Immersive Virtual Reality for Pediatric Pain

Tips for success, managing the paediatric patient in radiology

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

Application of virtual reality for supportive care in cancer patients: a systematic review

BACKGROUND

In recent years, virtual reality (VR) technology has been widely used to support cancer patients with physical, emotional, and functional needs. This systematic review aimed to investigate the application of VR in the supportive care of cancer patients.

METHOD

This systematic review was conducted in 2024. In this study, various databases including PubMed, Web of Science, Scopus, the Cochrane Library, Ovid, IEEE Xplore, and ProQuest were searched, and quantitative, qualitative, and mixed-method studies which were in English and published up to 20th May 2024 were included. The keywords consisted of "virtual reality," "supportive care," and "cancer". Studies were assessed in terms of quality and risk of bias using standard tools, and results were analyzed and reported narratively.

RESULTS

A total of 33 articles were reviewed. VR interventions, primarily using fully immersive head-mounted displays, were associated with significant reductions in anxiety, pain, and fatigue. VR also improved mood, relaxation, and overall quality of life, and some studies noted enhanced vital signs such as heart rate and blood pressure. This technology could be used along with other medical interventions. Both patients and healthcare providers reported high level of satisfaction with VR, and appreciated its ease of use and therapeutic benefits. However, some technical barriers, like inadequate visual performance and realism, were reported.

CONCLUSION

VR demonstrates substantial potential benefits as a supportive care tool for cancer patients, effectively addressing their psychological, physiological, psychosocial needs. Despite technical challenges, high level of user satisfaction and benefits underscore the need for further research to optimize VR interventions in cancer care.

Distracting children with virtual reality during otomicroscopy: A randomised control trial

OBJECTIVES

Virtual Reality (VR) is a successful distraction method for reducing procedure-related pain in children, though it has never been studied during otomicroscopy. Therefore, we investigated the efficacy of VR as a distraction method during otomicroscopy.

METHODS

This Randomised Control Trial (RCT) included 60 children aged 4-15 years. The patients were randomised to receive distraction by VR, tablet, or no distraction. Procedure-related pain was scored by patients and compared with previous examinations.

RESULTS

Patients' experience with otomicroscopy was significantly improved with VR compared to tablet (p < 0.05) and no distraction (p < 0.01). Pain scores did not differ significantly between groups.

CONCLUSION

VR did not reduce pain scores, but it improved the children's experience with otomicroscopy without causing significant adverse outcomes.

Interactive and passive mixed reality distraction: effects on cold pressor pain in adults

While interactive distractors are predicted to be more effective in reducing acute pain than passive distractors, the underlying mechanisms remain poorly understood. Previous work using Virtual-Reality (VR) has suggested that interactive distraction may be enhanced by increasing the person's sense of immersion. Despite the possible utility of immersive VR in reducing pain, some people report being disoriented and motion sick, and it doesn't allow for interactions with environment (e.g., following instructions from medical staff). Here, we explore the role of the immersion in the effectiveness of interactive distraction by employing an alternative technology, a Mixed-Reality (MR) headset that limits disorientation by projecting virtual objects into the real world. Healthy volunteers (18-35 years) participated in two experiments employing either a between (N = 84) or a within-subject (N = 42) design to compare Interactive and Passive distraction tasks presented via MR or a standard computer display. For both experiments, a cold-pressor task was used to elicit pain, with pain tolerance and pain perception being recorded. Analysis revealed that whilst interactive distraction was more effective in reducing pain perception and increasing pain tolerance than passive distraction, the interpretation of results was sensitive to experimental design. Comparison of devices did not reveal significant differences in pain tolerance or pain intensity, while pain unpleasantness was significantly reduced during the MR task using a within-subject design. Our findings add to existing VR studies reporting little additional analgesic benefit of new, immersive technologies compared to traditional computers, but underscores the important impact the choice of experimental design can have on the interpretation of results.

The effect of virtual reality versus standard-of-care treatment on pain perception during paediatric vaccination: A randomised controlled trial

AIMS AND OBJECTIVES

To determine the effect of immersive virtual reality (VR) on perceived pain and fear in children during vaccination and parental satisfaction with the procedure.

BACKGROUND

Virtual reality can reduce the perception of pain by children but only three studies have analysed its use during vaccination to date; these had small sample sizes and imperfect methodological designs.

DESIGN

A randomised controlled clinical trial.

METHODS

One hundred and sixty participants from the Tres Forques Health Center were randomly assigned to the intervention group (IG) (n = 82) in which distraction with immersive VR was used during the vaccination, while standard distraction techniques were used for the control group (n = 80). The primary outcome was pain (Wong-Baker FACES). Secondary outcomes included (Children's Fear Scale) and parental satisfaction with the vaccination procedure. Chi-squared tests were used for qualitative variables, relationships between quantitative variables were tested with Spearman correlations, and Mann-Whitney U- or Student t-tests were employed to assess the relationship between quantitative and qualitative variables.

RESULTS

Compared to the controls, the children in the IG reported significantly less pain and fear, while parental satisfaction was significantly higher. Reported pain and fear did not differ according to the sex of the patient. Child age was not linked to fear but was related to pain: the younger the patient, the greater the pain they described.

CONCLUSIONS

Immersive VR effectively controlled pain and fear in children during vaccination and increased parent satisfaction with the vaccination process. Patient sex did not influence the level of pain and fear but age did.

RELEVANCE TO CLINICAL PRACTICE

Improving vaccination experiences can reduce perceived pain and fear in children and increase parent satisfaction, thereby enhancing vaccination schedule adherence and improving group immunity.

REPORTING METHOD

The CONSORT Statement for non-pharmacological randomised clinical trials were followed.

Virtual Reality for the Management of Pain and Anxiety for IR Procedures: A Prospective, Randomized, Pilot Study on Digital Sedation

PURPOSE

To assess the analgesic and anxiolytic effects of virtual reality (VR) augmentation in patients undergoing peripherally inserted central catheter (PICC) placement or fine-needle aspiration thyroid biopsy.

MATERIALS AND METHODS

This is a prospective, single-center randomized controlled trial with 107 patients enrolled. Patients were randomly assigned to receive standard of care (SOC) or SOC+VR during PICC or thyroid biopsy procedures. Pain and anxiety were individually measured using the visual analog scale (VAS) before and after the procedure. Vital signs including heart rate and systolic and diastolic blood pressure were recorded. One-way analysis of variance test and Games-Howell post hoc analysis were used to assess effect size and statistical significance between SOC and SOC+VR measures.

RESULTS

The PICC cohort consisted of 59 patients (33 in SOC+VR and 26 in SOC), with a median age of 53.1 years (interquartile range [IQR], 38.3-62.7 years). The thyroid biopsy cohort consisted of 48 patients (26 in SOC+VR and 22 in SOC), with a median age of 60.1 years (IQR, 49.0-67.2 years). One-way analysis of individuals undergoing thyroid biopsies with adjunctive VR revealed an effect size of -1.74 points (SE ± 0.71; P = .018) on VAS pain scale when compared with SOC. Analysis of individuals undergoing PICC placements revealed an effect size of -1.60 points (SE ± 0.81; P = .053) on VAS anxiety when compared with SOC.

CONCLUSIONS

VR as a nonpharmacologic adjunct reduced some procedure-related pain and anxiety without increasing the procedural duration.

Effectiveness of Virtual Reality in Reducing Perceived Pain and Anxiety Among Patients Within a Hospital System: Protocol for a Mixed Methods Study

BACKGROUND

Within hospital systems, diverse subsets of patients are subject to minimally invasive procedures that provide therapeutic relief and necessary health data that are often perceived as anxiogenic or painful. These feelings are particularly relevant to patients experiencing procedures where they are conscious and not sedated or placed under general anesthesia that renders them incapacitated. Pharmacologic pain management and topical anesthetic creams are used to manage these feelings; however, distraction-based methods can provide nonpharmacologic means to modify the painful experience and discomfort often associated with these procedures. Recent studies support distraction as a useful method for reducing anxiety and pain and as a result, improving patient experience. Virtual reality (VR) is an emerging technology that provides an immersive user experience and can operate through a distraction-based method to reduce the negative or painful experience often related to procedures where the patient is conscious. Given the possible short-term and long-term outcomes of poorly managed pain and enduring among patients, health care professionals are challenged to improve patient well-being during medically essential procedures.

