Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study

Technology and Children's health: Effect of virtual reality on pain and clinical outcomes during hydrotherapy for children with burns

BACKGROUND

Virtual Reality (VR) has been frequently used as an engaging, interactive, and effective non-pharmacological distraction technique for children during painful procedures, including burnt wound care.

AIM

This study aimed to evaluate the effect of virtual reality on pain and clinical outcomes during hydrotherapy for children with burns.

DESIGN

A randomized controlled pretest, during, and post-test research design was utilized.

METHODS

Sixty children with burns underwent hydrotherapy, divided randomly and assigned equally into two groups. Children of the control group received the standard pharmacological treatment of the unit to manage pain and stabilize their physiological parameters throughout the three days of study. Children of the virtual reality intervention group received all basic standard care as the control group plus VR intervention across different software content, and interaction immersion designs which took place using a cell phone coupled with the three-dimensional (3D) image glasses. Outcome measures were physiological parameters, wound healing, and Face, Leg, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale.

SETTING

This study was carried out in the burns unit at the Plastic, Reconstructive, and Burns Surgery Center affiliated to Mansoura University, from September to November 2023.

RESULTS

Children in the study group had lower pain scores, more stable physiological parameters, and higher rates of wound healing compared to the control group with a statistically significant difference between both groups.

CONCLUSION

Using VR intervention significantly reduced pain intensity, enhanced physiological parameters and promoted the rate of wound healing in children with burns during hydrotherapy.

Virtual reality vs. tablet for procedural comfort using an identical game in children undergoing venipuncture: a randomized clinical trial

Introduction

Recent research has explored the effectiveness of interactive virtual experiences in managing pain and anxiety in children during routine medical procedures, compared to conventional care methods. However, the influence of the specific technology used as an interface, 3-dimensions (D) immersive virtual reality (VR) vs. 2D touch screens, during pediatric venipuncture, remains unexamined. This study aimed to determine if immersive VR is more effective than a tablet in reducing pain and anxiety during short procedures.

Methods

An interactive game was designed by clinicians and psychologists, expert in pain theory, hypnosis, and procedural pain and anxiety relief, and was tailored for both VR and tablet use. Fifty patients were randomly assigned to either the Tablet or VR group. The primary outcome measures were pain and anxiety levels during the procedure. Secondary outcome measures included the need for physical restraint, duration of the procedure, enjoyment levels, and satisfaction ratings from both parents and nurses.

Results

Participants, in both groups, had low levels of pain and anxiety. Physical restraint was infrequently used, procedures were brief, and high satisfaction levels were reported by patients, parents, and nurses.

Discussion

This study suggests that the type of technology used as a support for the game has a minimal effect on the child's experience, with both groups reporting low pain and anxiety levels, minimal physical restraint, and high enjoyment. Despite immersive VR's technological advancements, this study underscores the value of traditional tablets with well-designed interactive games in enhancing children's wellbeing during medical procedures.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT05065307].

Effects of Virtual Reality on Analgesia in Wound Care and Physical Therapy for Burn Patients: A Systematic Review and Meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to determine the effectiveness of virtual reality (VR) in alleviating pain and improving the experience of burn patients during wound care and physical therapy.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Database, and the Web of Science.

REVIEW/ANALYSIS METHODS

We searched four electronic databases for randomized controlled trials (RCTs) published from the earliest available date up to March 1, 2022. The primary outcome was worst pain intensity, while secondary outcomes encompassed pain unpleasantness intensity, time spent thinking about pain, and fun experience intensity. Risk of bias was evaluated using the Cochrane Collaboration's tool.

RESULTS

This study included 21 trials. The combined data revealed that the VR group experienced a significant reduction in worst pain intensity, pain unpleasantness intensity, and time spent thinking about pain compared to the control group. Moreover, VR treatment was associated with a significant increase in the fun experience intensity.

IMPLICATIONS FOR NURSING

Virtual reality has the potential value of auxiliary analgesia in burn care, and exploring a more perfect scheme of VR-assisted analgesia is worthwhile.

CONCLUSIONS

The results of this meta-analysis indicate that VR can effectively reduce worst pain intensity, pain unpleasantness intensity, and time spent thinking about pain during wound care and physical therapy for burn patients. Additionally, it enhances fun experience intensity of the treatment period. Therefore, VR shows promise as a valuable complementary pain management intervention for burn patients.

The Effect of Virtual Reality Application on Pain During Wound Care Dressing Change: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate the effect of virtual reality application on pain during a wound care dressing change.

DESIGN

Systematic review and meta-analysis DATA SOURCES: PubMed, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL (EBSCOhost), and YÖKTEZ REVIEW/ANALYSIS METHODS: The last screening of all databases was performed on 20.07.2022. Parallel-group RCTs suitable for the research subject were included in the study. The "Cochrane risk-of-bias tool" was used to measure the risk of bias. A heterogeneity test was done with the I2 value and the p value for the Q statistics. Five methods were employed to assess publication bias. Sensitivity analysis was performed for studies with a high risk of bias.

RESULTS

As a result of the screening, 13 RCTs involving 882 wound care patients were included in the study. It was determined that the virtual reality application reduced pain moderately during a wound care dressing change (SMD= -0.60; 95% CI= -0.73 and -0.46; p < .001). The fixed effect model was used because the value of heterogeneity (I2 = 0%, p = 0.796) was low in the analysis. No significant results were obtained in the moderator analysis.

CONCLUSION

It was found that the virtual reality application moderately reduced pain during a wound dressing change and was a reliable application. However, it was suggested that the virtual reality application alone was insufficient to reduce pain during wound care and should be applied together with analgesic or anesthetic drugs included in the standard wound care procedure.

Greater usage and positive mood change for users of a dynamic VR app before and after the COVID-19 pandemic onset

Americans reported an increase in stress during the novel coronavirus disease 2019 (COVID-19). Virtual reality (VR) apps have been shown to distract users from stressors in the environment, but little is known about the efficacy of specific content features to reduce stress or improve mood for consumer users during a pandemic. The present study investigated secondary archival data to explore how mood and usage behavior changed before and after the onset of COVID-19 for consumer users of a VR app with dynamic, interactive content. Study findings indicate that the COVID-19 pandemic had significant effects on user behavior and mood. Users created more accounts and used app content more often during the pandemic, while reporting increased negative mood states. This suggests that users were motivated to use the content to cope with pandemic stressors. Users also experienced a greater positive mood change after using the content during the pandemic than before, which implies that elements related to the VR app content met users' psychological needs. Passive content with less interactivity resulted in a greater positive mood state after the COVID-19 onset, likely related to its capacity to reduce stress, facilitate restoration, and improve persistent affective states in stressful environments. This study offers a vital window into how consumer users respond to psychosocial pandemic stressors outside of a controlled environment as well as the prospective for VR app content to serve as a valuable mental health intervention during similar stressful events.

Efficacy of virtual reality for pain relief in medical procedures: a systematic review and meta-analysis

BACKGROUND

Effective pain control is crucial to optimise the success of medical procedures. Immersive virtual reality (VR) technology could offer an effective non-invasive, non-pharmacological option to distract patients and reduce their experience of pain. We aimed to evaluate the efficacy of Immersive virtual reality (VR) technology in reducing patient's pain perception during various medical procedures by conducting a systematic review and meta-analysis.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, CINAHL, and SIGLE until December 2022 for all randomised clinical trials (RCT) evaluating any type of VR in patients undergoing any medical procedure. We conducted a random effect meta-analysis summarising standardised mean differences (SMD) with 95% confidence intervals (CI). We evaluated heterogeneity using I 2 and explored it using subgroup and meta-regression analyses.

RESULTS

In total, we included 92 RCTs (n = 7133 participants). There was a significant reduction in pain scores with VR across all medical procedures (n = 83, SMD - 0.78, 95% CI - 1.00 to - 0.57, I 2 = 93%, p = < 0.01). Subgroup analysis showed varied reduction in pain scores across trial designs [crossover (n = 13, SMD - 0.86, 95% CI - 1.23 to - 0.49, I 2 = 72%, p = < 0.01) vs parallel RCTs (n = 70, SMD - 0.77, 95% CI - 1.01 to - 0.52, I 2 = 90%, p = < 0.01)]; participant age groups [paediatric (n = 43, SMD - 0.91, 95% CI - 1.26 to - 0.56, I 2 = 87%, p = < 0.01) vs adults (n = 40, SMD - 0.66, 95% CI - 0.94 to - 0.39, I 2 = 89%, p = < 0.01)] or procedures [venepuncture (n = 32, SMD - 0.99, 95% CI - 1.52 to - 0.46, I 2 = 90%, p = < 0.01) vs childbirth (n = 7, SMD - 0.99, 95% CI - 1.59 to - 0.38, I 2 = 88%, p = < 0.01) vs minimally invasive medical procedures (n = 25, SMD - 0.51, 95% CI - 0.79 to - 0.23, I 2 = 85%, p = < 0.01) vs dressing changes in burn patients (n = 19, SMD - 0.8, 95% CI - 1.16 to - 0.45, I 2 = 87%, p = < 0.01)]. We explored heterogeneity using meta-regression which showed no significant impact of different covariates including crossover trials (p = 0.53), minimally invasive procedures (p = 0.37), and among paediatric participants (p = 0.27). Cumulative meta-analysis showed no change in overall effect estimates with the additional RCTs since 2018.

