Effectiveness of virtual reality intervention on reducing the pain, anxiety and fear of needle-related procedures in paediatric patients: A systematic review and meta-analysis

Extended Reality Interventions for Health and Procedural Anxiety: Panoramic Meta-Analysis Based on Overviews of Reviews

BACKGROUND

Extended reality (XR) technologies are increasingly being used to reduce health and procedural anxieties. The global effectiveness of these interventions is uncertain, and there is a lack of understanding of how patient outcomes might vary between different contexts and modalities.

OBJECTIVE

This research used panoramic meta-analysis to synthesize evidence across the diverse clinical contexts in which XR is used to address common outcomes of health and procedural anxiety.

METHODS

Review-level evidence was obtained from 4 databases (MEDLINE, Embase, APA PsycINFO, and Epistemonikos) from the beginning of 2013 until May 30, 2023. Reviews that performed meta-analysis of randomized controlled trials relating to patient-directed XR interventions for health and procedural anxiety were included. Studies that analyzed physiological measures, or focused on technologies that did not include meaningful immersive components, were excluded. Furthermore, data were only included from studies that compared intervention outcomes against no-treatment or treatment-as-usual controls. Analyses followed a preregistered, publicly available protocol. Trial effect sizes were extracted from reviews and expressed as standardized mean differences, which were entered into a 3-level generalized linear model. Here, outcomes were estimated for patients (level 1), studies (level 2), and anxiety indications (level 3), while meta-regressions explored possible influences of age, immersion, and different mechanisms of action. Where relevant, the quality of reviews was appraised using the AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews, Revised Instrument) tool.

RESULTS

Data from 83 individual trials were extracted from 18 eligible meta-analyses. Most studies involved pediatric patient groups and focused on procedural, as opposed to general, health anxieties (eg, relating to needle insertion, dental operations, and acute surgery contexts). Interventions targeted distraction-, education-, and exposure-based mechanisms, and were provided via a range of immersive and nonimmersive systems. These interventions proved broadly effective in reducing patient anxiety, with models revealing significant but heterogeneous effects for both procedural (d=-0.75, 95% CI -0.95 to -0.54) and general health (d=-0.82, 95% CI -1.20 to -0.45) indications (when compared with nontreatment or usual-care control conditions). For procedural anxieties, effects may be influenced by publication bias and appear more pronounced for children (vs adults) and nonimmersive (vs immersive) technology interventions, but they were not different by indication.

CONCLUSIONS

Results demonstrate that XR interventions have successfully reduced patient anxiety across diverse clinical contexts. However, significant uncertainty remains about the generalizability of effects within various unexplored indications, and existing evidence is limited in methodological quality. Although current research is broadly positive in this area, it is premature to assert that XR interventions are effective for any given health or procedural anxiety indication.

The Effect of storybook use in pediatric health services on children's fear and anxiety levels: A meta-analysis study

BACKGROUND

Invasive procedures are commonly used in pediatric healthcare, and storybooks can be used as an adjunct analgesic method.

OBJECTIVES

This study was conducted to evaluate the effectiveness of using storybooks as a distraction technique to reduce fear and anxiety in pediatric healthcare. This study was conducted with the aim of revealing the level of effect of storybook use on children's fear and anxiety level in pediatric health services.

METHODS

For this meta-analysis study, the studies were obtained by searching PubMed, Web of Scıence, Scopus, EBSCOhost, Google Scholar and YÖK Thesis Center databases in April-June 2024 without any year limitation. After the reviews, 15 studies were included in the study. The data were synthesized by meta-analysis and narrative methods.

FINDINGS

In this meta-analysis, it was found that storybook use in pediatric health services was effective on children's anxiety (SMD: -4.412, 95 % CI: -7.727 to -1.097; Z = -2.608, p = 0.009; I2 = 99.890 %) and fear (SMD: -1.13, 95 % CI: -1.71 to -0.54; Z = -3.78, p = 0.000; I2 = 83.065 %) levels. In addition, it was determined that the characteristics of the intervention group, age group, the characteristics and content of the storybook, the duration of the intervention and the time of the intervention played a role in the effectiveness of the storybook use intervention in pediatric health services on children's anxiety and fear levels.