OBJECTIVE

The purpose of this pilot project is to assess the efficacy of using VR as a distraction-based intervention for anxiety or pain management compared to other nonpharmacologic interventions in a variety of hospital settings, specifically in patients undergoing lumbar puncture procedures and bone marrow biopsies at the oncology ward, patients receiving nerve block for a broken bone at an anesthesia or surgical center, patients undergoing a cleaning at a dental clinic, patients conscious during an ablation procedure at a cardiology clinic, and patients awake during a kidney biopsy at a nephrology clinic. This will provide the framework for additional studies in other health care settings.

METHODS

In a single visit, patients eligible for the study will complete brief preprocedural and postprocedural questionnaires about their perceived fear, anxiety, and pain levels. During the procedure, research assistants will place a VR headset on the patient and the patient will undergo a VR experience to distract from any pain felt from the procedure. Participants' vitals, including blood pressure, heart rate, and rate of respiration, will also be recorded before, during, and after the procedure.

RESULTS

The study is already underway, and results support a decrease in perceived pain by 1.00 and a decrease in perceived anxiety by 0.3 compared to the control group (on a 10-point Likert scale). Among the VR intervention group, the average rating for comfort was 4.35 out of 5.

CONCLUSIONS

This study will provide greater insight into how patients' perception of anxiety and pain could potentially be altered. Furthermore, metrics related to the operational efficiency of providing a VR intervention compared to a control will provide insight into the feasibility and integration of such technologies in routine practice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52649.

Safety of virtual reality use in children: a systematic review

The study aimed to systematically review available literature regarding the safety of virtual reality (VR) use via head-mounted display in children under 14 years of age. The study was a systematic review including all study designs. A search was conducted in January 2023 in PubMed and EMBASE using key terms referring to 'virtual reality', 'paediatrics' and 'safety'.  Following title and abstract and full-text screening, data were extracted and a narrative synthesis undertaken. Twenty-six studies met criteria for inclusion in the final review.  Limited data suggest that VR may cause mild cybersickness symptoms (not severe enough to cause participants to discontinue use of VR) and that for children with existing amblyopia using VR may result in double vision, which resolves on cessation of VR exposure.  Two randomised control trials did not report differences in adverse events between the intervention (VR use) and control groups. Reporting of safety data was poor; only two studies used a validated measure, and in the remaining studies, it was often unclear how adverse events were defined (if at all), how they were categorised in terms of severity and how they were recorded.     Conclusion: There is limited evidence regarding any potential harms from short exposure to VR in children under 14 years under supervision. Additional research is required to understand increases in cybersickness during and after VR exposure, and the impact of repeated exposure.  Adverse events need to be accurately and routinely recorded to determine any hitherto unknown safety concerns for children < 14 years using VR. What is Known: • Virtual reality (VR) is increasingly being applied in paediatrics, with benefits in terms of anxiety reduction, improved pain management associated with procedures, as an adjunct to physiotherapy and supporting treatments in autistic spectrum disorder.. • Safety guidance in relation to VR use, particularly in younger children, is limited. What is New: • A systematic review of available literature regarding the safety of VR use via head-mounted display in children under 14 years of age demonstrated limited evidence regarding any potential harms from short exposure to VR.. • Studies rarely report safety data and adverse side effects are poorly defined, measured and/or reported. • The lack of a validated measure for evaluating VR-associated symptoms in children compounds the challenging ethical issues of undertaking research into the effects of VR on younger children.

Augmented Reality and Virtual Reality in Spine Surgery: A Comprehensive Review

Augmented reality (AR) and virtual reality (VR) are powerful technologies with proven utility and tremendous potential. Spine surgery, in particular, may benefit from these developing technologies for resident training, preoperative education for patients, surgical planning and execution, and patient rehabilitation. In this review, the history, current applications, challenges, and future of AR/VR in spine surgery are examined.

A bibliometric analysis of research on pediatric preoperative anxiety (2007-2022)

Objective

This study aimed to analyze the current state of research on preoperative anxiety in children through CiteSpace, VOSviewer, and the identification of hot spots and frontiers.

Method

Relevant data were retrieved from the Web of Science Core Collection using the search terms children and preoperative anxiety. Data were analyzed using VOSviewer (version 1.6.18), CiteSpace (5.7. R5) software, and Scimago Graphica.

Results

A total of 622 articles were published between 2007 and 2022, with an increasing trend over time. Kain, Zeev N. (13; 2.09%) and Dalhousie University (15; 2.41%) were the most influential authors and most prolific institutions, respectively. The United States (121; 19.45%) was the country with the most publications. Pediatric anesthesia (55; 8.84%) had the most publications. High-frequency keywords were categorized into three themes, including nonpharmacologic interventions for preoperative anxiety in children, preoperative medications, and risk factors for anxiety; of these, "predictor" (38; 2016) and "sedative premedication" (20; 2016) were the most studied keywords over the past 6 years. "Distraction" (67; 2019) and "dexmedetomidine" (65; 2019) have been the main areas of interest in recent years.

Conclusion

Research on preoperative anxiety in children has been the focus of increasing attention over the past fifteen years, with the majority of publications from high-income countries. This review provides a useful perspective for understanding research trends, hot topics, and research gaps in this expanding field.

A brief virtual reality intervention for pre-operative anxiety in adults

OBJECTIVE

Virtual reality (VR) is a promising non-pharmacologic tool for managing health care anxiety. We assessed the feasibility and acceptability of a pre-operative VR intervention by adult patients and medical staff and measured anxiety in adult patients pre- and post-VR intervention.

STUDY DESIGN

We recruited 30 patients scheduled to undergo oral surgery and 8 medical staff as participants. The patients completed a verbal demographic survey and rated their anxiety before the VR intervention and at 1 minute and 2 minutes post-intervention. We administered the Acceptability of Intervention Measure to the patients to measure their perceptions of the VR intervention and the Feasibility of Intervention Measure to the medical staff to assess their perception of VR implementation. We performed an analysis of variance to compare pre-operative anxiety over time and assess demographic differences.

RESULTS

The patients showed high and consistent acceptability of the pre-operative use of VR among patients, but acceptability varied among medical staff. The patients experienced a statistically significant reduction of pre-operative anxiety (P = .003).

CONCLUSION

A brief VR pre-intervention is highly accepted by and very beneficial for patients undergoing oral surgery, positively affecting anxiety reduction. The perception of VR by health care providers needs to be explored to increase acceptability.

Preoperative anxiety management in pediatric patients: a systemic review and meta-analysis of randomized controlled trials on the efficacy of distraction techniques

Background

This study addresses the pervasive issue of heightened preoperative anxiety in healthcare, particularly among pediatric patients. Recognizing the various sources of anxiety, we explored both pharmacological and nonpharmacological interventions. Focusing on distraction techniques, including active and passive forms, our meta-analysis aimed to provide comprehensive insights into their impact on preoperative anxiety in pediatric patients.

Methods

Following the PRISMA and Cochrane guidelines, this meta-analysis and systematic review assessed the efficacy of pharmaceutical and distraction interventions in reducing pain and anxiety in pediatric surgery. This study was registered on PROSPERO (CRD42023449979).

Results

This meta-analysis, comprising 45 studies, investigated pharmaceutical interventions and distraction tactics in pediatric surgery. Risk of bias assessment revealed undisclosed risks in performance and detection bias. Distraction interventions significantly reduced preoperative anxiety compared to control groups, with notable heterogeneity. Comparison with Midazolam favored distraction techniques. Subgroup analysis highlighted varied efficacies among distraction methods, with a notable reduction in anxiety levels. Sensitivity analysis indicated stable results. However, publication bias was observed, suggesting a potential reporting bias.

Conclusion

Our study confirms distraction techniques as safe and effective for reducing pediatric preoperative anxiety, offering a valuable alternative to pharmacological interventions.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=449979, PROSPERO [CRD42023449979].