CONCLUSIONS

Immersive VR technology offers effective pain control across various medical procedures, albeit statistical heterogeneity. Further research is needed to inform the safe adoption of this technology across different medical disciplines.

Virtual reality facilitated exercise improves pain perception: A crossover study

STUDY OBJECTIVE

Both virtual reality (VR) and exercise are recognized for their analgesic and anxiolytic properties. The purpose of this study is to evaluate the ability of VR-facilitated exercise to modulate pain.

DESIGN

Within-subject cross-over clinical trial.

SETTING

The Stanford Chariot Program conducted this study at Lucile Packard Children's Hospital Stanford (LCPHS).

PATIENTS

Healthy participants meeting inclusion criteria were recruited by volunteer solicitation from LCPHS.

INTERVENTIONS

Participants were randomized by hand dominance and subjected to a standardized cold pressor test with no VR or exercise. After a 5-min wash-out period, participants repeated the test on their other hand while experiencing a VR-facilitated exercise condition. Pain sensitivity, pain tolerance, and sympathetic activation data were collected during both conditions.

MEASUREMENTS

Pain sensitivity was scored 0-10 and collected every 30 s. Pain tolerance was recorded as the duration a participant could endure the painful stimuli. Sympathetic activation was measured by skin conductance response density (SCRD) and recorded in 30 s epochs by a biosensor. In all analyses, data were nested by participant.

MAIN RESULTS

Forty-one participants completed both interventions. Pain sensitivity was reduced in the VR-facilitated exercise condition (p < 0.0001). There was no difference in pain tolerance between conditions. While both conditions resulted in an increase in sympathetic activity, SCRD was higher at all time points in the VR-facilitated exercise condition.

CONCLUSIONS

The reduction in pain sensitivity indicates VR-facilitated exercise results in improved pain perception. VR-facilitated exercise may be especially useful for patients with chronic pain or other conditions requiring physical therapy, where pain may be exacerbated by exercise.

Global Scientific Trends in Virtual Reality for Pain Treatment From 2000 to 2022: Bibliometric Analysis

Background

Virtual reality (VR) is a computer simulation technique that has been increasingly applied in pain management over the past 2 decades.

Objective

In this study, we used bibliometrics to explore the literature on VR and pain control, with the aim of identifying research progress and predicting future research hot spots.

Methods

We extracted literature on VR and pain control published between 2000 and 2022 from the Web of Science Core Collections and conducted bibliometric analyses. We analyzed the publication and citation trends in the past 2 decades, as well as publication and citation analyses of different countries, institutions, journals, and authors. For references, we conducted cocitation and burst analyses. For keywords, we conducted co-occurrence, clustering, timeline view, and citation burst analyses.

Results

Based on 1176 publications, we found that there was a continuous increase in publication and citation volumes, especially in the last 5 years. The United States was the most representative country, and the University of Washington was the most representative institution, with both having the most publications and citations. The most popular journal in this field was Burns, and Hoffman HG was the most productive author, leading many studies on patients with burn pain. The reference with the most citation burst was a study on the verification of new hardware in pain control. The keywords with the highest citation bursts related to various situations of pain such as "burn pain," "wound care," "low back pain," and "phantom limb."

Conclusions

VR has been applied in various clinical situations for pain management, among which burns and pediatric surgery have achieved satisfactory results. We infer that VR will be extended to more clinical pain situations in the future, such as pain control in wound care, low back pain, and phantom limb pain. New research hot spots will include the development of software and hardware to improve the immersive experience of VR for pain control. However, our work was based solely on English literature from the Web of Science database. For future studies, we recommend that researchers explore literature from multiple databases to enhance the scope of their research.

Role of virtual reality distraction technique to improve chest burns with acute respiratory distress syndrome (ARDS) following smoke inhalation in middle-aged adults - A randomized controlled study

BACKGROUND

Burns of the chest region constitute a common burn and develops skin contractures around the thorax region. Inhalation of toxic gases and chemical irritants during the fire leads to Acute Respiratory Distress Syndrome (ARDS). Breathing exercises are painful but are needed to help counteract contractures and increase lung capacity. These patients are usually in pain and extremely anxious about chest physiotherapy. Virtual reality distraction is one such technique that is gaining immense popularity when compared to other pain distraction techniques. However, studies examining the efficacy of the virtual reality distraction technique in this population are lacking.

OBJECTIVES

To find and compare the effects of the virtual reality distraction technique as a pain alleviation tool for reducing pain during chest physiotherapy in chest burns patients with ARDS in middle-aged adults.

METHODS

A randomized controlled study was conducted at the physiotherapy department between 1st Sep 2020 and 30th Dec 2022. The eligible sixty subjects were randomized into two groups: The virtual reality distraction group (n = 30) received virtual reality distraction technique and the control group (n = 30) received progressive relaxation technique before chest physiotherapy as a pain distraction technique. All the participants received chest physiotherapy as a common treatment (treatment as usual). Primary (Visual Analogue Scale - VAS) and secondary (forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, peak expiratory flow (PEF), residual volume (RV), functional residual capacity (FRC), total lung capacity (TLC), RV/TLC, and diffusing capacity for carbon monoxide of the lungs (DLCO) outcome measures were measured at baseline, after four weeks, eight weeks and at six months follow up. The effects between the two groups were analyzed using the independent t-test and chi-square test. The intra-group effect was analyzed with a repeated measure ANOVA test.

RESULTS

Baseline demographic characters and study variables show homogenous distribution between the groups (p > 0.05). Four weeks following two different training protocols virtual reality distraction group shows more significant changes in pain intensity, FVC, FEV1, FEV1/FVC, PEF, RV, FRC, TLC, RV/TLC, and DLCO (p = 0.001) but not in RV (p = 0.541). The similar improvements were noted in the 8 weeks and 6 months follow up.

CONCLUSION

The reports of the study concluded that virtual reality distraction is an effective and useful technique in reducing pain and increasing lung capacity in chest burn patient with ARDS following smoke inhalation in community-dwelling middle-aged adults. In the virtual reality distraction group, the patients reported significantly less pain and clinically meaningful changes in pulmonary functions as compared to the control group (physiotherapy + relaxation).

Effectiveness of Virtual Reality in Anxiety and Pain Management in Children and Adolescents Receiving Cancer Treatment: A Systematic Review and Meta-analysis of Randomized Controlled Trials

TRIALS

The study aimed to investigate the effect of virtual reality interventions on relieving pain and anxiety in children and adolescents receiving cancer treatment. A search that involved Cochrane Library (comprising Cochrane Central Register of Controlled Trials (CENTRAL)), PubMed, ProQuest, MEDLINE, Web of Sciences, Science Direct, and Scopus electronic databases covering the records from January 1, 2000 up to May, 2023 was conducted to determine randomized controlled trials that could be included in our study. The results of the search were limited to "anxiety and pain, adolescents, children, virtual reality, cancer." Of the 160 articles that were reached during the search, seven were found eligible based on inclusion criteria. Hedges' g effect size was calculated for each article. Random effects model was used to test effect sizes and moderator variables. The registration number of this meta-analysis on PROSPERO is CRD42022304737. The outcomes were pain and anxiety. Compared with standard care, virtual reality had a medium and significant effect on anxiety (g = 0.60, 95% CI: [- 1.05 - 0.15]) and pain (g = - 0.667, 95% CI: [- 1.08- -0.24]). In addition, age has been identified as an important moderator in the use of virtual reality in pain management. This meta-analysis shows that virtual reality applications are effective interventions for reducing pain and anxiety in the field of pediatric oncology. However, it is necessary to carry out randomized controlled trials that have large samples for evidence-based virtual reality applications in pediatric oncology.

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.

