait and immersive tendencies were collected at T0. Anxiety state and pain intensity were assessed at each time points. Satisfaction was examined at T3.

Results

Forty-two participants were quasi-randomly assigned to the VRH or control group. No statistically significant interaction group by time was observed regarding all measured variables, including primary endpoint. However, a significant effect of time was found for anxiety and pain when considering both groups together, toward a progressive reduction.

Conclusion

In the context of our study, there appears to be no significant effect of VRH at reducing anxiety in participants with chronic pain undergoing Rf-Tc. Anxiety decreases along the procedure, while pain is attenuated by the local anesthetic infiltration of the Rf site. Our results suggest that the presence of a caregiver throughout the procedure might explain the progressive decrease in anxiety. Future randomized controlled trials are needed to precisely study the effectiveness of the VRH tool, and the possibility of using it as a complementary approach for anxiety during invasive procedures.

Clinical experience with medical hypnosis as an adjunctive therapy in heart surgery

Heart surgery patients are at high risk for psychological trauma and comorbid psychological disorders. Depression, anxiety, and post-traumatic stress disorders in this patient group are predictors of outcomes after cardiac surgery. Medical hypnosis is effective for non-pharmacologic prevention and treatment of psychological disorders and has been associated with improved health-related quality of life and better cardiovascular outcomes. This contribution makes note of evidence of the effectiveness of medical hypnosis in a discussion of the clinical experience with specific hypnotherapeutic tools and interventions from the perspective of the mental health team in one large cardiac center in Germany. Based on our experience, we encourage heart centers to educate their heart surgery care teams about the core concepts of medical hypnosis and to make hypnotherapeutic techniques available as an adjunctive therapy.

Virtual Reality for Pain and Anxiety Management in Cardiac Surgery and Interventional Cardiology

Pain and anxiety are common in patients undergoing cardiac surgery and percutaneous cardiac interventions. Virtual reality (VR) is an emerging non-pharmacological tool for pain and anxiety management. However, its application around cardiac procedures remains relatively unexplored. In this review, we perform a targeted non-systematic literature review to assess the current state-of-the-art of VR for pain and anxiety management in patients undergoing cardiac procedures. Contexts of interest were preprocedural, periprocedural, and postprocedural applications. Existing trials show inconsistent results. The majority of studies in the preprocedural (7 studies, n = 302), periprocedural (1 study, n = 99), and postprocedural stage (4 studies, n = 214) demonstrate significant reduction of pain and anxiety through VR distraction therapy or VR patient education. However, larger-scale trials (2 preprocedural studies [n = 233], 1 periprocedural study [n = 32], 2 postprocedural studies [n = 300]) report no effect. Current literature on effectiveness of VR for pain and anxiety management in cardiac surgery and interventional cardiology remains inconclusive.

Immersive virtual reality in orthopaedics-a narrative review

PURPOSE

This narrative review explores the applications and benefits of immersive virtual reality (VR) in orthopaedics, with a focus on surgical training, patient functional recovery, and pain management.

METHODS

The review examines existing literature and research studies on immersive VR in orthopaedics, analyzing both experimental and clinical studies.

RESULTS

Immersive VR provides a realistic simulation environment for orthopaedic surgery training, enhancing surgical skills, reducing errors, and improving overall performance. In post-surgical recovery and rehabilitation, immersive VR environments can facilitate motor learning and functional recovery through virtual embodiment, motor imagery during action observation, and virtual training. Additionally VR-based functional recovery programs can improve patient adherence and outcomes. Moreover, VR has the potential to revolutionize pain management, offering a non-invasive, drug-free alternative. Virtual reality analgesia acts by a variety of means including engagement and diverting patients' attention, anxiety reduction, and specific virtual-body transformations.

CONCLUSION

Immersive virtual reality holds significant promise in orthopaedics, demonstrating potential for improved surgical training, patient functional recovery, and pain management but further research is needed to fully exploit the benefits of VR technology in these areas.

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.