Effects of virtual reality on chest tube removal pain management in patients undergoing coronary artery bypass grafting: a randomized clinical trial

The pain associated with chest tube removal (CTR) is one of the significant complications of cardiac surgery. The management of this pain is recognized as a vital component of nursing care. The application of distraction techniques using virtual reality (VR) is an effective and straightforward non-pharmacological approach to alleviate pain. This study aimed to determine the impact of VR technology on the management of pain caused by CTR following coronary artery bypass grafting (CABG). This randomized clinical trial was conducted on 70 patients undergoing CABG at Imam Reza and Qaem hospitals in Mashhad, Iran, in 2020. The patients were randomly divided into two groups of 35. For the intervention group, a 360-degree video was played using VR glasses 5 min before the CTR procedure. The pain intensity was measured before, immediately after, and 15 min after CTR, using the Visual Analogue Scale. Also, the Depression Anxiety and Stress Scale-21 (DASS-21), and the Rhoten Fatigue Scale (RFS) were used to evaluate intervention and control groups before the CTR procedure. The collected data was analyzed using statistical tests, such as Chi-square, independent t-test, and Mann-Whitney test. The patients were homogeneous in terms of stress, anxiety, and fatigue levels before CTR, and they did not show any significant differences (P > 0.05). The average pain intensity score of patients in the intervention group significantly decreased immediately and 15 min after CTR, compared to the control group (P < 0.001). Given the positive impact of VR distraction on the severity of pain associated with CTR in patients undergoing CABG, this technique can serve as an effective, accessible, and cost-efficient non-pharmacological approach for managing pain in these patients.Trial registration: This study was registered in the Iranian Registry of Clinical Trials (code: IRCT20190708044147N1; approval date, 08/26/2019).

Digital Therapeutics for Improving Effectiveness of Pharmaceutical Drugs and Biological Products: Preclinical and Clinical Studies Supporting Development of Drug + Digital Combination Therapies for Chronic Diseases

Limitations of pharmaceutical drugs and biologics for chronic diseases (e.g., medication non-adherence, adverse effects, toxicity, or inadequate efficacy) can be mitigated by mobile medical apps, known as digital therapeutics (DTx). Authorization of adjunct DTx by the US Food and Drug Administration and draft guidelines on "prescription drug use-related software" illustrate opportunities to create drug + digital combination therapies, ultimately leading towards drug-device combination products (DTx has a status of medical devices). Digital interventions (mobile, web-based, virtual reality, and video game applications) demonstrate clinically meaningful benefits for people living with Alzheimer's disease, dementia, rheumatoid arthritis, cancer, chronic pain, epilepsy, depression, and anxiety. In the respective animal disease models, preclinical studies on environmental enrichment and other non-pharmacological modalities (physical activity, social interactions, learning, and music) as surrogates for DTx "active ingredients" also show improved outcomes. In this narrative review, we discuss how drug + digital combination therapies can impact translational research, drug discovery and development, generic drug repurposing, and gene therapies. Market-driven incentives to create drug-device combination products are illustrated by Humira® (adalimumab) facing a "patent-cliff" competition with cheaper and more effective biosimilars seamlessly integrated with DTx. In conclusion, pharma and biotech companies, patients, and healthcare professionals will benefit from accelerating integration of digital interventions with pharmacotherapies.

[The prospect of using virtual reality technology in combination with psychotherapeutic methods in children with functional abdominalgia]

OBJECTIVE

The literature review addresses the effectiveness of psychotherapeutic methods in the treatment of functional abdominal pain syndrome and studying the prospects for using virtual reality technology in combination with psychotherapeutic methods according to the available literature.

MATERIAL AND METHODS

A search was conducted for available literature in the eLibrary and PubMed databases, published for the period 2017-2022, using the keywords: abdominalgia, psychotherapeutic methods, gut-brain axis, virtual reality technology.

RESULTS

Currently, the biopsychosocial concept of the etiopathogenesis of abdominal pain syndrome, which is not associated with an organic disease of the gastrointestinal tract, is used. A significant contribution to the formation of the disease is made by genetic, neuropsychological, neurophysiological factors, and disruption of the interaction of the gut-brain axis. Cognitive behavioral therapy, yoga, and hypnotherapy are applicable as effective psychotherapeutic methods in the complex treatment of abdominal pain syndrome in children. A promising direction is the use of virtual reality technology to increase the effectiveness of psychotherapeutic methods and reduce chronic abdominal pain syndrome by influencing the gut-brain axis. Practical research work devoted to this issue is currently rare.

CONCLUSION

In the complex treatment of functional abdominal pain syndrome in children, various psychotherapeutic methods are used, the most effective are cognitive behavioral therapy and hypnotherapy. It is necessary to stimulate domestic research work studying the joint use of virtual reality technology and psychotherapeutic methods in children aged 7 to 18 years.

The effect of virtual reality on pain, kinesiophobia and function in total knee arthroplasty patients: A randomized controlled trial

BACKGROUND

Virtual reality (VR) has emerged as a promising new therapeutic approach, showing promise in the treatment of patients with a variety of diseases. This study aimed to investigate the effect of VR on pain, kinesiophobia, and function in patients undergoing total knee arthroplasty (TKA).

METHODS

This randomized controlled trial was performed on patients who had TKA due to osteoarthritis at Gazi University Hospital from October 2019 to August 2021. For this study, 21 female TKA patients were divided into two groups by the blocked randomization method: VR (n = 10) and exercise (n = 11). The exercise group was given a home exercise program. The VR group received immersive VR application in addition to the exercise. Pain, kinesiophobia, pain catastrophizing, knee range of motion, functional status, and quality of life were assessed. The Wilcoxon Test and Mann-Whitney U Test were used for comparison of the results.

RESULTS

The VR group had a statistically significant difference in the intensity of pain at rest, at night, and during the Timed Up and Go Test (TUG), kinesiophobia, pain catastrophizing, active knee flexion, the TUG, and the stair-climb test scores (P = 0.005 (95% confidence interval (CI) (-5.000, -1.000)), P = 0.005 (95% CI (-7.000, -2.000)), P = 0.023 (95% CI (-4.000, 0)), P = 0.006 (95% CI (-15.000, -3.000)), P = 0.012 (95% CI (-19.000, -3.000)), P = 0.010 (95% CI (4.000, 17.333)), P = 0.017 (95% CI (-14.700, -0.850)), P = 0.011 (95% CI (-23.100, -1.000)), respectively).

CONCLUSION

In the early period following total knee arthroplasty, using virtual reality integrated with exercise helps to reduce pain, kinesiophobia and pain catastrophizing, and to improve functional outcomes in female patients.

Bibliometric Analysis of Research Articles on Virtual Reality in the Field of Pain Medicine Published from 1993 to 2022

Purpose

This study aims to analyze global and regional (China, Japan, and South Korea) research on virtual reality (VR) in the field of pain medicine over the past 30 years. Specifically, we quantify VR-related publications, examine the distribution of research topics on chronic and acute pain, and identify trends and future directions.

Methods

The Web of Science Core Collection (WoSCC) database was used for bibliometric analysis. This study included articles written in English between 1993 and 2022. The search strategy used predefined terms related to VR and pain. Based on the articles' titles and abstracts, two pain physicians independently reviewed and classified them as acute or chronic pain. Quantitative data on countries, institutions, journals, and research categories were analyzed. VOSviewer software was used for keyword mapping and clustering.

Results

We analyzed 808 VR-related articles on pain medicine. Over the past three decades, the number of publications in this field has increased steadily. The United States of America (n = 259) had the highest number of publications. Moreover, China (n = 42), Japan (n = 18), and South Korea (n = 24) also contributed continuously. Acute and chronic pain research accounted for 44.2% and 37.9% of the articles, respectively. The most common acute pain topic was procedure-related (n = 129, 16.0%), whereas the most common chronic pain topic was neuropathic (n = 104, 12.9%). Keywords clustered around neuroscience, pediatric pain management, and chronic pain management.

