Manipulating presence influences the magnitude of virtual reality analgesia

Excessive pain during medical procedures performed in unanesthetized patients is frequently reported, but can be reduced with virtual reality (VR) distraction. Increasing the person's illusion of going into the virtual world may increase how effectively VR distracts pain. Healthy volunteers aged 18-20 years participated in a double-blind between-groups design. Each subject received a brief baseline thermal pain stimulus, and the same stimulus again minutes later with either a Low Tech or a High Tech VR distraction. Each subject provided subjective 0-10 ratings of cognitive, sensory and affective components of pain, and rated their illusion of going inside the virtual world. Subjects in the High Tech VR group reported a stronger illusion of going into the virtual world (VR presence) than subjects in the Low Tech VR group, (4.2 vs. 2.5, respectively, P = 0.009) and more pain reduction (reduction of worst pain is 3.1 for High Tech VR vs. 0.7 for Low Tech VR, P < 0.001). Across groups, the amount of pain reduction was positively and significantly correlated with VR presence levels reported by subjects ( r = 0.48 for 'worst pain', P < 0.005).     

Effects of Hypnotic Analgesia and Virtual Reality on the Reduction of Experimental Pain Among High and Low Hypnotizables

This research compared a no-treatment control condition and 3 experimentally induced pain treatment conditions: (a) virtual reality distraction (VRD), (b) hypnotic analgesia (HA), and (c) HA + VRD in relieving finger-pressure pain. After receiving baseline pain stimulus, each participant received hypnosis or no hypnosis, followed by VRD or no VRD during another pain stimulus. The data analysis indicated that, overall, all 3 treatments were more effective compared to the control group, irrespective of whether it involved hypnotic analgesia, virtual reality distraction, or both (hypnosis and virtual reality). Nevertheless, the participants responded differently to the pain treatment, depending on the hypnotizability level. High hypnotizables reported hypnotic analgesia, but low hypnotizables did not show hypnotic analgesia. VR distraction reduced pain regardless of hypnotizability.     

Effects of Distraction on Reducing Pain During Invasive Procedures in Children with Cancer: A Systematic Review and Meta-Analysis

BackgroundDistraction is a known behavioral intervention that is widely used for pain management in the pediatric population. However, there is a shortage of reviews reporting the efficacy of distraction for procedural pain reduction in pediatric oncology settings.AimTo determine the current evidence on the effects of distraction on procedural pain in children with cancer.DesignThis systematic review and meta-analysis was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelinesSettingsSix different databases from 1990 to June 2019.MethodA literature search was conducted to identify the effects of distraction on procedural pain reduction in children with cancer. A meta-analysis was undertaken along with applying a mixed effect model to quantify the standardized mean difference in the 95% confidence interval (CI) as the overall effects.ResultsTen randomized controlled trials were included. Distraction during an invasive procedure had a large effect on pain intensity (–0.92, 95% CI –1.48 to –0.36, p = .001) and on needle insertion as well (–1.12, 95% CI –1.52 to –0.72, p = .000), but only a moderate effect on lumbar puncture procedures (-0.57, 95% CI -1.02 to -0.12, p = .012). Uncertain effects on pain relief showed up in a virtual reality (VR) distraction (-0.93, 95% CI -2.63 to 0.76, p = .28) and during active distraction (-0.72, 95% CI -1.48 to 0.03, p = .06).ConclusionsDistraction is an efficacious intervention to reduce procedural pain during needle insertion or lumbar puncture procedures in children with cancer. However, the efficacy of active distraction and VR remain uncertain. Future research should focus on specific comparisons of different forms of distractions with larger sample sizes.     

Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study

OBJECTIVE: The pain experienced by burn patients during physical therapy range of motion exercises can be extreme and can discourage patients from complying with their physical therapy. We explored the novel use of immersive virtual reality (VR) to distract patients from pain during physical therapy. SETTING: This study was conducted at the burn care unit of a regional trauma center. PATIENTS: Twelve patients aged 19 to 47 years (average of 21% total body surface area burned) performed range of motion exercises of their injured extremity under an occupational therapist's direction. INTERVENTION: Each patient spent 3 minutes of physical therapy with no distraction and 3 minutes of physical therapy in VR (condition order randomized and counter-balanced). OUTCOME MEASURES: Five visual analogue scale pain scores for each treatment condition served as the dependent variables. RESULTS: All patients reported less pain when distracted with VR, and the magnitude of pain reduction by VR was statistically significant (e.g., time spent thinking about pain during physical therapy dropped from 60 to 14 mm on a 100-mm scale). The results of this study may be examined in more detail at www.hitL.washington.edu/projects/burn/. CONCLUSIONS: Results provided preliminary evidence that VR can function as a strong nonpharmacologic pain reduction technique for adult burn patients during physical therapy and potentially for other painful procedures or pain populations.     