Effects of virtual reality working memory task difficulty on the passive processing of irrelevant auditory stimuli

The virtual reality (VR) environment is claimed to be highly immersive. Participants may thus be potentially unaware of their real, external world. The present study presented irrelevant auditory stimuli while participants were engaged in an easy or difficult visual working memory (WM) task within the VR environment. The difficult WM task should be immersive and require many cognitive resources, thus few will be available for the processing of task-irrelevant auditory stimuli. Sixteen young adults wore a 3D head-mounted VR device. In the easy WM task, the stimuli were nameable objects. In the difficult WM task, the stimuli were abstract objects that could not be easily named. A novel paradigm using event-related potentials (ERPs) was implemented to examine the feasibility of quantifying the extent of processing of task-irrelevant stimuli occurring outside of the VR environment. Auditory stimuli irrelevant to the WM task were presented concurrently at every 1.5 or 12 s in separate conditions. Performance on the WM task varied with task difficulty, with accuracy significantly lower during the difficult task. The auditory ERPs consisted of N1 and a later P2/P3a deflection which were larger when the auditory stimuli were presented slowly. ERPs were unaffected by task difficulty, but significant correlations were found. N1 and P2/P3a amplitudes were smallest when performance on the Easy WM task was highest. It is possible that even the easy WM task was so immersive and required many processing resources that few were available for the co-processing of the task-irrelevant auditory stimuli.

Virtual reality hypnosis diminishes experimental cold pain and alters autonomic responses

Immersive virtual reality (VR) is a promising tool to reduce pain in clinical setting. Digital scripts displayed by VR disposals can be enriched by several analgesic interventions, which are widely used to reduce pain. One of these techniques is hypnosis induced through the VR script (VRH) which is facilitated by immersive environment and particularly efficient even for low hypnotizable patients. The aim of this study is to assess the efficacy of a VRH script on experimentally induced cold pain perception (intensity and unpleasantness) and physiological expression. 41 healthy volunteers had been recruited in this within-subjects study. They received 9 stimulations of 20 s (3 non-nociceptive cold; 3 low nociceptive cold and 3 highly nociceptive cold) during a VRH session of 20 min (VRH condition) or without VRH (noVRH condition). Physiological monitoring during the cold pain stimulation protocol consisted of recording heart rate, heart rate variability and respiratory frequency. Maximum cold pain intensity perception, measured through the visual analog scale (VAS) on 10, was of 3.66 ± 1.84 (VAS score/10) in noVRH condition and 2.46 ± 1.54 in VRH (Wilcoxon, p < 0.0001). Considering pain unpleasantness perception, 3.68 ± 2.06 in noVRH and 2.21 ± 1.63 in VRH (Wilcoxon, p < 0.0001). Hypnotizability negatively correlated with the decrease in VAS intensity from noVRH to VRH (Spearman r = -0.45; p = 0.0038). In our sample, we found that 31/41 volunteers (75.6%) displayed a reduction of more than 10% of their VAS pain intensity and unpleasantness scores. Trait anxiety was the best predictor of the VRH responders, as well as heart rate variability. In addition, respiratory rate was diminished under VRH in every subgroup. VRH is an effective tool to reduced pain intensity and unpleasantness in a vast majority of healthy subjects. We further indicate in this study that heart rate variability parameter RMSSD (root mean square of successive differences) is a good predictor of this effect, as well as anxiety as a personality trait (but not state anxiety). Further studies are expected to determine more precisely to whom it will be the most useful to offer tailored, non-pharmacological pain management solutions to patients.

Merging virtual and physical experiences: extended realities in cardiovascular medicine

Technological advancement and the COVID-19 pandemic have brought virtual learning and working into our daily lives. Extended realities (XR), an umbrella term for all the immersive technologies that merge virtual and physical experiences, will undoubtedly be an indispensable part of future clinical practice. The intuitive and three-dimensional nature of XR has great potential to benefit healthcare providers and empower patients and physicians. In the past decade, the implementation of XR into cardiovascular medicine has flourished such that it is now integrated into medical training, patient education, pre-procedural planning, intra-procedural visualization, and post-procedural care. This review article discussed how XR could provide innovative care and complement traditional practice, as well as addressing its limitations and considering its future perspectives.

Virtual and augmented reality in intensive care medicine: a systematic review

BACKGROUND

Virtual reality (VR) and augmented reality (AR) are rapidly developing technologies that offer a wide range of applications and enable users to experience digitally rendered content in both physical and virtual space. Although the number of studies about the different use of VR and AR increases year by year, a systematic overview of the applications of these innovative technologies in intensive care medicine is lacking. The aim of this systematic review was to provide a detailed summary of how VR and AR are currently being used in various areas of intensive care medicine.

METHODS

We systematically searched PubMed until 1st March 2023 to identify the currently existing evidence for different applications of VR and AR for both health care providers in the intensive care unit and children or adults, who were in an intensive care unit because of a critical illness.