Extended Reality Use in Paediatric Intensive Care: A Scoping Review

Background: Extended reality (XR) technology such as virtual and augmented reality is increasingly being utilised in paediatric medicine due to its role in medical education and reported positive impacts on outcomes including pain, anxiety, and sleep. To the author's knowledge, no previous reviews investigating the use of XR in paediatric intensive care have been undertaken. Objectives: To scope the use of XR in paediatric intensive care, and assess its barriers to adoption, including safety considerations, cleaning and infection control. Eligibility criteria: All articles of any methodological design discussing the use of XR within paediatric intensive and critical care were included. Sources of evidence: Four databases (EMBASE, CINAHL, PsychInfo, PubMed) and Google Scholar were searched without any limitations on publication year. Charting methods: Data was extracted into Microsoft Excel by two authors independently (AG & SF) and cross-checked for completeness. Results: One hundred and eighty-eight articles were originally identified. Following the application of eligibility criteria 16 articles utilising XR in clinical interventions (n = 7) and medical education (n = 9) were included. Articles utilised VR and AR for highly variable purposes within both medical education (eg disaster preparedness, intubation) and clinical interventions (eg decrease pain, nausea, anxiety and improve Glasgow Coma Scale). Conclusions: While research into the use of XR in paediatric intensive care is still in its infancy it has increased dramatically over the past 5 years within two key areas. Firstly, in healthcare education, to assist in the acquisition of PICU-specific knowledge and practice of skills such as intubation of difficult airways. Secondly, studies have evaluated and demonstrated that with appropriate use, VR appears to be a safe and feasible intervention to decrease pain and anxiety in PICU patients.

Desktop Virtual Reality Offers a Novel Approach to Minimize Pain and Anxiety during Burn Wound Cleaning/Debridement in Infants and Young Children: A Randomized Crossover Pilot Study

Although most scald burn injuries involve children under six, because of the challenges of using head mounted displays with young children there is very little research exploring the use of VR in children under six. The current clinical pilot study measured the analgesic effectiveness of our new desktop VR system (with no VR helmet) in children under six during burn wound care (a within-subjects design with randomized treatment order). Between December 2021-April 2022, nine children with burn injuries (10 months to 5 years age, mean = 18 months) participated. The mean burn size was 10% Total Body Surface Area, range 2-22%. Using nurse's ratings, VR significantly reduced children's pain during burn wound care by 40% on the observational Faces, Legs, Activity, Crying, and Consolability (FLACC) pain scale. Specifically, non-parametric within-subject sign tests compared nurse's ratings of the young patients' pain during burn wound care using usual pain medications with no VR = 6.67, (SD = 2.45) vs. adjunctive Animal Rescue World VR (VR = 4.00, SD = 2.24, p < 0.01). The observational Procedure-Behavior Checklist (PBCL) nurse's scale measured a 34% reduction in anxiety with VR as compared to pharmacologic treatment alone (p < 0.005). Similarly, when using single graphic rating scales the patients' parents reported a significant 36% decrease in their child's pain during VR (p < 0.05), a 38% (p < 0.005) decrease in their child's anxiety during VR, and a significant increase in patients' joy during VR. It can be concluded that during burn wound care with no distraction (traditional pain medications), children under 6 years old experienced severe pain during a 10 min burn wound cleaning session. During burn wound care combining desktop virtual reality and traditional pain medications, the same pediatric patients experienced only mild pain during burn wound cleaning/debridement. VR significantly reduced the children's pain and anxiety during burn wound care.

Adding tactile feedback increases avatar ownership and makes virtual reality more effective at reducing pain in a randomized crossover study

Severe pain is a widespread health problem in need of novel treatment approaches. In the current study we used real water to give virtual objects (i.e., animated virtual water) more realistic physical properties (wet liquid qualities). Healthy volunteers aged 18-34 participated in a within-subject randomized study comparing participants' worst pain during brief thermal stimuli with (1) No Immersive Virtual Reality (VR), versus (2) during VR + no tactile feedback versus (3) VR + real water (with tactile feedback from co-located real objects). Tactile feedback significantly decreased pain intensity (VR analgesia, p < 0.01), compared to VR with no tactile feedback, and compared to No VR (baseline). Tactile feedback made the virtual water feel significantly more real, increased participant's sense of presence, and both VR conditions were distracting (significantly reduced accuracy on an attention demanding task). As a non-pharmacologic analgesic, mixed reality reduced pain by 35% in the current study, comparable to the analgesia from a moderate dose of hydromorphone in previous published experimental studies. Tactile feedback also significantly increased avatar embodiment, the participants illusion of ownership of the virtual hands, which has potential to improve the effectiveness of avatar therapy for chronic pain in future studies. Mixed reality should be tested as treatment in pain patients.

Parents' perceptions of their child's pain assessment in hospital care: A cross-sectional study

PURPOSE

A prerequisite for successful pain management is identifying the pain and assessing its intensity. The aim of this study was to describe parents' perceptions of their child's pain assessment in hospital care.

DESIGN AND METHODS

This study was a descriptive cross-sectional study. A questionnaire was completed by parents (n = 261) whose child was hospitalized in one of the pediatric units (n = 6) of the University Hospital in Finland. Quantitative data were analyzed using statistical methods; open-ended data were analyzed using inductive content analysis.

RESULTS

Parents reported that their children experienced moderate (36%) to severe pain (42%) during hospitalization. The most intense pain experienced by the children was associated with needle-related procedures (41%). A large proportion of parents (83%) were involved in their child's pain assessment. Parents were satisfied with their child's pain assessment but perceived some shortcomings. Parents hoped that a variety of methods would be used to assess their child's pain and that the parents' and child's views on pain would be taken into account.

CONCLUSIONS

Most children experience moderate to severe pain during hospitalization. Parents are often involved in pain assessment but are rarely instructed to use pain scales.

PRACTICE IMPLICATIONS

Child's pain should be assessed regularly and frequently enough. It is important that the child and parents are involved in shared decision-making about pain assessment and treatment, and they have opportunities to ask questions. Guidance should be offered to parents about the use of pain assessment scales.

Metaverse applied to musculoskeletal pathology: Orthoverse and Rehabverse

The Metaverse is 'an integrated network of 3D virtual worlds.' It incorporates digitally created realities into the real world, involves virtual copies of existing places and changes the physical reality by superimposing digital aspects, allowing its users to interact with these elements in an immersive, real-time experience. The applications of the Metaverse are numerous, with an increasing number of experiences in the field of musculoskeletal disease management. In the field of medical training, the Metaverse can help facilitate the learning experience and help develop complex clinical skills. In clinical care, the Metaverse can help clinicians perform orthopedic surgery more accurately and safely and can improve pain management, the performance of rehabilitation techniques and the promotion of healthy lifestyles. Virtualization can also optimize aspects of healthcare information and management, increasing the effectiveness of procedures and the functioning of organizations. This optimization can be especially relevant in departments that are under significant care provider pressure. However, we must not lose sight of the fundamental challenges that still need to be solved, such as ensuring patient privacy and fairness. Several studies are underway to assess the feasibility and safety of the Metaverse.

A comparison of interactive immersive virtual reality and still nature pictures as distraction-based analgesia in burn wound care

PURPOSE

Non-pharmacologic adjuncts to opioid analgesics for burn wound debridement enhance safety and cost effectiveness in care. The current study explored the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults, and tested whether interactive VR would reduce pain more effectively than nature stimuli viewed in the same VR goggles.

METHODS

Forty-eight patients with severe burn injuries (44 adults and 4 children) had their burn injuries debrided and dressed in a wet wound care environment on Study Day 1, and 13 also participated in Study Day 2.

INTERVENTION

The study used a within-subject design to test two hypotheses (one hypothesis per study day) with the condition order randomized. On Study Day 1, each individual (n = 44 participants) spent 5 min of wound care in an interactive immersive VR environment designed for burn care, and 5 min looking at still nature photos and sounds of nature in the same VR goggles. On Study Day 2 (n = 12 adult participants and one adolescent from Day 1), each participant spent 5 min of burn wound care with no distraction and 5 min of wound care in VR, using a new water-friendly VR system. On both days, during a post-wound care assessment, participants rated and compared the pain they had experienced in each condition. OUTCOME MEASURES ON STUDY DAYS 1 AND 2: Worst pain during burn wound care was the primary dependent variable. Secondary measures were ratings of time spent thinking about pain during wound care, pain unpleasantness, and positive affect during wound care.

RESULTS

On Study Day 1, no significant differences in worst pain ratings during wound care were found between the computer-generated world (Mean = 71.06, SD = 26.86) vs. Nature pictures conditions (Mean = 68.19, SD = 29.26; t < 1, NS). On secondary measures, positive affect (fun) was higher, and realism was lower during computer-generated VR. No significant differences in pain unpleasantness or "presence in VR" between the two conditions were found, however. VR VS. NO VR. (STUDY DAY 2): Participants reported significantly less worst pain when distracted with adjunctive computer generated VR than during standard wound care without distraction (Mean = 54.23, SD = 26.13 vs 63.85, SD = 31.50, t(11) = 1.91, p < .05, SD = 17.38). In addition, on Study Day 2, "time spent thinking about pain during wound care" was significantly less during the VR condition, and positive affect was significantly greater during VR, compared to the No VR condition.