CONCLUSION

The use of story books in children's health services reduces the level of fear and anxiety in children.

The effect of musical-animated toys and audiobooks on fear and pain in the tracheostomy care of children in the palliative care

OBJECTIVE

The study aimed to evaluate the effects of musical-animated toys and audiobooks on the fear and pain in the tracheostomy care of children in the palliative care clinic.

METHODS

The study design was a single-center, single-arm, crossover-controlled study. The sample consisted of 16 children who were 3-6 years old. Musical-animated toys and audiobooks were used to divert the children's attention during tracheostomy care. The children whose control data were collected on the first day were shown musical-animated toys on the second day and listened to an audiobook a week later. The children were video-recorded during the interventions.

RESULTS

The children who received musical-animated toy and audiobook interventions during and after tracheostomy care expressed less pain than those in the control group, and their fear levels were less during the care.

CONCLUSION

Audiobook and musical-animated toy interventions were effective in reducing children's procedure-related fear and pain during tracheostomy care in the pediatric palliative care clinic.

Extended Reality Analgesia Evidence Reviews Often Lack Sufficient Intervention Detail

Background

Evidence synthesis projects such as systematic reviews and meta-analyses are defined by the focal research question addressed through assemblage and analysis of all relevant literature. In complex intervention domains such as medical extended reality (MXR), there are a plethora of intervention factors that could be included in research questions, which define study inclusion criteria and, in turn, shape the generalizability of results. This article quantifies how recently published evidence syntheses of MXR interventions for pain management characterize the primary studies they assess.

Method

Inclusion criteria for analysis consisted of English-language scoping reviews, systematic reviews, and meta-analyses, published in 2021-2023, that evaluated MXR-based interventions for pain management in any setting. We employed quantitative content analysis to assess characterization of intervention features.

Results

Of the 61 synthesis publications that met inclusion criteria, 29 (48%) included only minimal description of MXR intervention content, 14 (23%) included substantial content descriptions, and the remainder did not describe intervention content within synthesized studies. Hardware details were reported for 15 (25%) of publications in a minimal way, 28 (46%) in a substantial way, and not reported in 18 (30%) of syntheses. Among the 39 papers that included a meta-analysis, 10 (25%) explicitly evaluated the role of intervention features in intervention efficacy.

Conclusion

Findings suggest considerable variability in the characterization of intervention elements (content and hardware), which can limit accurate conclusions about the generalizability of synthesis findings. Accordingly, we make recommendations to guide future evidence syntheses in the MXR domain.

Golden Breath: Feasibility and acceptability of a biofeedback-based virtual reality game on reducing children's needle-related pain and fear

BACKGROUND

Needle procedures can cause pain and fear in children. Current literature reports that biofeedback-based virtual reality applications may help alleviate children's pain and fear. This study aims to evaluate the feasibility, acceptability, and safety of the newly developed game Golden Breath, which uses biofeedback-based virtual reality to reduce children's needle-related pain and fear.

METHODS

The development of Golden Breath includes; (1) development of the application's features based on needs assessment, (2) gamification of the application content based on literature, (3) development of the prototype, (4) expert evaluation and feedback on the application content, (5) usability testing by 11 children (4-12 years).

RESULTS

Regarding acceptability, the expert evaluation showed a high usability of the system. All children provided positive feedback and reported high satisfaction with Golden Breath. The game was feasible and effective for reducing children's pain and fear levels during needle procedures. Golden Breath was deemed safe for children because it did not cause symptoms such as dizziness, vomiting, or nausea.

CONCLUSION

The expert evaluation, children's feedback, and pilot study results showed that the Golden Breath game is feasible, acceptable, and safe for children during the needle-related procedure. The pilot study revealed that the Golden Breath game effectively reduced pain and fear during blood sampling in children.

PRACTICE TO IMPLICATIONS

It is recommended that healthcare professionals use Golden Breath to optimize the well-being of children receiving treatment for chronic and acute diseases.