Conclusion

Our study revealed academic achievements and growing interest in VR-related research in pain medicine. Researchers worldwide have shown balanced interest in applying VR technology to acute and chronic pain, with specific contributions from China, Japan, and South Korea. Harnessing VR technology is promising for improving pain management and enhancing patients' quality of life in the field of pain medicine.

Virtual Reality Therapy as an Adjunct to Physiotherapy for Postoperative Pain Management: A Case Report of Laparoscopic Open Pyeloplasty for Hydronephrosis

Hydronephrosis occurs when the tubes connecting the kidneys and bladder become blocked. These tubes carry urine from the kidneys, where it is created, to the bladder, where it is stored until elimination. When one or both ureters get blocked, serious complications and symptoms might arise. These symptoms include urinary tract obstruction, urine backflow, kidney distension, increased intra-renal pressure, impaired kidney function, infection risk, urinary incontinence, which is the involuntary loss of urine, and discomfort in the side, abdomen, or groin. This case report describes the effective postoperative management of abdominal surgery with virtual reality therapy (VRT) combined with standard medical care as additional therapy and physical therapy for hydronephrosis in a 22-year-old male patient. After undergoing laparoscopic open pyeloplasty, the patient developed right-sided hydronephrosis due to ureteral stenosis. He had a ureteral stent inserted and received physical therapy, including pelvic floor muscle training, core strengthening, and diaphragmatic breathing exercises. After four weeks of physical therapy, the patient reported improvement in his symptoms, including reduced discomfort and increased urination. These findings imply that physical therapy, in addition to advanced treatment with the help of VRT for hydronephrosis following abdominal surgery, might be beneficial.

Centering Patient and Clinician Voices in Developing Tools to Address Pain Related School Impairment: A Phase I Study of a Virtual Reality School Simulation for Children and Adolescents with Chronic Pain

Building on growing evidence supporting virtual reality (VR) interventions for pain management, this study describes the process of developing vReal-School (vRS), a VR-based school simulation for children and adolescents with chronic pain and associated school impairment. Following guidelines for developing user-centered VR interventions, initial phases of intervention development focus on understanding and incorporating patient and clinician perspectives when designing this digital health tool. Phase I entailed focus groups with patients undergoing intensive interdisciplinary pain treatment (IIPT). A total of 19 participants across four focus groups shared their experiences related to dealing with pain at school and provided initial feedback on the concept of a VR-based school simulation. In phase II, we pilot-tested a vRS prototype and collected patient and clinician feedback via mixed method approaches. Phase I results highlight four themes related to pain in school, including physical/environmental challenges and solutions, academic challenges and solutions, peer interaction challenges and solutions, and teacher interaction challenges and solutions. These themes guided the development of our vRS prototype. Nine patients and eleven treating clinicians then engaged with the vRS prototype and provided feedback via semi-structured interviews and validated self-report measures. The results indicate high levels of patient engagement/immersion (mean total score of 17.0 on the Child Presence Measure). Qualitative feedback from both groups identified positive aspects of vRS, including finding the simulation realistic and easy to use and offering ways to address school functioning goals that are not otherwise feasible in the IIPT setting. Areas for improvement included integrating more physical movement as well as increasing the number of scenarios and the level of demands of the tasks available. Both patients and clinicians found vRS to be useful in the IIPT context and relevant to treatment goals. This user input will guide subsequent iterations of intervention development.

Current Evidence for Biological Biomarkers and Mechanisms Underlying Acute to Chronic Pain Transition across the Pediatric Age Spectrum

Chronic pain is highly prevalent in the pediatric population. Many factors are involved in the transition from acute to chronic pain. Currently, there are conceptual models proposed, but they lack a mechanistically sound integrated theory considering the stages of child development. Objective biomarkers are critically needed for the diagnosis, risk stratification, and prognosis of the pathological stages of pain chronification. In this article, we summarize the current evidence on mechanisms and biomarkers of acute to chronic pain transitions in infants and children through the developmental lens. The goal is to identify gaps and outline future directions for basic and clinical research toward a developmentally informed theory of pain chronification in the pediatric population. At the outset, the importance of objective biomarkers for chronification of pain in children is outlined, followed by a summary of the current evidence on the mechanisms of acute to chronic pain transition in adults, in order to contrast with the developmental mechanisms of pain chronification in the pediatric population. Evidence is presented to show that chronic pain may have its origin from insults early in life, which prime the child for the development of chronic pain in later life. Furthermore, available genetic, epigenetic, psychophysical, electrophysiological, neuroimaging, neuroimmune, and sex mechanisms are described in infants and older children. In conclusion, future directions are discussed with a focus on research gaps, translational and clinical implications. Utilization of developmental mechanisms framework to inform clinical decision-making and strategies for prevention and management of acute to chronic pain transitions in children, is highlighted.

The effects of playing digital games on children's pain, fear, and anxiety levels during suturing: A randomized controlled study

OBJECTIVE

The aim was to determine the effects of digital game play on children's pain, fear, and anxiety levels during suturing.

METHODS

Data were obtained from 84 children between the ages of 8 and 17 years at the pediatric emergency department between January 16 and March 19, 2020, using the Socio-Demographic and Clinical Characteristics Form, the Wong-Baker Faces Pain Rating Scale (WBFPS), the Visual Analogue Scale (VAS), the Fear of Medical Procedures Scale (FMPS), and the State-Trait Anxiety Inventory for Children (STAI-CH). A four-block randomization system was used. The study group (n = 42) played digital games during the suturing procedure, unlike the control group (n = 42). Ethical permissions were obtained from the ethical committee, hospital, and families.

RESULTS

Before the suturing procedure, there was no statistically significant difference between the groups' mean scores. The intervention group was found to have statistically significantly lower WBFPS and VAS pain scores than the control group during the suturing procedure, and after the procedure, statistically significantly lower WBFPS, VAS, FMPS, and STAI-CH mean scores than the control group.

CONCLUSIONS

The digital game-playing approach applied before and during the suture procedure was found to be effective in reducing children's pain, fear, and anxiety levels.

Virtual Reality and Neurofeedback for Management of Cancer Symptoms: A Feasibility Pilot

Background: Evidence suggests the usefulness of complementary and alternative medicine approaches, like neurofeedback and virtual reality, for the management of cancer-related pain and mood. It is not well-understood whether neurofeedback delivered through virtual reality is feasible and acceptable to patients actively undergoing cancer treatment. Objective: The purpose of this study was to explore the feasibility and acceptability of a nature-based virtual reality combined with neurofeedback as a non-pharmacologic strategy for managing cancer-related pain and anxiety. Methods: This study utilized a mixed-methods approach. Participants included 15 cancer patients undergoing treatment. Patients engaged in a 22-minute nature-based virtual reality experience, wearing a virtual reality headset with a Brainlink headband measuring EEG activity. Participants were asked to complete the Edmonton Symptom Assessment System revised version (ESAS-r) before (T1) and after (T3) the experience to measure pain and anxiety. They were asked their level of pain midway through the experience (T2) and completed a follow-up interview afterward. Results: This study revealed feasible delivery of a virtual reality intervention combined with neurofeedback for patients seeking cancer treatment. All participants (100%) completed the intervention experience. Patients report this is an acceptable approach to managing cancer-related pain and anxiety. Comparisons between patients' pain scores at T1, T2, and T3 reveal statistically significant reductions in pain (p .001). Patients also report decreased depression and anxiety. Conclusion: This is the first study examining virtual reality combined with neurofeedback as a non-pharmacologic intervention for managing cancer symptoms during treatment. The study reveals it is a promising for managing cancer-symptoms.

A Virtual Reality Exergame: Clinician-Guided Breathing and Relaxation for Children with Muscular Dystrophy

This study introduces a VR-based breathing and relaxation exergame tailored for individuals with Duchenne muscular dystrophy (DMD). DMD is a rare neuromuscular disease that leads to respiratory muscle dysfunction with anxiety being a common comorbidity. Clinical management requires frequent visits to rare disease specialists to manage symptom progression. Limited availability and/or proximity of rare disease experts present challenges to care and can lead to missed care opportunities and reduced quality of life. We propose a breathing and relaxation exergame with remote telehealth applicability that incorporates shared patient-clinician VR interaction, and physiological sensors that provide both real-time feedback to the patient and health analytics for the clinician. The game focuses on two key aspects of DMD clinical care that can be mediated through control of breathing: relaxation/mindfulness training and respiratory muscle exercise. The system was evaluated among 13 individuals, including 4 participants with DMD. Feedback surveys, interviews, and focus group discussions with participants, accompanying family members, and clinicians demonstrated the feasibility of this VR tool for telehealth or as part of a home exercise program.