CONCLUSION

The current study is innovative in that it is the first to show the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults. However, contrary to predictions, interactive VR did not reduce pain more effectively than nature stimuli viewed in the same VR goggles.

The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review

Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.

My Virtual Self: The Role of Movement in Children's Sense of Embodiment

There are vast potential applications for children's entertainment and education with modern virtual reality (VR) experiences, yet we know very little about how the movement or form of such a virtual body can influence children's feelings of control (agency) or the sensation that they own the virtual body (ownership). In two experiments, we gave a total of 197 children aged 4-14 years a virtual hand which moved synchronously or asynchronously with their own movements and had them interact with a VR environment. We found that movement synchrony influenced feelings of control and ownership at all ages. In Experiment 1 only, participants additionally felt haptic feedback either congruently, delayed or not at all - this did not influence feelings of control or ownership. In Experiment 2 only, participants used either a virtual hand or non-human virtual block. Participants embodied both forms to some degree, provided visuomotor signals were synchronous (as indicated by ownership, agency, and location ratings). Yet, only the hand in the synchronous movement condition was described as feeling like part of the body, rather than like a tool (e.g., a mouse or controller). Collectively, these findings highlight the overall dominance of visuomotor synchrony for children's own-body representation; that children can embody non-human forms to some degree; and that embodiment is also somewhat constrained by prior expectations of body form.

Virtual reality in pediatrics, effects on pain and anxiety: A systematic review and meta-analysis update

INTRODUCTION

Medical procedures are often accompanied by pain and anxiety in pediatric patients. A relatively new technique to reduce pediatric pain and anxiety is virtual reality. Virtual reality is both applied as a distraction tool and as an exposure tool to prepare patients for medical procedures. Research into the application of virtual reality in medical settings is rapidly evolving. This meta-analysis is an update of the meta-analysis of Eijlers et al. investigating the effectiveness of virtual reality as an intervention tool on pain and anxiety in pediatric patients undergoing medical procedures.

METHODS

We searched the databases Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and PsycINFO. For each of these databases, different search strategies were developed. The search period from the meta-analysis from Eijlers et al., reaching until April 2018, was extended to December 2020. Pain and anxiety outcomes during medical procedures were compared for virtual reality and standard care conditions for various medical procedures.

RESULTS

The search yielded 1824 articles, of which 13 met our inclusion criteria. Combined with 13 articles of Eijlers' review study, this resulted in 26 articles. Virtual reality was applied as distraction (n = 23) during medical procedures or as exposure (n = 4) before medical procedures. The effect of virtual reality distraction was mostly studied in patients during venous access (n = 10). The overall weighted standardized mean difference for virtual reality distraction was -0.67 (95% CI, -0.89 to -0.45; p < .001) on patient-reported pain (based on 21 studies) and -0.74 (95% CI, -1.00 to -0.48; p < .001) on patient-reported anxiety (based on 10 studies). The effect of virtual reality as an exposure tool on patient-reported anxiety was significant too (standardized mean difference = -0.58; 95% CI, -1.15 to -0.01; p < .05).

DISCUSSION

The current updated systematic review and meta-analysis indicates that virtual reality is a useful tool to reduce pain and anxiety in pediatric patients undergoing a range of medical procedures as it significantly decreases pain and anxiety outcomes when compared to care as usual.

The effects of virtual reality technology on reducing pain in wound care: A meta-analysis and systematic review

Virtual reality (VR) technology has been widely used in clinical nursing care in recent years. We aimed to systematically evaluate the effect and safety of VR technology on pain control in wound care, to provide evidence and support for clinical wound care. We searched PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, China Biomedical Literature Database, China National Knowledge Infrastructure (CNKI), Wanfang Data Knowledge Service Platform, and Chinese Science and Technology Journal databases for randomised controlled trials (RCTs) on the application of VR technology in wound care up to December 20, 2021. Two researchers independently assessed the quality of the included RCTs and extracted associated data. RevMan5.3 statistical software was used for data analysis. 13 RCTs involving 1258 adult patients were included, of whom 588 patients underwent VR intervention. VR technology intervention could reduce the VAS score(MD = -1.13, 95%CI:-2.01~-0.26, P < .001), pain cognition score(MD = -3.94, 95%CI:-4.59 ~ -3.30, P < .001), pain emotion score(MD = -5.21, 95%CI: -10.46 ~ -0.04, P < .001), pain sensation score (MD = -4.94, 95%CI: -9.46 ~ -0.42, P = .03) and blood pressure(MD = -4.66, 95%CI: -8.63 ~ -0.69, P = .02) during would care. There were no significant differences on the heart rate (MD = -1.85, 95%CI: -5.71 ~ -2.01, P = .45) and VR interestingness (MD = 28.96, 95%CI: -22.10 ~ 80.02, P = .27) of the VR group and control group. No publication biases among the synthesised outcomes were found (all P > .001). VR technology can effectively reduce the pain degree and sensation of patients during wound care, which may be an effective auxiliary non-drug method used for pain relief during wound care.

Virtual Reality Animal Rescue World: Pediatric virtual reality analgesia during just noticeable pressure pain in children aged 2-10 years old (crossover design)

BACKGROUND AND AIMS

Excessive pain during medical procedures is a worldwide medical problem. Most scald burns occur in children under 6, who are often undermedicated. Adjunctive Virtual Reality (VR) distraction has been shown to reduce pain in children aged 6-17, but little is known about VR analgesia in young children. This study tests whether desktop VR (VR Animal Rescue World) can reduce the just noticeable pressure pain of children aged 2-10.

METHODS

A within-subject repeated measures design was used. With treatment order randomized, each healthy volunteer pediatric participant underwent brief cutaneous pressure stimuli under three conditions: (1) no distraction, (2) a verbal color naming task (no VR), and (3) a large TV-based desktop VR distraction. A hand-held Wagner pressure pain stimulation device was used to generate just noticeable pain sensations. Participants indicated when a steadily increasing non-painful pressure stimulus first turned into a painful pressure sensation (just noticeable pain).

RESULTS

A total of 40 healthy children participated (43% aged 2-5 years; and 57% aged 6-10 years). Compared to the no distraction condition, the 40 children showed significant VR analgesia (i.e., a significant reduction in pain sensitivity during the VR Animal Rescue World condition), t(39) = 9.83, p < 0.001, SD = 6.24. VR was also significantly more effective at reducing pain sensitivity vs. an auditory color naming task, t(39) = 5.42, p < 0.001, SD = 5.94. The subset of children aged 2-5 showed significant reductions in pain during VR. Children under 6 showed greater sensitivity to pain during no distraction than children aged 6-10.

CONCLUSION

During no distraction, children under 6 years old were significantly more sensitive to pain than children aged 6-10. Virtual reality (VR) significantly reduced the "just noticeable" pressure pain sensitivity of children in both age groups.

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.

Effect of Virtual Reality-Based Interventions on Pain During Wound Care in Burn Patients; a Systematic Review and Meta-Analysis

INTRODUCTION

Burn patients undergo daily painful wound care procedures, including washing, debridement, and dressing. This systematic review and meta-analysis aimed to examine the effect of virtual reality (VR)-based interventions on pain during wound care in burn patients.

METHODS

A comprehensive systematic search was conducted on international electronic databases such as Scopus, PubMed, and Web of Science with keywords extracted from Medical Subject Headings such as "Virtual reality", "Virtual reality therapy", "Virtual reality exposure therapy", "Virtual reality immersion therapy", "Exergaming", "Active-video gaming", "Burns", "Wound healings", "Pain", and "Pain management" from the earliest to May 6, 2022. The Joanna Briggs Institute (JBI) critical appraisal checklist was used to assess the quality of randomized control trials and quasi-experimental studies.

RESULTS

1,293 patients with burns were included in 30 studies, and their mean age was 22.89 (SD=7.63) years. 70.72% of the participants were male, and 67.05% were in the intervention group. This meta-analysis showed that VR significantly decreased pain severity in the intervention group compared to the control group (standard mean difference (SMD): -0.70, 95%CI: -0.97 to -0.43, Z=5.05, P<0.001, I²:82.0%). Immersive VR intervention showed statistically significant effects in reducing pain intensity among the intervention group, compared to the control group (SMD: -0.73, 95%CI: -0.97 to -0.49, Z=5.88, P<0.001, I²:69.3%); however, this finding was not the same for non-immersive VR (SMD: -0.62, 95%CI: -1.43 to 0.19, Z=1.51, P=0.132, I²:91.2%).

CONCLUSION

It is suggested that health policymakers and managers equip burn wards with immersive VR devices to provide the basis for this intervention when caring for patients with burn wounds.