Child-Centered Care: A Qualitative Study Exploring Pediatric Hospitalization Through Children's Perspectives

Background/Objectives: Hospitalization can be stressful for children due to the influence of unfamiliar environments, separation from family, and interactions with healthcare professionals. This study aimed to explore children's hospitalization experiences from a child-centered care perspective to develop interventions that better meet their emotional and psychological needs. Methods: This qualitative study employed Husserl's descriptive phenomenology to explore hospitalization experiences among children aged 9-13 years. Conducted at a primary health center in Spain from October 2022 to June 2023, the study used purposive sampling to select participants hospitalized within the past six months. Data were collected through in-depth interviews and children's self-created drawings, analyzed using thematic analysis with ATLAS.ti software. Results: A total of 10 school-age children (five boys and five girls) were interviewed. Three main themes emerged: (1) Emotions and Feelings-children described fear, anxiety, and loneliness during their hospital stay; (2) Experiences of Pain and Discomfort-participants reported physical pain and discomfort; (3) Interactions with Medical Staff-children expressed a need for more detailed explanations and clearer communication. Conclusions: The findings highlight the importance of family-centered care and improved communication between healthcare providers and children. Strategies like art therapy and flexible visiting hours could provide better emotional support. Tailored communication to children's developmental levels is crucial. Integrating these strategies into clinical practice could enhance the well-being of hospitalized children. Future research should focus on evaluating these interventions to improve pediatric care.

Effectiveness of Virtual Reality for Managing Pain, Fear, and Anxiety in Children and Adolescents Undergoing Needle-Related Procedures: Systematic Review with Meta-Analysis

The most frequently performed invasive procedures in hospitals and healthcare centers are needle-related procedures, such as intravenous cannulation and phlebotomy, and they are identified as the major sources of pain, fear, and anxiety in children and adolescents. The objective of this systematic review was to evaluate the effectiveness of VR as a distraction measure to reduce pain, fear, and anxiety in children and adolescents undergoing needle-related invasive procedures. For this purpose, the CINAHL, Scopus, WOS, and Cochrane Library scientific databases were used. The protocol review was registered in PROSPERO (ID:42024563245), and inclusion and exclusion criteria were applied. Twenty-one studies were included in the systematic review, involving a total of 2663 participants. Significant differences favored the use of virtual reality for the control of pain intensity (WBFSpatients p = 0.001; MD = -1.83; 95% CI -2.93 to -0.72; WBFSparents p = 0.0002; MD = -2.61; 95% CI -4.00 to -1.23; WBFSnurses p = 0.0001; MD = -2.71; 95% CI -2.82 to -2.60; VAS/NRS p = 0.001, MD = -0.71; 95% CI -1.13 to -0.28), anxiety (CAMpatient p = 0.02, MD = -2.92; 95% CI -5.45 to -0.38; CAMparents p = 0.01, MD = -3.87; 95% CI -6.99 to -0.75) and fear (CFSpatients p = 0.0005, MD = -1.27; 95% CI -1.99 to -0.56; CFSparents p = 0.0005, MD = -1.33; 95% CI -2.08 to -0.58; and CFSnurses p = 0.04, MD = -1.13; 95% CI -2.24 to -0.03). However, high heterogeneity was noted. The use of virtual reality as a distraction appears to be a valuable strategy for reducing pain, fear, and anxiety during needle-related procedures, although further studies with higher methodological rigor, based on a standardized protocol, are needed.

Effectiveness of ShotBlocker application on reducing the pain of needle-related procedures in children: A systematic review and meta-analysis

PROBLEM

Needle-related procedures are quite common throughout life, especially during childhood. Pain caused by these procedures is the most common complication. ShotBlocker is an alternative non-pharmacological method to reduce pain during injection-related procedures. However, the effectiveness of the ShotBlocker application in children for reducing pain needle-related procedures remains unclear. This review aimed to evaluate the effectiveness of ShotBlocker application on pain during needle-related procedures in children from Randomized Controlled Trials.

ELIGIBILITY CRITERIA

Eight electronic databases were searched until November 2023 for articles published in English. The methodological quality and evidence strength were appraised using the Cochrane Risk of Bias 2 tool and the GRADE approach. A random-effects model was used to determine the effect of the ShotBlocker application on pain levels. The review included results involving assessments from the child, parents, and an observer in pain evaluation.