Acceptability and Tolerability of Extended Reality Relaxation Training with and without Wearable Neurofeedback in Pediatric Migraine

Objective. To determine the acceptability of using extended reality (XR) relaxation training as a preventive treatment for pediatric migraine. Methods. Youths aged 10-17 years old with migraine were recruited from a specialty headache clinic and completed baseline measures evaluating their vestibular symptoms and attitudes about technology. The patients were then instructed in three XR-based relaxation training conditions (fully immersive virtual reality with and without neurofeedback, and augmented reality with neurofeedback), in counterbalanced order, and completed acceptability and side effect questionnaires after each. The patients also took XR equipment home for one week to use for relaxation practice and again completed the measures about their experience. The acceptability and side effect data were compared against predetermined acceptable thresholds and were evaluated for their association with the participant characteristics. Results. The aggregate acceptability questionnaire scores exceeded our minimum threshold of 3.5/5, with the two fully immersive virtual reality conditions preferred over augmented reality for relaxation training (z = -3.02, p = 0.003, and z = -2.31, p = 0.02). The endorsed side effects were rated by all but one participant as mild, with vertigo being the most common. The acceptability ratings were not reliably associated with age, sex, typical hours per day of technology use, or technology attitudes, but were inversely related to the side effect scores. Conclusions. The preliminary data on acceptability and tolerability of immersive XR technology for relaxation training among youths with migraine supports further intervention development work.

Effects of an Immersive Virtual Reality Intervention on Pain and Anxiety Among Pediatric Patients Undergoing Venipuncture: A Randomized Clinical Trial

IMPORTANCE

Venipuncture is one of the most painful and distressing procedures experienced by pediatric patients. Emerging evidence suggests that providing procedural information and distraction using immersive virtual reality (IVR) may reduce pain and anxiety among children undergoing needle-related procedures.

OBJECTIVES

To examine the effects of IVR on reducing the pain, anxiety, and stress experienced by pediatric patients undergoing venipuncture.

DESIGN, SETTING, AND PARTICIPANTS

This 2-group randomized clinical trial recruited pediatric patients aged 4 to 12 years undergoing venipuncture from a public hospital in Hong Kong between January 2019 and January 2020. Data were analyzed from March to May 2022.

INTERVENTIONS

Participants were randomly allocated to an intervention (an age-appropriate IVR intervention offering distraction and procedural information) or a control (standard care only) group.

MAIN OUTCOMES AND MEASURES

The primary outcome was child-reported pain. Secondary outcomes included child-reported anxiety, heart rate, salivary cortisol, length of procedure, and satisfaction of health care professionals with the procedure (rated on a 40 point scale, with higher scores indicating greater satisfaction). Outcomes were assessed 10 minutes before, during, immediately after, and 30 minutes after the procedure.

RESULTS

A total of 149 pediatric patients were recruited, with 86 female patients (57.7%) and 66 patients (44.3%) diagnosed with fever. Compared with the 74 participants in the control group (mean [SD] age, 7.21 [2.49] years), the 75 participants in the IVR group (mean [SD] age, 7.21 [2.43] years) reported significantly less pain (β = -0.78; 95% CI, -1.21 to -0.35; P < .001) and anxiety (β = -0.41; 95% CI, -0.76 to -0.05; P = .03) immediately after the intervention. Health care professional satisfaction in the IVR group (mean [SD] score, 34.5 [4.5]) was significantly higher than that in the control group (mean [SD] score, 32.9 [4.0]; P = .03). Moreover, the length of venipuncture procedure in the IVR group (mean [SD] duration, 4.43 [3.47] minutes) was significantly shorter than that in the control group (mean [SD] duration, 6.56 [7.39] minutes; P = .03).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, integrating procedural information and distraction in an IVR intervention for pediatric patients undergoing venipuncture significantly improved pain and anxiety in the IVR group compared with the control group. The results shed light on the global trends of research on IVR and its clinical development as an intervention for other painful and stressful medical procedures.

TRIAL REGISTRATION

Chinese Clinical Trial Registry identifier: ChiCTR1800018817.

How to use participatory design to develop an eHealth intervention to reduce preprocedural stress and anxiety among children visiting the hospital: The Hospital Hero app multi-study and pilot report

BACKGROUND

Medical procedures can cause considerable stress and anxiety among children. Current interventions mainly diminish stress and anxiety during procedures, while stress and anxiety often build up at home. Moreover, interventions often focus on either distraction or preparation. eHealth can combine multiple strategies and provide a low-cost solution that can be used outside the hospital.

OBJECTIVE

To develop an eHealth solution to diminish preprocedural stress and anxiety, and to evaluate the app on use, usability and user experience in practice. We also aimed to gain in-depth insights in children's and caregivers' opinions and experiences to inform future improvements.

METHODS

This is a multi-study report on the development (Study 1) and evaluation (Study 2) of a first version of the developed app. In study 1 we adopted a participatory design approach in which children's experiences were central to the design process. We performed an experience journey session with stakeholders (n = 13) to map the child's outpatient journey, identify pains and gains, and formulate the desired experience journey. Iterative development and testing with children (n = 8) and caregivers (n = 6) resulted in a working prototype. The prototype was tested with children, resulting in a first version of the Hospital Hero app. The app was evaluated on use, user-experience and usability during an eight-week pilot study in practice (Study 2). We triangulated data from online interviews with children and caregivers (n = 21) and online questionnaires (n = 46).

RESULTS

Multiple stress and anxiety experience touchpoints were identified. The Hospital Hero app supports children in their hospital journey by facilitating preparation at home and providing distraction at the hospital. The pilot study showed that the app was evaluated positively on usability and user-experience and is considered feasible. Qualitative data showed five themes: (1) user-friendliness, (2) coherence and power of storytelling, (3) motivation and reward, (4) fit with real hospital journey, (5) procedural comfort.

DISCUSSION

Using participatory design, we developed a child-centered solution that supports children in the entire hospital journey and may diminish preprocedural stress and anxiety. Future efforts should create a more tailored journey, define an optimal engagement window and formulate implementation strategies.

Virtual Reality in Health Science Education: Professors’ Perceptions

Virtual reality (VR) is a simulated experience in a three-dimensional (3D) computer-simulated world. Recent advances in technology position VR as a multipurpose technology in the healthcare sector and as a critical component in achieving Health 4.0. In this article, descriptive and correlationally quantitative research is carried out on the assessments made by Latin American health sciences university professors on the didactic use of virtual reality technologies. The main objective was to analyze the differences in the perceptions expressed by the public or private tenure of the universities where the professors teach. In addition, gender and age gaps were identified in the assessments obtained from each of the types of universities. The results reveal that Latin American health science professors at private universities have a higher selfconcept of their digital skills for the use of virtual reality in the lectures. This greater selfconcept also leads to a reduction in the gender and age gaps in the participating private universities with respect to the public counterparts. It is advisable to increase both faculty training in the didactic use of virtual reality and funding for its use, mainly in public universities.

Virtual Reality-Augmented Physiotherapy for Chronic Pain in Youth: Protocol for a Randomized Controlled Trial Enhanced With a Single-Case Experimental Design

BACKGROUND

Chronic musculoskeletal (MSK) pain is a prominent health concern, resulting in pain-related disability, loss of functioning, and high health care costs. Physiotherapy rehabilitation is a gold-standard treatment for improving functioning in youth with chronic MSK pain. However, increasing physical activity can feel unattainable for many adolescents because of pain-related fear and movement avoidance. Virtual reality (VR) offers an immersive experience that can interrupt the fear-avoidance cycle and improve engagement in physiotherapy. Despite promising initial findings, data are limited and often lack the rigor required to establish VR as an evidence-based treatment for MSK pain.