Virtual reality mobility for burn patients (VR-MOBILE): A within-subject-controlled trial protocol

In the acute phase, burn patients undergo several painful procedures. Pediatric burn care procedures conducted in hydrotherapy have been known to generate severe pain intensity and moderate to high levels of anxiety. Hydrotherapy treatments are done with the use of opioids and benzodiazepines for pain and anxiety. Unfortunately, nonpharmacological methods are rarely combined with pharmacological treatments despite evidence showing that distraction can serve as an effective method for pain management and can potentially decrease analgesic requirements in other painful medical procedures. Virtual reality (VR) is a method that uses distraction to interact within a virtual environment. The use of VR is promising for pain reduction in varying settings. Considering the lack of optimal pain and anxiety management during burn wound care and the positive effect of an immersive distraction for painful procedures, using VR for burn wound care procedures may show promising results. This is a within-subject randomized controlled trial design in which each participant will serve as his/her own control. A minimum of 20 participants, aged 7 to 17 years old undergoing a burn care session, will receive both standard and experimental treatments during the same session in a randomized order. The experimental treatment will consist of combining VR distraction using the video game Dreamland® to the current standard pharmacological care as per unit protocol. The control group will only receive the unit's standard pharmacological care. The mean difference in both pain intensity scores and in anxiety between the two different sequences will be the primary outcomes of this study. This study evaluates the effect of VR on burn wound care. If results from this study show a positive effect of VR compared to standard care, this protocol may provide guidance on how to implement this type of immersive care as part of the tools available for distraction of painful procedures for acute burn victims.

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.

A Systematic Review of the Effectiveness of Virtual Reality-Based Interventions on Pain and Range of Joint Movement Associated with Burn Injuries

Background: Burns are mild or severe lesions produced in living tissue, due to the action of different agents. This pathology is considered the third cause of accidental death in the world by the World Health Organization. Among the most disabling sequelae in these patients, pain and range of motion have the greatest impact. A recommended tool to complement the treatment or management of the symptoms associated with burns is virtual reality. Objective: The objective of this study was to analyse the effectiveness of virtual-reality therapy for pain relief and the improvement of the range of joint movement in patients who have suffered burns. Methodology: This study is a systematic review conducted following the PRISMA statements. An electronic literature search was performed in the following databases: PubMed, Cochrane, Dialnet, Scopus and Science Direct. The inclusion criteria were: participants with burns in any part of the body, interventions with virtual reality with or without complementary treatment, studies in both Spanish and English, and outcome measures of pain and range of motion. Results: Finally, 10 studies were included in the review. The sample consisted of one pilot study, three randomized controlled clinical trials, one prospective randomized controlled clinical trial, one control group and treatment group trial, one interventional clinical trial and three comparative studies. The most commonly used assessment tools for pain were the graphic rating scale (GRS) and for range of motion the goniometer. The use of virtual-reality games significantly reduced pain scores during physiotherapy and occupational therapy treatments as well as in nursing care. The range of motion improved significantly during virtual-reality exercises performed during a physiotherapy treatment in 33% of studies included in this review. Conclusion: The results of the studies analysed in this systematic review suggest that the use of virtual reality for the management of pain and range of movement limitations associated with burn injuries could control these symptoms and decrease their negative consequences on the person.

Virtual reality as a patient education tool in healthcare: A scoping review

OBJECTIVE

To explore what is currently known about the use of virtual reality (VR) as a patient education tool in healthcare.

METHODS

Arksey and O'Malley's scoping review method and the PRISMA-ScR Checklist were employed. Four peer-reviewed databases were searched (Medline, Embase, PsychINFO, the Cochrane library). Pre-defined selection criteria identified 18 studies for inclusion. Results were synthesized using a narrative approach.

RESULTS

VR as an educational tool in healthcare is feasible and acceptable, and may improve patient's knowledge about their illness and satisfaction with treatment. Most studies used the Oculus VR glasses or headset, educated patients though the use of 3D 360° VR anatomical models, and were conducted with people affected with cancer. Opportunities exist for exploring unintended consequences, and the role of VR in educating populations with lower health literacy.

CONCLUSION

VR could assist in communicating medical information and knowledge to patients, but more research is needed, particularly to identify for whom and in what situations this method is most useful and to improve understanding about the potential unintended consequences.

PRACTICE IMPLICATIONS

Health professionals should consider using VR to educate their patients, and researchers can use this as a road map on how to address knowledge gaps in this field.

Virtual Reality for Pain Relief in the Emergency Room (VIPER) - a prospective, interventional feasibility study

Background

Pain is one of the most common, yet challenging problems leading to emergency department (ED) presentation, despite the availability of a wide range of pharmacological therapies. Virtual reality (VR) simulations are well studied in a wide variety of clinical settings, including acute and chronic pain management, as well as anxiety disorders. However, studies in the busy environment of an adult ED are scarce.

The aim of this study is to explore the feasibility and effectiveness of a VR simulation for pain and anxiety control in a convenience sample of adult ED patients presenting with traumatic and non-traumatic pain triaged 2–5 (i.e., urgent to non-urgent) with a pain rating of ≥ 3 on a numeric rating scale (NRS 0–10).

Methods

Prospective within-subject, repeated measures interventional feasibility pilot study at a Swiss University ED. The intervention consisted of a virtual reality simulation in addition to usual care. Pain and anxiety levels were measured using a verbally administered numeric rating scale (NRS) before and after the intervention. Information on patient experience was collected using established rating scales.

Results

Fifty-two patients were enrolled. The most common pain localisations were extremities (n = 15, 28.8%) and abdomen (n = 12, 23.1%). About one third of patients presented with trauma-associated pain (n = 16, 30.8%). Duration of pain was mainly acute (< 24 h) (n = 16, 30.8%) or subacute (> 24 h) (n = 32, 61.5%). The majority of patients were triage category 3, i.e. semi-urgent (n = 48, 92.3%). Significant reduction in pain (NRS median pre-VR simulation 4.5 (IQR 3–7) vs. median post-VR simulation 3 (IQR 2–5), p < 0.001), and anxiety levels (NRS median pre-VR simulation 4 (IQR 2–5) vs. median post-VR simulation 2 (IQR 0–3), p < 0.001) was achieved, yielding moderate to large effect sizes (Cohen’s d estimate for pain reduction = 0.59 (95% CI 0.19—0.98), for anxiety level on NRS = 0.75 (95% CI 0.34—1.15). With medium immersion and good tolerability of the VR simulation, user satisfaction was high.

Conclusions

Virtual reality analgesia for pain and anxiety reduction in the busy setting of an ED is feasible, effective, with high user satisfaction. Further randomized controlled studies are needed to better characterize its impact on pain perception and resource utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00671-z.

Effects of Virtual Reality-Based Aerobic Exercise on Perceptions of Pain and Fatigue in Individuals with Spinal Cord Injury

Virtual reality (VR) has become an effective alternative to promote exercise. However, limited studies have investigated the effect of VR on pain and fatigue in individuals with spinal cord injury (SCI). Objective: The purpose of this study was to investigate the effects of using VR during exercise on pain and fatigue in individuals with SCI. This study employed a concurrent nested mixed-methods design. Materials and Methods: Eleven individuals with SCI completed a 6-minute exercise test using arm ergometry with and without VR. Pain and fatigue questionnaire data were collected using Pain Self Efficacy Questionnaire, the Fatigue Severity Scale, and the Fatigue Assessment Scale. Qualitative data were collected after the VR session. Results: Participants experienced less pain and fatigue during VR exercise than during non-VR exercise. Qualitative data were consistent with the questionnaire results. Conclusion: Clinicians should consider the use of VR in reducing pain and fatigue.

"A Wanderer's Tale": The development of a virtual reality application for pain and quality of life in Australian burns and oncology patients

OBJECTIVES

The primary objective of this study was to co-design and conduct a pilot evaluation of a novel, immersive virtual reality (VR) experience for procedural pain and anxiety in an Australian healthcare setting. The secondary objective was to identify key parameters that can facilitate the development and implementation of VR experiences in clinical practice.

METHOD

A qualitative, Design Box method was selected for co-design. It was used with adult burns survivors and adolescents and young adults (AYAs) with cancer, and healthcare professionals from these fields to identify the practical and design parameters required for the application of VR technology within the clinical setting. Results informed the development of the VR experience that was evaluated by consumers and healthcare professionals, who completed qualitative surveys. Thematic analysis was conducted on co-design notes and survey data.

RESULTS

Procedural pain and management was a challenge for both cohorts, but particularly the burns cohort. Anxiety was significant challenge for both cohorts. Boredom and quality of life was a significant challenge, particularly for the AYA oncology cohort. These results informed the development of "A Wanderers Tale," an Australiana-themed, gaze-controlled VR application for Oculus Quest platforms. Thematic analysis results suggest that cultural preferences, procedural contexts of use, and agency through customization and interaction are three parameters to consider when creating or selecting VR experiences for application in health.