SAMPLE

A total of nine studies with 1205 children patients were included.

RESULTS

The evaluation data showed that ShotBlocker application significantly reduced the pain caused by needle-related procedures in children. The Cochrane GRADE approach showed moderate level evidence for the effect of ShotBlocker application on pain during needle procedures.

CONCLUSIONS

As a result of the studies included in this meta-analysis, it was determined that ShotBlocker application significantly reduced the pain caused by needle-related procedures in children.

IMPLICATIONS

ShotBlocker, a non-pharmacological method, can be used by pediatric nurses to reduce pain during needle-related procedures in children. Randomized controlled studies with well-designed methods are needed to create strong evidence in this field.

The effect of virtual reality distraction on haemodialysis patients' pain and anxiety during arteriovenous fistula puncture: a randomised controlled trial

Background

Pain and anxiety during arteriovenous fistula (AVF) puncture are crucial factors affecting haemodialysis (HD) patients' quality of life.

Aim

The aim of this study is to assess the effect of virtual reality (VR) distraction on pain, anxiety, satisfaction and haemodynamics during AVF puncture.

Methods

This randomised controlled trial study was conducted in a Haemodialysis unit at Mansoura University Hospital. Ninety-six patients were randomly divided into the intervention (n = 48) and control (n = 48) groups. Six minutes prior to the puncture, patients in the intervention group used VR glasses to experience a 360° 'Relax River VR tour', whereas patients in the control group received no intervention.

Results

Following the intervention, pain, anxiety, systolic blood pressure and heart rate were significantly lower, and satisfaction scores were significantly higher in the intervention group than in the control group (p < 0.05).

Conclusion

VR distraction may help alleviate pain, anxiety and increase satisfaction. It may be considered a safe and cost-effective non-pharmacological therapy for HD patients undergoing AVF puncture.

Tips for success, managing the paediatric patient in radiology

Paediatric radiology is a fascinating and diverse field of medicine with many opportunities to gain expertise in a range of imaging modalities and body areas. Working with children makes imaging both rewarding and challenging, due to the wide range of patient ages encountered and the inherent variation in developmental needs. This requires a patient-focussed approach to manage their anxiety and ensure cooperation of the patient and their carers. Several approaches to dealing with children have been developed including recognising individual needs, empathising with the child and carers, and involving the use of play and a range of age-relevant preparation materials. All of these make the radiology imaging environment and encounter a more effective and collaborative process. The purpose of this manuscript is to present a practical guide to overcoming these challenges, by making the child the focus of their radiological examination.

Strategies to minimize procedure-related pain and anxiety: lessons from pediatric dermatology

PURPOSE OF REVIEW

Recent studies have suggested that prolonged or repeated episodes of general anesthesia early in childhood may adversely affect neurodevelopment. This, combined with rising healthcare costs and decreasing access, has sparked interest in performing pediatric procedures in the office setting when possible. It is essential to address the physical and psychological discomfort that often accompany this experience, particularly in children.

RECENT FINDINGS

Healthcare providers performing procedures on children can draw from a spectrum of established techniques, new technology, and novel use of medications to decrease peri-procedural pain and anxiety. These techniques include distraction, optimization of local anesthesia, and mild to moderate sedation.

SUMMARY

We recommend using a combination of techniques to minimize pain and anxiety to improve safety, decrease healthcare costs, improve patient experience, and prevent childhood trauma and persistent negative perception of the healthcare system.

Virtual Reality Distraction for Needle-Related Pain and Distress in Children: A Multicenter Randomized Controlled Trial