RESULTS

After screening the literature, a total of 59 studies were included. Of note, a substantial number of publications consists of case reports, study plans or are lacking a control group. Furthermore, study designs are seldom comparable. However, there have been a variety of use cases for VR and AR that researchers have explored. They can help intensive care unit (ICU) personnel train, plan, and perform difficult procedures such as cardiopulmonary resuscitation, vascular punctures, endotracheal intubation or percutaneous dilatational tracheostomy. Patients might benefit from VR during invasive interventions and ICU stay by alleviating stress or pain. Furthermore, it enables contact with relatives and can also assist patients in their rehabilitation programs.

CONCLUSION

Both, VR and AR, offer multiple possibilities to improve current care, both from the perspective of the healthcare professional and the patient. It can be assumed that VR and AR will develop further and their application in health care will increase.

The Role of Hypnotherapy in Postoperative Cardiac Surgical Patients, A Scoping Review of Current Literature

OBJECTIVE

Hypnotherapy has been proposed as an emerging tool that can be implemented in management of different aspects of postoperative cardiac surgical care. This technique involves hypnotic induction to redirect focus and attention away from post-surgical pain. Emerging literature has shown that hypnosis significantly improves emotional distress immediately preceding surgical procedures and these effects have been demonstrated to extend into the postoperative period. The purpose of this scoping review is to summarize current literature on the role of hypnotherapy in the management of perioperative pain, anxiety, and depression in patients undergoing cardiac surgery.

METHODS

A database search was conducted using PubMed, Embase, and Google Scholar. We included all comparative studies (randomized and non-randomized) that examined the effect of hypnotherapy on pain, anxiety, and depression in patients undergoing cardiac surgery. Included articles were restricted to adult patients and English language only.

RESULTS

Literature search yielded a total of 64 articles, of which, 14 duplicates were removed. After title and abstract screening, only 18 articles were included for full-text review. Six studies (with a total number of 420 patients) were included in the final analysis. Of these, five were randomized control trials and one was a cohort study.

CONCLUSION

Our findings suggest that there may be a potential role for the use of hypnotherapy in the management of pain, anxiety, and depressive symptoms in the perioperative period of cardiac surgery. However, more robust evidence is required to justify its incorporation in the routine perioperative management pathways in this group of patients.

Effect modifiers of virtual reality in pain management: a systematic review and meta-regression analysis

ABSTRACT

There is a rapidly growing body of evidence for the application of virtual reality (VR) in pain management, however, with varying effectiveness. Little is known about patient-related and VR-related factors affecting efficacy of VR. A systematic review and meta-analysis was performed including 122 randomised controlled trials (9138 patients), reporting on subjectively reported pain scores comparing an immersive VR intervention to a non-VR control group. Virtual reality significantly reduced pain in the pooled analysis (standardized mean difference = -0.65, 95% CI -0.76 to -0.54, P < 0.001). Subgroup analyses showed no significant differences between type of pain, ie, VR effects were similar in acute, chronic, and procedural pain conditions. Univariate and multivariate meta-regression analyses were performed to investigate the effect of intervention, patient, and pain characteristics on VR. Virtual reality effectively reduced pain, especially in patients reporting moderate to severe pain and in younger subjects. Studies comparing VR with a control group receiving no distraction methods were associated with higher effect sizes. The effect of VR was not related to a specific frequency or duration of use. Type of software and interaction level were related to VR effects in the univariable, but not in the multivariable, meta-regression analysis. Heterogeneity was considerable for all meta-analyses, and risk of bias was moderate to high in most included studies. Studies on mechanisms behind VR analgesia in younger patients and patients reporting moderate to severe pain are recommended to confirm our hypotheses while taking into account risk of bias and the comparator. Optimal application of VR using treatment modules for long-term pain conditions are an important issue for future research.

Effect of Distraction Interventions on Anxiety in Children Undergoing Surgery: A Meta-Analysis

Due to the unfamiliarity of the surroundings, children having surgery endure worry and tension. Untreated anxiety in children impairs postoperative healing and causes changes in postoperative behavior. The purpose of this review was to determine the efficacy of distraction therapies on anxiety in children undergoing surgery. The systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. PubMed via MEDLINE, CINAHL, ProQuest, Web of Science, and the Cochrane Central Register of Controlled Trials were used to find relevant trials. Full-text papers published in English from January 1, 2000 to December 31, 2021 were included. Children undergoing surgery aged 1 to 18 years were included. A data extraction form was created to extract data from the selected studies. According to the Cochrane risk of bias assessment tool, studies were classified as “low risk,” “high risk,” or “unclear risk.” Review Manager software was used to do a quantitative meta-analysis. Thirteen studies looked at the effect of distraction intervention on children. Nine of them were selected for meta-analysis. The distraction interventions included in this review were: handheld video game, play dough and play with blocks and puzzles, tablet-based interactive distraction, animated video, painting and storytelling, age-appropriate video, distraction with video glasses, watching a movie, and bringing favorite toy during hospital stay. Meta-analysis showed that distraction interventions are effective on preoperative anxiety in children (standardized mean difference = –17.07, 95% confidence interval: 27.11–7.02, p = 0.0009).