OBJECTIVE

This trial evaluates physiorehabilitation with VR in adolescents with MSK pain. This protocol outlines the rationale, design, and implementation of a randomized controlled trial enhanced with a single-case experimental design.

METHODS

This study is a 2-group randomized controlled trial assessing the use of physiorehabilitation with VR in adolescents with MSK pain. The authors will collaborate with physical therapists to integrate VR into their standard clinical care. For participants enrolled in standard physiotherapy, there will be no VR integrated into their physical therapy program. Primary outcomes include physical function and engagement in VR. Secondary outcomes include pain-related fear and treatment adherence. Moreover, we will obtain clinician perspectives regarding the feasibility of integrating the intervention into the flow of clinical practice.

RESULTS

The pilot study implementing physiorehabilitation with VR demonstrated that high engagement and use of physiorehabilitation with VR were associated with improvements in pain, fear, avoidance, and function. Coupled with qualitative feedback from patients, families, and clinicians, the pilot study results provide support for this trial to evaluate physiorehabilitation with VR for youth with chronic MSK pain. Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024.

CONCLUSIONS

Significant breakthroughs for treating MSK pain require mechanistically informed innovative approaches. Physiorehabilitation with VR provides exposure to progressive challenges, real-time feedback, and reinforcement for movement and can include activities that are difficult to achieve in the real world. It has the added benefit of sustaining patient motivation and adherence while enabling clinicians to use objective benchmarks to influence progression. These findings will inform the decision of whether to proceed with a hybrid effectiveness-dissemination trial of physiorehabilitation with VR, serving as the basis for potential large-scale implementation of physiorehabilitation with VR.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04636177; https://clinicaltrials.gov/ct2/show/NCT04636177.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40705.

Effect of a game-based intervention on preoperative pain and anxiety in children: A systematic review and meta-analysis

BACKGROUND

Games are increasingly being used as a means of alleviating pain and anxiety in paediatric patients, in the view that this form of distraction is effective, non-invasive and non-pharmacological.

AIMS

To determine whether a game-based intervention (via gamification or virtual reality) during the induction of anaesthesia reduces preoperative pain and anxiety in paediatric patients.

METHODS

A systematic review with meta-analysis of randomised controlled trials was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using RevMan software. The review was based on a search of the EMBASE, CINAHL, Medline, SciELO and Scopus databases, conducted in July 2021. No restriction was placed on the year of publication.

RESULTS

26 studies were found, with a total study population of 2525 children. Regarding pain reduction, no significant differences were reported. For anxiety during anaesthesia induction, however, a mean difference of -10.62 (95% CI -13.85, -7.39) on the Modified Yale Preoperative Anxiety Scale, in favour of game-based intervention, was recorded.

CONCLUSIONS

Game-based interventions alleviate preoperative anxiety during the induction of anaesthesia in children. This innovative and pleasurable approach can be helpful in the care of paediatric surgical patients.

RELEVANCE TO CLINICAL PRACTICE

In children, preoperative management is a challenging task for healthcare professionals, and game-based strategies could enhance results, improving patients' emotional health and boosting post-surgery recovery. Distractive games-based procedures should be considered for incorporation in the pre-surgery clinical workflow in order to optimise healthcare.

Alice in Wonderland: The effects of body size and movement on children's size perception and body representation in virtual reality

Previous work shows that in adults, illusory embodiment of a virtual avatar can be induced using congruent visuomotor cues. Furthermore, embodying different-sized avatars influences adults' perception of their environment's size. This study (N = 92) investigated whether children are also susceptible to such embodiment and size illusions. Adults and 5-year-old children viewed a first-person perspective of different-sized avatars moving either congruently or incongruently with their own body. Participants rated their feelings of embodiment over the avatar and also estimated the sizes of their body and objects in the environment. Unlike adults, children embodied the avatar regardless of visuomotor congruency. Both adults and children freely embodied different-sized avatars, and this affected their size perception in the surrounding virtual environment; they felt that objects were larger in a small body and vice versa in a large body. In addition, children felt that their body had grown in the large body condition. These findings have important implications for both our theoretical understanding of own-body representation, and our knowledge of perception in virtual environments.

Role of Occupational Therapy in Pain Management

This new position statement from the American Occupational Therapy Association (AOTA) describes occupational therapy's role in pain management. AOTA asserts that occupational therapy practitioners are distinctly prepared to work independently and to contribute to interprofessional teams in the treatment of pain. Practitioners strive to ensure active engagement in meaningful occupations for clients at risk for and affected by pain.

Role of Occupational Therapy in Pain Management

The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, collectively referred to as occupational therapy practitioners (AOTA, 2020b), are distinctly prepared to work independently and to contribute to interprofessional teams in the treatment of pain. Occupational therapy practitioners work to ensure active engagement in meaningful occupations for "persons, groups, or populations (i.e., the client)" (AOTA, 2020b, p. 1) at risk for and affected by pain.

Biophilic virtual reality on children's anxiety and pain during circumcision: A randomized controlled study

INTRODUCTION

The aim of this study was to evaluate the effects of the biophilic virtual reality (BVR) method on children's pain and anxiety undergoing circumcision.

MATERIALS AND METHODS

This randomized controlled study used a parallel trial design guided by the CONSORT checklist. A total of 106 children were included in the analysis. Intraoperative anxiety was assessed by using the simplified Chinese version of the modified Yale Preoperative Anxiety Scale (CmYPAS), Visual Analogue Scale (VAS), heart rate (HR), and Anxiety index (Ai). Intraoperative pain was assessed by using the Faces Pain Scale-Revised (FPS-R), and Pain index (Pi). The Pearson correlation analysis was used to analyze the relationship between Ai and the CmYPAS. The primary outcomes were CmYPAS, VAS, and FPS-R, which were analyzed using the Kruskal-Wallis test.

RESULTS

Baseline variables were not significantly different between the BVR group (34 patients), the indoor virtual reality (IVR) group (36 patients), and the blank control group (36 patients). The CmYPAS scores during surgery were significantly lower in the BVR group and the IVR group versus the blank control group (25.0[22.9-29.2], 22.9[22.9-29.2], 33.3[33.3-38.5] respectively; P < 0.001). The VAS scores during surgery were significantly lower in the BVR group and the IVR group versus the blank control group (5.0[3.0-7.0], 3.0[2.0-5.0], 6.0[5.0-8.8] respectively; P < 0.001). The FPS-R scores during surgery were significantly lower in the BVR group and IVR group versus the blank control group (2.0[1.8-4.2], 3.0[2.0-4.8], 5.5[5.0-8.0], respectively; P < 0.001). At removal of the foreskin, Pi were significantly lower in the BVR group and IVR group versus the blank control group (6.9[4.1], 7.7[3.3], 9.8[6.2] respectively; P = 0.033). The Ai scores at each time point were significantly lower in the BVR group and IVR group versus the control (P = 0.015, P = 0.006 respectively). The correlation analysis of Ai (at removal of the foreskin) and CmYPAS scores in children showed that the Pearson correlation coefficient was 0.194 (P = 0.046).

DISCUSSION

This is the first RCT to investigate the effects of BVR in children undergoing circumcision. This study demonstrates a reduction in pediatric intraoperative pain and anxiety with the use of virtual reality (VR).

CONCLUSION

Intraoperative VR may be an effective noninvasive modality for reducing pain and anxiety during circumcision. Pi and Ai might be used to assess subjective pain and anxiety in patients.

Mobile phone virtual reality game for pediatric home burn dressing pain management: a randomized feasibility clinical trial

BACKGROUND

Virtual reality (VR) gaming is considered a safe and effective alternative to standard pain alleviation in the hospital. This study addressed the potential effectiveness and feasibility of a VR game that was developed by our research team for repeated at-home burn dressing changes.