This international multicenter randomized controlled trial aimed to compare the effectiveness of virtual reality (VR) distraction with an identical non-VR game in reducing needle-related pain and anxiety in children undergoing venous blood draw. The study involved 304 children aged 5-9 years undergoing a blood draw procedure, randomly allocated to one of three groups: VR distraction, non-VR distraction, and control group (usual care). The distraction task was based on the Multiple Object Tracking (MOT) paradigm, and the game was identical in design and gameplay for both VR and non-VR distraction groups. The primary outcome was self-reported pain intensity using the Faces Pain Scale-Revised (FPS-R). Secondary outcomes included child distress, attention/distraction to the blood draw, and parent and medical staff satisfaction with procedure. Analyses were conducted using analysis of variance and multivariable linear regression models. The results showed that VR distraction and non-VR distraction performed similarly, showing large effect sizes compared with standard care. There was no significant difference between the two types of distraction. The study's findings suggest that VR and non-VR distraction are similarly effective in reducing needle-related pain and anxiety in children undergoing venous blood draw. This is the first well-powered study comparing modern VR distraction with an identical task displayed on a smartphone or monitor screen. The study's results have important implications for using VR in clinical settings and suggest that investing in expensive VR equipment for acute pain management may not be necessary. The study protocol was pre-registered on Open Science Framework at https://osf.io/frsyc.

The effect of VR headsets used during burn dressing in children on satisfaction and anxiety level of their parents

PURPOSE

The aim of this study was to determine the effect of virtual reality used during burn dressing in children on the satisfaction and anxiety levels of their parents.

METHODS

The study, which was designed as a prospective randomized controlled trial, was carried out with the parents of children aged 5-10 years who visited the only burns unit of a hospital in the northern region of Turkiye between 5 July 2021 and 1 April 2022 for dressing. There were a total of 52 participants in the study, 26 in the control and 26 in the intervention group.

RESULTS

The mean age of the children was 7.31 ± 1.81 years in the intervention group and 7.08 ± 1.72 in the control group. After the dressing was applied to the children, the mean anxiety score of the parents of the children was found to be 0.09 ± 0.28 in the intervention group and 0.64 ± 0.53 in the control group. The mean nursing care satisfaction score of the parents in the intervention group was found to be 4.70 ± 0.50 while it was 2.80 ± 0.26 in the control group.

CONCLUSIONS

In the study, while the anxiety levels of the ones in the intervention group decreased after the dressing, their satisfaction levels with nursing care were found higher than the control group.

PRACTICE IMPLICATIONS

Nursing interventions that would reduce the pain and anxiety experienced by children during medical procedures are also effective in reducing the anxiety of parents, and therefore, they should be included in distraction efforts with their children.

Virtual emotions and Criminal Law

This article examines the role that Criminal Law should play in regulating the non-therapeutic use of immersive Virtual Reality (VR), specifically its massive use by consumers. The starting point has been to consider VR as an intermediate risk scenario, for the purposes of Criminal Law, between the criminality entirely generated in the physical world and that developed in the 2D digital environments [cybercrimes and criminality linked to social networks and persuasive Artificial Intelligence (AI)]. Firstly, specialize literature has been analyzed to establish the nature of virtual reality. From a technical standpoint, virtual reality is a neurotechnology infused with high-risk artificial intelligence; an inseparable synthesis of non-invasive neurotechnology and a set of AI systems, considered high-risk for the fundamental rights of citizens. From the perspective of its functioning, VR is a "transformative" neurotechnology capable of altering what people perceive as reality. This is possible, because its realism lies in the emotional immersion of the user in the virtual experience, similarly to how our brain functions. Therefore, the key idea in the immersive functioning of virtual reality is its capacity to evoke and modify human emotions, which results its greater harmful potential compared to the 2D environment. From there, three central and specific areas of (legally unaddressed) risk arise: (1) the special comprehensive nature of the data collected and stored during its use; (2) its ability to mentally reproduce the "physical" experience of the avatar in the user; and (3) its significant capacity to manipulate individuals. Secondly, the paper examines both the reported cases and the foreseeable criminality in virtual worlds or "proto-metaverse," focusing on the three risk areas, and exemplifying them with attacks on mental privacy, sexual freedom, and consumer manipulation. Finally, it is proposed that Criminal Law should also intervene (as soon as possible) to define the "red lines" of massive virtual reality use by citizens. With a democratic and human-centered approach, a basic legal framework is outlined for the criminalization of specific harms and risks associated with virtual reality, adapting the existing legal framework as necessary.