SIGNIFICANCE OF RESULTS

This work describes a novel method for the use VR as an adjuvant pain management tool in patients with burns and cancer. The VR experience may provide a culturally, practice and procedure-appropriate tool in comparable settings of care. The study also describes interdisciplinary co-design and evaluation approaches that can help maximize the use of VR to improve healthcare approaches that address clinical challenges in pain, anxiety, and quality of life for patients while in hospital.

The effect of virtual reality on pain, anxiety, and fear during burn dressing in children: A randomized controlled study

AIM AND OBJECTIVES

Virtual Reality (VR) can be used during painful procedures in children. This research was conducted to determine the effect of VR on the pain, anxiety, and fear levels experienced by patients during burn dressing.

METHODS

A randomized between groups study design was used to test whether VR reduced pain, fear, and anxiety during burn wound cleaning. The experimental (VR group) (n = 33) and the control group (n = 32) were determined using the simple randomization method for the children participating in the study (n = 65). The data were collected using the Wong-Baker FACES Pain Rating Scale, Children's Fear Scale, and State- Trait Anxiety Inventory for Children. In addition, oxygen saturation and heart rate measurements were recorded before and after the procedure.

RESULTS

Using a between groups t-test, burn injured children in the group that received virtual reality (M = 2.6, SD = 1.9, SE= 0.21) showed significantly less pain intensity during burn wound care than the No VR control group (M = 4.2, SD =1.0, SE= 0.19, t = -5.89, p < 0.005). Similarly, the VR group reported significantly lower fear during wound care (M= 2.24, SD = 1.1, SE=0.19) than the No VR control group (M=3.72, SD = 0.6, SE=0.10, t = 6.70, p < 0.005), and on a scale from 0 to 100, patients in the VR group showed significantly less anxiety (36.46, SD = 8.1, SE=1.40) than patients in the No VR group (M= 53.16, SD = 7.4, SE=1.35, t = 8.52, p < 0.005). Heart rate during wound care was significantly lower in the VR group (M=119.60, SD = 8.1, SE=1.40) than in the No VR control group (M=129.56, SD = 10.64, SE=1.88, t = -4.25, p < 0.005). However, no significant difference in Oxygen saturation was found, (VR = 97.03, SD = 0.90, SE= 0.17, vs. No VR = 96.94, SD = 0.29, SE=0.23, t = 0.326, p > 0.05).

CONCLUSIONS

VR is an effective method in reducing pain, fear, and anxiety caused by burn dressing in children aged 7-12. The use of VR during burn dressing was determined to have positive results on some physical and psychological parameters.

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

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

Quantifying virtual reality pain modulation in healthy volunteers: A randomized, crossover study

STUDY OBJECTIVE

Virtual reality (VR) is an emerging tool to reduce pain and anxiety during procedures. Although VR's clinical benefits are reported, biometric data quantifying VR's effect on pain tolerance is lacking. We used time-lapse, subjective, and biometric data to evaluate VR's effect on modulating pain.

DESIGN

Randomized, controlled crossover within-subject clinical trial.

SETTING

This study was conducted in the Chariot Lab at Lucile Packard Children's Hospital and outdoors at Stanford University School of Medicine.

PATIENTS

156 healthy volunteers were included.

INTERVENTIONS

Participants underwent pain-inducing ice immersions while connected to biometric sensors. Participants were randomized to immerse their dominant or non-dominant hand with VR or control (no VR) for one immersion, and then crossed-over to the other hand for the second immersion. We instructed participants to submerge their hand until they reached their pain tolerance or until four minutes elapsed.

MEASUREMENTS

Outcomes included ice immersion duration, perceived pain scores, and skin conductance response density (SCRD), a marker of sympathetic arousal. We used survival analysis and mixed effects models to compare measurements with and without VR.

MAIN RESULTS

153 participants were included in the analysis. Participants with VR were 64% less likely to remove their hands from the ice bath throughout the immersion's duration compared to control (P < 0.001). Participants with VR reported significantly lower pain scores after controlling for dominant hand treatment assignment, VR vs. no VR treatment order, and gender (P < 0.001). SCRD increased as time progressed for both VR and control groups (P = 0.047 combined), with no significant mean group differences.

CONCLUSIONS

Participants with VR were more likely to survive the 4-min ice bath challenge longer and with lower levels of pain perception, supporting VR's effectiveness as a distraction tool during painful procedures. We observed no differences in sympathetic response when comparing VR to no VR.

Virtual reality-based distraction for intravenous insertion-related distress in children: a study protocol for a randomised controlled trial

INTRODUCTION

Intravenous (IV) insertions are among the most performed procedures for children seeking medical care; they are often a painful and stressful experience for both children and their caregivers. Paediatric distress and pain that is inadequately treated may lead to a frightened and uncooperative child, repeated IV attempts and overall frustration with care for both the family and clinical team. We hypothesise that distraction via an immersive virtual reality (VR) experience may reduce the associated distress for children undergoing IV insertions.

METHODS AND ANALYSIS

This two-armed randomised controlled superiority trial will be conducted in a Canadian paediatric emergency department and will aim to enrol 80 children overall. Children will be randomised to receive either departmental standard of care alone or standard of care plus an immersive VR experience. Children 6-17 years of age who are undergoing IV insertion and have topical anaesthetic application will be considered for inclusion. Our primary objective is to compare the reduction of distress between the two study arms. The primary outcome will be the child's observed distress score as measured by the Observational Signs of Behavioral Distress-Revised tool. Secondary outcomes include the child's pain intensity and fear, parental anxiety, satisfaction with the IV procedure, as well as adverse events. Recruitment launched in September 2020 and is expected to end in March 2022.

ETHICS AND DISSEMINATION

This study has been approved by the Health Research Ethics Board (University of Alberta). Informed consent will be obtained from parents or guardians, and assent from children. Study data will be submitted for publication irrespective of results. This study is funded through a Women and Children's Health Research Institute Innovation grant. Purchase of the VR equipment was facilitated through a Stollery Children's Hospital Foundation small equipment grant.

TRIAL REGISTRATION NUMBER

NCT04291404Cite Now.

Effect of immersive virtual reality on pain in different dental procedures in children: A pilot study

BACKGROUND

Implementing effective pain management is important to increase patient compliance during paediatric dental procedures.

AIM

This pilot study was conducted to evaluate the effectiveness of virtual reality (VR) on pain perception in dental procedures in children.

MATERIAL AND METHODS

Fifty-four children aged between 5 and 12 years were included. Patients scheduled to receive dental procedures not requiring local anesthesia (eg, fluoride therapy) were assigned to Group A, and patients scheduled to receive painful dental procedures requiring local anesthesia (eg, pulp therapy, teeth extraction) were assigned to Group B. Patients in each group were randomly assigned and were equally likely to either receive VR during their dental procedure, or treatment as usual (without VR). Visual analog scale (VAS), Wong-Baker FACES rating scale, and the 'Face, Legs, Activity, Cry, Consolability' scale (FLACC scale) were used to assess the pain levels during dental procedures.

RESULTS

Patients receiving painful dental procedures requiring local anesthesia reported significant reductions in pain intensity/worst pain during the dental procedure on all subjective and behavioral pain measures of pain intensity with the use of VR distraction technique (P < .05 on each). Patients receiving non-painful dental procedures showed the predicted pattern but no significant reduction in worst pain during VR.

CONCLUSION

The use of VR was found to be an effective distraction tool to ease pain and anxiety in the tested dental procedures, for children receiving painful dental procedures.

An Exploratory Study on the Effectiveness of Virtual Reality Analgesia for Children and Adolescents with Kidney Diseases Undergoing Venipuncture

The current study evaluated the effectiveness of VR analgesia among pediatric and adolescent patients with kidney disease undergoing venipuncture. Patients at an Italian Children’s hospital (N = 82, age range 7–17 years) undergoing venipuncture were randomly assigned to a No VR group (non-medical conversation) vs. a Yes VR group (VR analgesia). After the procedure, patients gave 0–10 Verbal Numeric Pain Scale ratings. Compared with patients in the No VR Group, patients in the Yes VR group reported significantly lower “Pain intensity”(No VR mean = 2.74, SD = 2.76 vs. Yes VR mean = 1.56, SD = 1.83) and the VR group also rated “Pain unpleasantness” significantly lower than the No VR group (No VR mean = 2.41, SD = 0.94 vs. Yes VR mean = 1.17, SD = 1.80). Patients distracted with VR also reported having significantly more fun during the venipuncture procedure. No side effects emerged. In addition to reducing pain intensity, VR has the potential to make venipuncture a more fun and less unpleasant experience for children with CKD, as measured in the present study for the first time. Finally, in exploratory analyses, children aged 7–11 in the VR group reported 55% lower worst pain than control subjects in the same age range, whereas children aged 12 to 17 in the VR group only reported 35% lower worst pain than control subjects. Additional research and development using more immersive VR is recommended.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

RATIONALE

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

OBJECTIVE

To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

DESIGN

The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

METHODS

Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

RESULTS

The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

CONCLUSIONS

The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Impact of Virtual Reality Technology on Pain and Anxiety in Pediatric Burn Patients: A Systematic Review and Meta-Analysis

INTRODUCTION

Virtual reality (VR) has the potential to lessen pain and anxiety experienced by pediatric patients undergoing burn wound care procedures. Population-specific variables require novel technological application and thus, a systematic review among studies on its impact is warranted.