METHODS

A randomized clinical trial was conducted among patients recruited from the outpatient burn clinic of a large American Burn Association-verified pediatric burn center between September 2019 and June 2021. We included English-speaking burn patients aged 5-17 years old requiring daily dressing changes for at least 1 week after first outpatient dressing change. One group played an interactive VR game during dressing changes, while the other utilized standard distraction techniques available in the home for up to a week. Both child and caretaker were asked to assess perceived pain on a numerical rating scale (NRS) of 0-10. For the VR group, patients were also asked to rate various aspects of the VR game on a NRS of 0-10 and caregivers were asked questions assessing ease of use.

RESULTS

A total of 35 children were recruited for this study with 24 fully completing study measures. The majority of participants were male (n=19, 54.3%), White (n=29, 82.9%), and with second degree burns (n=32, 91.4%). Children and caregivers in the VR group reported less pain than the control group at the 4th dressing change. Participants in the VR group showed a clinically meaningful (≥30%) reduction in child-reported overall pain (33.3%) and caregiver-reported worst pain (31.6%) in comparison with subjects in the control group. Children's satisfaction with the VR remained at a high level across dressing changes over the 1-week period, with reported realism and engagement increasing over time. Over half of the children (54.5%) enjoyed playing the game and did not report any challenges nor any side effects.

CONCLUSIONS

Subjects found the VR to be a useful distraction during home dressing changes and reported no challenges/side effects. VR should be considered as a nonpharmacologic companion for pain management during at-home burn dressing changes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04548635. Registered September 14, 2020-retrospectively registered.

Virtual reality (VR) to reduce anxiety in children in the plaster room: a study protocol for a randomised controlled trial

Background

Paediatric fractures are highly prevalent and are most often treated with plaster. The removal of plaster is often an anxious experience for children. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings. This study aims to investigate the effect of VR on the anxiety level of children with fractures that undergo plaster removal or replacement in the plaster room.

Methods

This study is designed as a randomised controlled trial (RCT). The sample size is 270 patients, aged 5 to 17 years, with a fracture of the upper or lower extremity treated with plaster. The intervention group will be distracted with VR goggles and headphones during the replacement or removal of the plaster, whereas the control group will receive standard care. As a primary outcome, the level of anxiety will be measured with the Child Fear Scale (CFS). Secondary outcomes include anxiety reduction (difference between CFS after and CFS before plaster procedure) and Numeric Rating Scales (NRS) pain and satisfaction. Additionally, the children’s fastest heart rate during the procedure will be recorded. An unpaired samples t-test or a Mann-Whitney U test (depending on the data distribution) will be used to analyse the data.

Discussion

When completed, this trial will provide evidence on the potential role of VR in children with fractures treated with plaster. The purpose is to increase the quality of healthcare by decreasing anxiety and possibly pain perception of children during a plaster procedure.

Trial registration

Netherlands Trial Register NL9065. Registered on 27 November 2020

A randomised pilot trial of virtual reality-based relaxation for enhancement of perioperative well-being, mood and quality of life

A cancer diagnosis and subsequent treatment can trigger distress, negatively impact coping resources, and affect well-being as well as quality of life. The aim of this pilot study was to investigate feasibility and clinical effects of a VR intervention on quality of life, well-being and mood in cancer patients undergoing surgery compared to a non-VR intervention and a control group. 54 patients with colorectal cancer or liver metastases from colorectal cancer undergoing elective curatively intended surgery were recruited and randomised to one of two intervention groups or a control group receiving standard treatment. Participants assigned to one of the intervention groups either received a VR-based intervention twice daily or listened to music twice daily. Adherence to the intervention was 64.6% in the music group and 81.6% in the VR group. The VR intervention significantly reduced heart rate (- 1.2 bpm; 95% CI - 2.24 to - 0.22; p = 0.02) and respiratory rate (- 0.7 brpm; 95% CI - 1.08 to - 0.25; p = 0.01). Self-reported overall mood improved in both groups (VR: + 0.79 pts; 95% CI 0.37-1.21; p = 0.001; music: + 0.59 pts; 95% CI 0.22-0.97; p = 0.004). There was no difference in quality of life between the three groups. Both interventions groups reported changes in feelings. Adherence rates favoured the VR intervention over the music group. Observed clinical outcomes showed stronger intragroup effects on mood, feelings, and vital signs in the VR group. The study demonstrated feasibility of a VR intervention in cancer patients undergoing surgery and should encourage further research investigating the potential of VR interventions to positively influence well-being and mood in cancer patients.

Adjunct Digital Interventions Improve Opioid-Based Pain Management: Impact of Virtual Reality and Mobile Applications on Patient-Centered Pharmacy Care

Digital therapeutics (DTx, mobile medical apps, software as a medical device) are rapidly emerging as clinically effective treatments for diverse chronic diseases. For example, the Food and Drug Administration (FDA) has recently authorized a prescription virtual reality (VR) app for treatment of moderate to severe low back pain. The FDA has also approved an adjunct digital therapy in conjunction with buprenorphine for opioid use disorder, further illustrating opportunities to integrate digital therapeutics with pharmacotherapies. There are ongoing needs to disseminate knowledge about advances in digital interventions among health care professionals, policymakers, and the public at large. This mini-review summarizes accumulating clinical evidence of digital interventions delivered via virtual reality and mobile apps to improve opioid-based analgesia. We identified relevant randomized controlled trials (RCTs) using Embase and PubMed databases which reported pain scores with a validated pain scale (e.g., visual analog scales, graphic rating scale, numeric rating scale) and use of a digital intervention in conjunction with opiates. Among identified RCTs, the majority of studies reported improved pain scores in the digital intervention group, as compared to “treatment as usual” group. Our work suggests that VR and mobile apps can be used as adjunct digital therapies for pain management. We discuss these findings in the context of how digital health technologies can transform patient-centered pharmacy care.

Virtual Reality for Distraction and Relaxation in a Pediatric Hospital Setting: An Interventional Study With a Mixed-Methods Design

Accumulating evidence supports the use of virtual reality (VR) as an effective pain and anxiety management tool for pediatric patients during specific medical procedures in dedicated patient groups. However, VR is still not widely adopted in everyday clinical practice. Feasibility and acceptability measures of clinicians' experiences are often missing in studies, thereby omitting an important stakeholder in VR use in a clinical setting. Therefore, the aim of this mixed-methods study was to investigate the feasibility, acceptability, tolerability (primary outcomes), and preliminary effectiveness (secondary outcome) of Relaxation-VR in both pediatric patients aged 4–16 years and clinicians. Relaxation-VR is a VR application prototype aimed to provide distraction and relaxation for a variety of patient populations and procedures and is used to reduce anxiety, stress (tension) and pain for children in hospital. Multiple measures of acceptability, feasibility and tolerability, and pre-to-post changes in measures of pain, anxiety, stress and happiness were assessed in pediatric patients. At the end of the study, acceptability and feasibility of VR use was assessed in clinicians. Results indicate that VR use (in particular, the Relaxation-VR prototype) for both distraction and relaxation is acceptable, feasible and tolerable for a variety of pediatric patients aged 4–16 years, as assessed in both patients and clinicians, and can reduce anxiety, pain and tension (stress), and increase happiness in a hospital setting.

Efectividad de la Realidad Virtual (RV) en la disminución del distrés de niños y adolescentes con cáncer: Revisión sistemática

Introducción: Aunque se han publicado muchos estudios que han intentado demostrar la eficacia de diferentes tratamientos psicológicos en pacientes con cáncer; hasta la fecha no se ha revisado la evidencia disponible sobre la eficacia de la Realidad Virtual (RV) para disminuir el distrés en niños y adolescentes con cáncer. Objetivo: El objetivo principal es evaluar la efectividad de la intervención con Realidad virtual en la disminución del distrés que padecen los niños y adolescentes con cáncer ante los procedimientos médicos, la hospitalización, o la propia enfermedad. Resultados: De los 22 artículos encontrados, se han seleccionado para la revisión un total de 8, que seguían un diseño experimental o cuasiexperimental en pacientes niños y jóvenes diagnosticados de cáncer tratados con RV. Conclusiones: Los resultados, aunque heterogéneos, sugieren mejorías a medio–largo plazo en las variables de ansiedad, depresión, aceptación, calidad de vida, distrés y flexibilidad psicológica. Además, la RV ha resultado ser más eficaz que otras técnicas. De este modo, a pesar de las limitaciones encontradas en este estudio, se han obtenido resultados prometedores para futuras revisiones y/ o metaanálisis.