Effectiveness of non-immersive virtual reality in the management of procedure-related pain in preschool children: a randomized clinical trial

The objective of this study is to assess the effectiveness of non-immersive virtual reality as a pain-distraction measure in children between the ages of 3 and 5 years undergoing painful injection procedures in an outpatient setting. We carried out a randomized, unmasked clinical trial in children undergoing venipuncture or intramuscular injection procedures. Patients were randomized to a distraction virtual reality video or standard care. After the procedure, three independent observers (parents, researchers, nursing staff) rated pain on the LLANTO pain scale. We recruited 122 subjects, half of which were randomized to virtual reality. The median age was of approximately 60 months (IQR: 15 months), and the sample was balanced with regard to sex. There were significant differences in LLANTO scales scores between the VR subjects and controls of - 3.34 (95% CI - 4.15; - 2.54), - 3.02 (95% CI - 3.90; - 2.14), and - 2.98 (95% CI - 3.87; - 2.09), as rated by parents, researchers, and nursing staff, respectively. Agreement between raters was high for all three types of observers, with Cohen Kappas over 0.79 in all cases. Bivariate analysis showed reductions in the risk of obtaining higher scores in the LLANTO scale. Linear regression models showed a reduction of approximately 3 points in the scale, regardless of the type of observer. These models were adjusted for sex, age, kind of procedure, use of prior analgesia, and recruitment center.

CONCLUSIONS

Non-immersive virtual reality is an effective adjunctive therapy for the reduction of pain in children undergoing painful injection procedures in an outpatient setting. This strategy may be used to improve the quality of care in pediatric outpatient services.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03985930 (Registered June 14, 2019).

WHAT IS KNOWN

•The use of immersive virtual reality (VR) has been described as an effective adjunctive distraction method during painful procedures in children over 5 years.

WHAT IS NEW

•The utility of non-immersive VR in children below that age is not yet clear. This randomized clinical trial comparing non-immersive VR vs. standard care showed an average reduction of three points in the LLANTO pain scale favoring non-immersive VR. Non-immersive VR is an effective and inexpensive non-pharmacological technique that reduces fear and pain in pediatric patients.

Virtual reality for pain management: an umbrella review

Background and objective

Virtual reality is a promising pain control strategy for various pain conditions. This umbrella review of systematic reviews and meta-analyses aims to evaluate the analgesic effects of virtual reality.

Methods

We searched for the relevant reviews in Scopus, PubMed and Cochrane library. Our primary outcome was pain, with secondary outcomes including disability, general health status, patient satisfaction, depression, balance, fear of movement, and adverse events. The quality of included articles was evaluated using the AMSTAR-2 tool.

Results

21 systematic reviews and meta-analyses with 274 studies and 17,680 patients were included in this review. All the reviews concluded benefits of virtual reality in managing pain conditions, including chronic and pain.

Discussion and conclusions

This umbrella review demonstrates successful application of virtual reality in pain control, including perioperative, periprocedural, and chronic pain settings. Virtual reality can be used as an alternative therapy for pain management in children and adults.

Paediatric pain management: from regional to virtual

PURPOSE OF REVIEW

Due to increased interest in opioid-sparing multimodal analgesic strategies both inside and outside of the operating room, anaesthesiologists have started to look towards regional anaesthesia as well as nonpharmacological pain-reducing techniques. The purpose of this article is to discuss current trends and recent developments in regional anaesthesia and virtual reality for paediatric pain management.

RECENT FINDINGS

The development of novel fascial plane blocks has expanded regional options for anaesthesiologists, especially when neuraxial anaesthesia is not a viable or straightforward option. Other regional techniques, such as spinal anaesthesia and continuous epidural analgesia for infants and neonates, are becoming more popular, as more paediatric anaesthesiologists become familiar with these techniques. Virtual reality for paediatric pain management is a relatively new area of study that has shown promise, but more research needs to be done before widespread adoption of this practice becomes a reality. Various preexisting pain-reducing strategies such as distraction and biofeedback are being integrated with virtual reality to help optimize its effect on pain and anxiety for paediatric patients.

SUMMARY

Regional anaesthesia and virtual reality are valuable tools that serve to alleviate pain in paediatric patients. Advances are being made within both fields in various healthcare settings for different types of pain. Over the next few years, they will likely both play an increasing role in paediatric pain management.