OBJECTIVE

The objective of this review was to evaluate the effectiveness of VR on pain in children with burn injuries undergoing wound care procedures.

METHODS

A systematic literature review was performed using PubMed and CINAHL databases from January 2010 to July 2021 with the keywords "pediatric," "burn," "virtual reality," and "pain." We included experimental studies of between- and within-subjects designs in which pediatric patients' exposure to virtual reality technology during burn wound care functioned as the intervention of interest. Two researchers independently performed the literature search, made judgements of inclusion/exclusion based on agreed-upon criteria, abstracted data, and assessed quality of evidence using a standardized appraisal tool. A meta-analysis was conducted to evaluate the effectiveness of the VR on burning procedural pain in pediatric population. Standardized mean difference (SMD) was used as an index of combined effect size, and a random effect model was used for meta-analysis.

RESULTS

Ten articles published between January 2010 and July 2021 passed the selection criteria: six randomized controlled trials and four randomized repeated-measures studies. Consistent results among the studies provided support for VR as effective in reducing pain and potentially pain related anxiety in children undergoing burn wound care through preprocedural preparation (n = 2) and procedural intervention (n = 8). VR effects on pain intensity ratings were moderate to large (SMD=0.60, 95%CI=0.28-0.93, p=0.0037 with no significant heterogeneity of VR intervention effects between studies. Only one study reported direct influence of VR intervention on pre-procedural situational anxiety with a moderate effect size (Cohen's d = 0.575, 95%CI = 0.11-1.04).

CONCLUSION

Children's exposure to VR during burn care procedures was associated with lower levels of pain and pain related anxiety. Moderate to large effect sizes support the integration of VR into traditional pediatric burn pain protocols irrespective of innovative delivery methods and content required for use in burned pediatric patients.

Being There: Exploring Virtual Symphonic Experience as a Salutogenic Design Intervention for Older Adults

This co-design study examined salutogenic potential of mobile virtual reality (VR) experiences as an alternative to participation in a community-based symphonic engagement program (B Sharp), previously found to benefit people with dementia (PWD) and their informal caregivers. Six focus groups were conducted with sixteen adults aged 76–90; three participants had dementia, and two were informal spousal caregivers. No participants had prior VR experience. The study assessed the feasibility of replicating the community-based-arts program in VR, with the goal of enhancing its salutogenic qualities (e.g., positive distraction, engagement, and social connection). Video-recordings of participants while using a mobile head-mounted display (HMD) were analyzed using qualitative thematic analysis to compare perceptions of different virtual experiences, including replication or enhancement of B Sharp and a campus tour. Findings suggest participants had positive perceptions of enhanced VR experiences with no adverse effects, although PWD were less enthusiastic and HMD usability was complicated by eyewear use and comfort with technology. Participants reacted most favorably to the enhanced symphonic experience, where they were “virtually” onstage during the performance, suggesting unique experiences beyond what is possible in the real world have the greatest potential for deep immersion for older adults. Results suggest VR has strong potential to replicate and enhance salutogenic qualities of community-based programming by enabling greater access to experiences for older adults and by increasing enjoyment and engagement through experiences not otherwise feasible. Furthermore, this study illuminates advantages of a user-centered, co-design approach when developing VR experiences with community partners and older adults.

Virtual Reality-Based Early Neurocognitive Stimulation in Critically Ill Patients: A Pilot Randomized Clinical Trial

This study focuses on the application of a non-immersive virtual reality (VR)-based neurocognitive intervention in critically ill patients. Our aim was to assess the feasibility of direct outcome measures to detect the impact of this digital therapy on patients’ cognitive and emotional outcomes. Seventy-two mechanically ventilated adult patients were randomly assigned to the “treatment as usual” (TAU, n = 38) or the “early neurocognitive stimulation” (ENRIC, n = 34) groups. All patients received standard intensive care unit (ICU) care. Patients in the ENRIC group also received adjuvant neurocognitive stimulation during the ICU stay. Outcome measures were a full neuropsychological battery and two mental health questionnaires. A total of 42 patients (21 ENRIC) completed assessment one month after ICU discharge, and 24 (10 ENRIC) one year later. At one-month follow-up, ENRIC patients had better working memory scores (p = 0.009, d = 0.363) and showed up to 50% less non-specific anxiety (11.8% vs. 21.1%) and depression (5.9% vs. 10.5%) than TAU patients. A general linear model of repeated measures reported a main effect of group, but not of time or group–time interaction, on working memory, with ENRIC patients outperforming TAU patients (p = 0.008, η_p² = 0.282). Our results suggest that non-immersive VR-based neurocognitive stimulation may help improve short-term working memory outcomes in survivors of critical illness. Moreover, this advantage could be maintained in the long term. An efficacy trial in a larger sample of participants is feasible and must be conducted.

Virtual reality therapy to control burn pain: systematic review of randomized controlled trials

BACKGROUND

Virtual reality therapy has been shown to be an excellent alternative to non-pharmacological treatment for the control of burn pain.

OBJECTIVE

To evaluate the effects of virtual reality therapy on pain control in people who have suffered burns published in the scientific literature.

METHOD

Systematic review carried out as recommended by Cochrane®. The search was carried out in the Embase, PubMed, Lilacs and Cochrane Library databases, in the period from March 2021. Randomized clinical trials were included without language restriction and year of publication. The risk of bias was assessed using the Cochrane® tool.

RESULTS

Of the 3755 articles found, only 17 articles were selected for reading in full. Of these, only four articles met the inclusion criteria. The results of the studies showed that the use of virtual reality therapy reduced the intensity of pain in children and adolescents with burns, despite the fact that most results are not statistically significant. No selected study had a high risk of bias.

CONCLUSIONS

Virtual reality therapy has been shown to be effective in controlling pain, reducing the time spent thinking about it and greater distraction during the procedures. However, most randomized clinical trials results were not statistically significant in at least one of the moments when pain was assessed. It is noteworthy that randomized clinical trials are still necessary to administer virtual reality therapy, especially in adults.

Effectiveness of technology-based interventions compared with other non-pharmacological interventions for relieving procedural pain in hospitalized neonates: a systematic review protocol

OBJECTIVE

The objective of this review is to evaluate the effectiveness of technology-based interventions in relieving procedural pain in hospitalized neonates compared with other non-pharmacological interventions.

INTRODUCTION

Neonates requiring hospital care often experience acute pain during medical procedures. The current best practice for relieving pain in neonates is the use of non-pharmacological interventions, such as oral solutions or intervention-based human touch. Technological solutions (such as games, eHealth applications, and mechanical vibrators) have become more commonplace in pediatric pain management over recent years. However, there is a knowledge gap about how effective technology-based interventions are at relieving pain in neonates.

INCLUSION CRITERIA

This review will consider experimental trials that include technology-based non-pharmacological interventions for relieving procedural pain in hospitalized neonates. Primary outcomes of interest include pain response to a procedure measured by a validated pain assessment scale for neonates, behavioral indicators, and/or changes in physiological indicators.

METHODS

MEDLINE (Ovid), CINAHL (EBSCO), Scopus (Elsevier), Cochrane Central Register of Controlled Trials, and the MEDIC databases will be searched for studies published in English, Finnish, and Swedish. Critical appraisal and data extraction will be conducted by two independent researchers following JBI methodology. Quantitative data will be pooled in statistical meta-analyses. If statistical analysis is not possible, the findings will be reported narratively.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021254218.

The Effect of Virtual Reality Game Preparation for Children scheduled for MRI (IMAGINE): a Randomized Controlled Trial Protocol (Preprint)

Background

It is known that magnetic resonance imaging (MRI) procedures generate fear and anxiety. Children may become restless during scanning, which results in movement artifacts requiring the MRI procedure to be repeated with sedation. Few studies seem to have looked at the effect of immersive virtual reality (IVR) on anxiety in children scheduled for MRI scans and how to identify which children are more responsive.

Objective

The aims of this study are 3-fold: develop an algorithm of predictability based on biofeedback, address feasibility and acceptability of preprocedural IVR game preparation for anxiety management during MRI procedures, and examine the efficacy of IVR game preparation compared with usual care for the management of procedural anxiety during MRI scans.