Virtual and augmented reality in critical care medicine: the patient's, clinician's, and researcher's perspective

Virtual reality (VR) and augmented reality (AR) are aspiring, new technologies with increasing use in critical care medicine. While VR fully immerses the user into a virtual three-dimensional space, AR adds overlaid virtual elements into a real-world environment. VR and AR offer great potential to improve critical care medicine for patients, relatives and health care providers. VR may help to ameliorate anxiety, stress, fear, and pain for the patient. It may assist patients in mobilisation and rehabilitation and can improve communication between all those involved in the patient's care. AR can be an effective tool to support continuous education of intensive care medicine providers, and may complement traditional learning methods to acquire key practical competences such as central venous line placement, cardiopulmonary resuscitation, extracorporeal membrane oxygenation device management or endotracheal intubation. Currently, technical, human, and ethical challenges remain. The adaptation and integration of VR/AR modalities into useful clinical applications that can be used routinely on the ICU is challenging. Users may experience unwanted side effects (so-called "cybersickness") during VR/AR sessions, which may limit its applicability. Furthermore, critically ill patients are one of the most vulnerable patient groups and warrant special ethical considerations if new technologies are to be introduced into their daily care. To date, most studies involving AR/VR in critical care medicine provide only a low level of evidence due to their research design. Here we summarise background information, current developments, and key considerations that should be taken into account for future scientific investigations in this field.

Discomfort improvement for critically ill patients using electronic relaxation devices: results of the cross-over randomized controlled trial E-CHOISIR (Electronic-CHOIce of a System for Intensive care Relaxation)

Purpose

To assess the impact of different electronic relaxation devices on common stressful patient symptoms experienced in intensive care unit (ICU).

Methods

Sixty critically ill patients were enrolled in four relaxation sessions using a randomized cross-over design: standard relaxation (TV/radio), music therapy (MUSIC-CARE©), and two virtual reality systems using either real motion pictures (DEEPSEN©) or synthetic motion pictures (HEALTHY-MIND©). The goal was to determine which device was the best to reduce overall patient discomfort intensity (0–10 Numeric Rating Scale (NRS); primary endpoint). Secondary endpoints were specific stressful symptoms (pain, anxiety, dyspnea, thirst, and lack of rest feeling) and stress response measured by Analgesia/Nociception Index (ANI). Multivariate mixed-effect analysis was used, taking into account patient characteristics and multiple measurements.

Results

Fifty patients followed the full research protocol, and ten patients did at least one research planned session of relaxation. HEALTHY-MIND© was associated with a significant decrease in overall discomfort, the primary endpoint (median NRS = 4[2–6] vs. 2[0–5]; p = 0.01, mixed-effect model), accompanied by a significant decrease in stress response (increase in ANI, secondary endpoint; p < 0.01). Regarding other secondary endpoints, each of the two virtual reality systems was associated with a decrease in anxiety (p < 0.01), while HEALTHY-MIND© was associated also with a decrease in pain (p = 0.001) and DEEPSEN© with a decrease in lack of rest (p = 0.01). Three incidents (claustrophobia/dyspnea/agitation) were reported among 109 virtual reality sessions. Cybersickness was rare (NRS = 0[0–0]).

Conclusion

Electronic relaxation therapy is a promising, safe, and effective non-pharmacological solution that can be used to improve overall discomfort in alert and non-delirious ICU patients. Its effectiveness depends on technical characteristics (virtual reality using a synthetic imagined world versus a real world or music therapy alone without virtual reality), as well as the type of symptoms.

Electronic relaxation therapies are effective supportive care tools for improving stressful symptoms in ICU patients.

Effectiveness depends on the type of symptom and the characteristics of the devices.

Overall discomfort and adrenergic stress response are more significantly improved by virtual reality using a synthetic imagined world than using a real world or music therapy alone.