Virtual Reality Augments Movement During Physical Therapy: A Pragmatic Randomized Trial

OBJECTIVE

Virtual reality facilitates physical therapy via improved engagement. Although shown to benefit specific patient populations, such as stroke patients, it is less established in otherwise healthy adults and children receiving outpatient physical therapy. The primary objective was to compare total physical therapy-guided movement supplemented with virtual reality with physical therapy-guided movement alone without virtual reality.

DESIGN

This pragmatic, randomized, crossover study compared physical therapy-guided movement supplemented with virtual reality with physical therapy-guided movement alone without virtual reality in outpatients (ages 6-80 yrs). This community sample had variable physical therapy indications (injury, postoperative, chronic pain), and in pre-existing conditions, therefore, participants served as their own controls. Participants received 10 mins of both physical therapy-guided movement supplemented with virtual reality and physical therapy-guided movement alone without virtual reality separated by 5 mins. The primary outcome was differences in aggregate movement of physical therapy-guided exercises. Secondary outcomes explored OMNI rating of perceived exertion and participant and physical therapist satisfaction. Paired t tests, χ2 tests, and regression models were used to analyze differences.

RESULTS

The 41 participants (17 pediatric and 24 adult) moved significantly more during physical therapy-guided movement supplemented with virtual reality compared with physical therapy-guided movement alone without virtual reality (1120.88 vs. 672.65 m, P < 0.001), regardless of which intervention was completed first. Physical therapy-guided movement supplemented with virtual reality treatment was associated with more movement of the target limbs, lower body (P < 0.001), and upper body (P < 0.05). The OMNI rating of perceived exertion scores did not differ between those who started with physical therapy-guided movement supplemented with virtual reality or physical therapy-guided movement alone without virtual reality, and physical therapist and patient surveys endorsed physical therapy-guided movement supplemented with virtual reality.

CONCLUSIONS

Patients completed more physical therapy-guided movement during physical therapy-guided movement supplemented with virtual reality than physical therapy-guided movement alone without virtual reality, and therapists and patients supported its use. Future studies will examine finer tracking of movements.

Systematic Review of Multimodal Human–Computer Interaction

This document presents a systematic review of Multimodal Human–Computer Interaction. It shows how different types of interaction technologies (virtual reality (VR) and augmented reality, force and vibration feedback devices (haptics), and tracking) are used in different domains (concepts, medicine, physics, human factors/user experience design, transportation, cultural heritage, and industry). A systematic literature search was conducted identifying 406 articles initially. From these articles, we selected 112 research works that we consider most relevant for the content of this article. The articles were analyzed in-depth from the viewpoint of temporal patterns, frequency of usage in types of technology in different domains, and cluster analysis. The analysis allowed us to answer relevant questions in searching for the next steps in work related to multimodal HCI. We looked at the typical technology type, how the technology type and frequency have changed in time over each domain, and how papers are grouped across metrics given their similarities. This analysis determined that VR and haptics are the most widely used in all domains. While VR is the most used, haptic interaction is presented in an increasing number of applications, suggesting future work on applications that configure VR and haptic together.

Technology to Assess and Treat Pain in Pediatric Rheumatology

Advancements in eHealth offer unique opportunities for assisting in and augmenting aspects of evidence-based pain evaluation and management with children and adolescents. In this article, we present an overview of some of the opportunities and challenges in pain eHealth for pediatric rheumatologists to consider while caring for children and adolescents seen in their practice.

Physiotherapist beliefs and perspectives on virtual reality-supported rehabilitation for the assessment and management of musculoskeletal shoulder pain: a focus group study protocol

Shoulder pain accounts for a large proportion of musculoskeletal disorders and years lived with disability. Musculoskeletal shoulder pain is challenging to manage and while research evidence suggests that exercise should be a cornerstone of shoulder pain rehabilitation, the exact type and dosage of exercise is unclear. Adherence is a barrier to successful outcomes with exercise-based management of musculoskeletal pain, especially for those with co-morbidities, high pain levels and reported boredom associated with competing prescribed exercise. Virtual reality (VR) may offer an effective platform for rehabilitation of musculoskeletal shoulder pain. Virtual Reality has been shown to be effective for management of acute and chronic pain conditions, for delivering education around various health conditions, and for supporting rehabilitation of neurological conditions. Therefore, it is possible that VR may have a role in the delivery of exercise and education for individuals with musculoskeletal shoulder pain. VR intervention design should involve several steps and begin with establishing early acceptability from users as to the suitability of the technology in clinical practice as well as potential barriers and facilitators to using the technology successfully. This study will therefore aim to explore physiotherapists beliefs and perspectives of immersive VR as a platform for assessment and rehabilitation in patients with musculoskeletal shoulder pain. Further, this study will inform the development of a VR intervention for use in the rehabilitation of musculoskeletal shoulder pain. A series of online focus groups will be conducted with physiotherapists in Ireland using a qualitative descriptive approach to data analysis. A six-phase process of data analysis will be carried out to identify important patterns and themes within the data. The current study will be the first to explore clinician's perspectives on the role of VR in musculoskeletal practice.

The Neuromatrix Theory of Pain and Transactional Theory of Stress and Coping: Improving Understanding of Pain Catastrophizing in Individuals With ACL Reconstruction and Knee Osteoarthritis

Individuals with anterior cruciate ligament reconstruction and early knee osteoarthritis symptoms commonly exhibit psychological impairments, such as pain catastrophizing. Pain catastrophizing is a negative cognitive–affective response to anticipated or actual pain and has been linked to greater pain intensity and decreased function in this population. However, an examination of the neuromatrix theory of pain and the transactional theory of stress and coping may help to explain the development and consequences of pain catastrophizing in individuals with anterior cruciate ligament reconstruction and early knee osteoarthritis symptoms. Exploration of these theoretical models will help clinicians better understand the impact of pain catastrophizing on post-injury outcomes, as well as help to identify intervention strategies to address maladaptive psychological responses and improve outcomes for individuals with anterior cruciate ligament reconstruction and early knee osteoarthritis symptoms.

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.

Use of virtual reality in the reduction of pain after the administration of vaccines in children in primary care centers: a randomized clinical trial (Preprint)

Background

Pain and anxiety caused by vaccination and other medical procedures in childhood can result in discomfort for both patients and their parents. Virtual reality (VR) is a technology that is capable of entertaining and distracting the user. Among its many applications, we find the improvement of pain management and the reduction of anxiety in patients undergoing medical interventions.

Objective

We aim to publish the protocol of a clinical trial for the reduction of pain and anxiety after the administration of 2 vaccines in children aged 3 to 6 years.

Methods

We will conduct a randomized, parallel, controlled clinical trial with 2 assigned groups. The intervention group will wear VR goggles during the administration of 2 vaccines, while the control group will receive standard care from a primary care center for the procedure. Randomization will be carried out by using the RandomizedR computer system—a randomization tool of the R Studio program. This trial will be an open or unblinded trial; both the subjects and the investigators will know the assigned treatment groups. Due to the nature of the VR intervention, it will be impossible to blind the patients, caregivers, or observers. However, a blind third-party assessment will be carried out. The study population will include children aged 3 to 6 years who are included in the patient registry and cared for in a primary care center of the region of Central Catalonia. They will receive the following vaccines during the Well-Child checkup: the triple viral+varicella vaccine at 3 years of age and the hepatitis A+diphtheria-tetanus-pertussis vaccine at 6 years of age.

Results

The study is scheduled to begin in January 2022 and is scheduled to end in January 2023, which is when the statistical analysis will begin. As of March 2022, a total of 23 children have been recruited, of which 13 have used VR during the vaccination process. In addition, all of the guardians have found that VR helps to reduce pain during vaccination.

Conclusions

VR can be a useful tool in pediatric procedures that generate pain and anxiety.

International Registered Report Identifier (IRRID)

PRR1-10.2196/35910