Methods

This study will have 2 phases. We will first conduct a field test with 10 participants aged 7 to 17 years to develop a predictive algorithm for biofeedback solution and to address the feasibility and acceptability of the research. After the field test, a randomized controlled trial will be completed using a parallel design with 2 groups: an experimental group (preprocedural IVR game preparation) and a usual care group (standard care as per the radiology department’s protocol) in an equal ratio of 49 participants per group for 98 participants. Recruitment will be carried out at a hospital in Quebec, Canada. The experimental group will receive a preprocedural IVR game preparation (IMAGINE) that offers an immersive simulation of the MRI scan. Participants will complete a questionnaire to assess the acceptability, feasibility, and incidence of side effects related to the intervention and the biofeedback device. Data collected will include sociodemographic and clinical characteristics as well as measures of procedure-related anxiety with the French-Canadian version of the State-Trait Anxiety Inventory for Children (score 1-3) and the Children’s Fear Scale (score 0-4). Physiological signs will be noted and include heart rate, skin conductance, hand temperature, and muscle tension. Measures of the level of satisfaction of health care professionals, parents, and participants will also be collected. Analyses will be carried out according to the intention-to-treat principle, with a Cronbach α significance level of .05.

Results

As of May 10, 2022, no participant was enrolled in the clinical trial. The data collection time frame is projected to be between April 1, 2022, and March 31, 2023. Findings will be disseminated through peer-reviewed publications.

Conclusions

Our study provides an alternative method for anxiety management to better prepare patients for an awake MRI procedure. The biofeedback will help predict which children are more responsive to this type of intervention. This study will guide future medical practice by providing evidence-based knowledge on a nonpharmacological therapeutic modality for anxiety management in children scheduled for an MRI scan.

Trial Registration

ClinicalTrials.gov NCT04988516; https://clinicaltrials.gov/ct2/show/NCT04988516

International Registered Report Identifier (IRRID)

PRR1-10.2196/30616

Interactive video games to reduce paediatric procedural pain and anxiety: a systematic review and meta-analysis

BACKGROUND

Procedural pain and anxiety in children can be poorly controlled, leading to significant short- and long-term sequelae, such as longer procedure times or future healthcare avoidance. Caregiver anxiety can exacerbate these effects. We aimed to evaluate the effect of interactive video game interventions on children's procedural pain and anxiety, including the effect of different types of video games on those outcomes.

METHODS

We conducted a systematic review and meta-analysis of the effectiveness of interactive video games compared with standard care in children (0-18 yr) undergoing painful procedures. We searched the databases MEDLINE, Embase, and PsycINFO. We conducted random-effects meta-analysis using 'R' of children's procedural pain and anxiety and caregivers' anxiety.

RESULTS

Of 2185 studies screened, 36 were eligible (n=3406 patients). Studies commonly involved venous access (33%) or day surgery (31%). Thirty-four studies were eligible for meta-analyses. Interactive video games appear to reduce children's procedural pain (standardised mean difference [SMD]=-0.43; 95% confidence interval [CI]: -0.67 to -0.20), anxiety (SMD=0.61; 95% CI: -0.88 to -0.34), and caregivers' procedural anxiety (SMD=-0.31; 95% CI: -0.58 to -0.04). We observed no difference between preparatory and distracting games, or between virtual reality and non-virtual reality games. We also observed no difference between interactive video games compared with standard care for most medical outcomes (e.g. procedure length), except a reduced need for restraint. Studies reported minimal adverse effects and typically had high intervention acceptability and satisfaction.

CONCLUSIONS

Our findings support introducing easily available video games, such as distraction-based conventional video games, into routine practice to minimise paediatric procedural pain and child/caregiver anxiety.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Virtual reality for pediatric periprocedural care

PURPOSE OF REVIEW

Commercial availability of virtual reality headsets and software has exponentially grown over the last decade as it has become more sophisticated, less expensive, and portable. Although primarily used by the general public for entertainment, virtual reality has been adopted by periprocedural clinicians to improve patient experiences and treatments. The purpose of this review is to explore recently reported evidence for virtual reality effectiveness for pediatric periprocedural care and discuss considerations for clinical implementation.

RECENT FINDINGS

In the preprocedure setting, practitioners use virtual reality to introduce children to periprocedural environments, distract attention from preprocedural vascular access, and increase cooperation with anesthesia induction. Intraprocedure, virtual reality decreases sedation requirements, and in some instances, eliminates anesthesia for minor procedures. Virtual reality also augments pain reduction therapies in the acute and extended rehabilitation periods, resulting in faster recovery and improved outcomes. Virtual reality seems to be well treated for pediatric use, given close clinical care and carefully curated content.

SUMMARY

Given the multiple clinical applications of virtual reality to supplement pediatric periprocedural care, practitioners should consider developing clinical programs that reliably provide access to virtual reality. Future research should focus on identification of patient characteristics and types of software that yield optimal patient outcomes.

Interacting with virtual objects via embodied avatar hands reduces pain intensity and diverts attention

The current study introduces a new paradigm for exploring cognitive factors in pain. Interacting with virtual objects via embodied avatar hands increased the illusion of “being there” in the virtual world, increased VR analgesia for acute pain, and reduced accuracy on an attention demanding task. Twenty-four healthy volunteer college students participated in this within-subject randomized crossover design study. During Phase 1, each participant received brief thermal pain stimuli during interactive embodied avatar VR vs. passive VR (no avatar and no interactivity), VR treatment order randomized. After each pain stimulus, participants provided subjective 0–10 ratings of pain. Compared to the passive VR condition, during the interactive avatar VR, participants reported significant reductions in (1) worst pain, (2) pain unpleasantness, (3) time thinking about pain and (4). they had significantly more fun during the pain stimulus (p = .000 for each). During Phase 2, participants performed a divided attention task in each of the two VR conditions. Participants made significantly more errors on the divided attention task during the interactive avatar VR condition, compared to passive VR, implicating an attention mechanism for how virtual reality reduces pain and helping understand how VR influences pain perception.

Trial registration: NCT04245475. Date of registration: 29/01/2020.

"Doc McStuffins: Doctor for a Day" Virtual Reality (DocVR) for Pediatric Preoperative Anxiety and Satisfaction: Pediatric Medical Technology Feasibility Study

Background

Preoperative anxiety is a common occurrence among children and is associated with a host of maladaptive postoperative behaviors. Consequently, increased attention has been placed on interventions to reduce preoperative anxiety and its associated outcomes. Child Life preparation prior to surgery includes evidence-based practices such as age-appropriate distraction and therapeutic play. Virtual reality (VR) is a promising addition to the Child Life toolbox to address anxiety prior to surgery. The current study evaluates the implementation and feasibility of a VR experience, “Doc McStuffins: Doctor for a Day Virtual Reality Experience” (DocVR), developed by Disney Junior in collaboration with Children’s Hospital Los Angeles, to target pediatric preoperative anxiety.

Objective

The primary aim of this study was to examine the feasibility and efficacy of DocVR for preoperative anxiety. A secondary aim was to improve patient, caregiver, and health care provider satisfaction with the preoperative experience.

Methods

In this study, 51 patients (age 6-14 years) scheduled for surgery in the ambulatory surgery center and the main operating room at Children’s Hospital Los Angeles were approached to participate in Disney’s DocVR experience. The patients played the DocVR experience for an average of 18 minutes (3-55 minutes). Irrespective of surgical procedure, patients and their families were eligible, as long as they had no known marked cognitive or visual impairments that would interfere with completing the survey and engaging in the DocVR experience.

Results

Patients who tried the DocVR experience (n=51) responded overwhelmingly positively to both the VR technology and to the game itself. Patients experienced a statistically significant decrease in anxiety following DocVR game play (Z=–3.26, P=.001). On the Facial Affective Scale, the percentage of patients who chose the face with the most positive facial expression to represent their affect increased from 23% (12/51) pre-VR to 49% (25/47) post-VR. Furthermore, 97% (38/39) of patients reported feeling more comfortable at the hospital, and 74% (28/38) reported feeling less scared at the hospital after playing the game. The game was enjoyed by 94% (46/49) of patients, and 88% (30/34) of patients reported feeling both “Interested” and “Involved” in the game.

Conclusions

DocVR is a feasible and beneficial VR experience to relieve pediatric preoperative anxiety and improve satisfaction in the preoperative area. The VR experience resulted in a decrease in overall anxiety and an increase in overall positive affect during the preoperative time. Patients also responded positively to the game, confirming their interest in the content and affirming the quality of the DocVR experience. The positive response to the game indicates that DocVR has the potential to make the overall preoperative experience less anxiety-producing and more comfortable, which leads to improved patient satisfaction. Naturally, improved patient outcomes lead to improved caregiver and health care provider satisfaction.