Effects of Patient Education and Distraction Approaches Using Virtual Reality on Pre-operative Anxiety and Post-operative Pain in Patients Undergoing Laparoscopic Cholecystectomy

BackgroundFear of post-operative pain often contributes to pre-operative anxiety; accordingly, pain and anxiety are among the most common complications in patients undergoing laparoscopic cholecystectomy (LC).AimThe present study aimed to determine the effects of patient education and distraction using virtual reality (VR) on pre-operative anxiety and post-operative pain in patients undergoing LC.MethodThis randomized clinical trial included 150 patients in the surgery wards of educational hospitals in Mashhad, Iran, in 2020. The participants were randomly assigned to three groups of education, distraction, and control. The education and distraction groups watched two five-minute animations and three 360-degree images of nature using VR glasses 2 hours before and 4 hours after the surgery, respectively. On the other hand, the control group received routine care. Anxiety was measured using Spielberger's State Anxiety Inventory before and half an hour after the intervention. Moreover, the pain was measured using the visual analog scale and McGill Pain Questionnaire.ResultsThe results demonstrated a significant reduction in the two VR groups regarding the pre-operative anxiety mean scores, compared with the control group (p < .001). Furthermore, a significant reduction was observed in post-operative pain scores of patients in the two intervention groups compared with the control group (p = .001).ConclusionsAs evidenced by the results, both VR approaches of patient education and distraction equally decreased pre-operative anxiety and post-operative pain in patients undergoing LC.     

Distracting children during blood draw: looking through distraction cards is effective in pain relief of children during blood draw

Inal S, Kelleci M. International Journal of Nursing Practice 2012; 18 : 210–219 Distracting children during blood draw: Looking through distraction cards is effective in pain relief of children during blood draw This study aims to investigate the effects of distraction method by way of looking through distraction cards/Flippits® to reduce procedural pain and anxiety during blood draw. In this method we distract attention of the children with distraction cards/Flippits®. Flippits® consist of various eye‐catching pictures and shapes. Then we asked the children questions about the cards during the blood draw procedure that he or she can only answer if he or she examines the cards carefully. This study is a prospective, randomized controlled trial. The sample consisted of 123 children of ages between 6 and 12. We randomly assigned subjects into two groups. Group 1 received no intervention, whereas Group 2 received distraction in the form of looking through distraction cards/Flippits®. Pre‐procedural and procedural anxiety was assessed using the anxiety scale from the Children's Anxiety and Pain Scales by parents' and observer's report. Procedural pain was assessed using Faces Pain Scale‐Revised by children, parent and observer reports. Results show that pre‐procedural anxiety did not differ significantly. However, the experimental group had significantly lower pain levels than the control group during the blood draw procedure. Also experimental group had significantly lower anxiety levels than the control group.     

虚拟现实分散患者注意力舒缓拔牙疼痛的效果

目的 探讨虚拟现实分散患者注意力缓解智齿拔除术中疼痛的效果.方法 将122例18～60岁需拔除上颌智齿的成人患者纳入试验,按就诊先后顺序分配到试验组和对照组各61例.试验组患者在进行常规拔牙时,于拔牙前5min至拔牙结束使用虚拟现实系统分散患者注意力.对照组患者接受常规方法拔牙,未使用虚拟现实系统分散患者注意力.使用视觉模拟量表(VAS)、牙科焦虑问卷对两组患者拔牙过程中的疼痛和焦虑进行评估.结果 试验组患者VAS得分为(2.09±1.68)分,对照组为(3.07±2.34)分,两组比较,差异有统计学意义(t=-2.677,P＜0.05);试验组拔牙时焦虑问卷得分为(4.44±3.26)分,对照组为(5.06±3.00)分,两组比较,差异无统计学意义(t=-1.093,P＞0.05).结论 虚拟现实分散患者注意力能有效缓解智齿拔除术中的疼痛.     

Virtual reality distraction during pediatric intravenous line placement in the emergency department: A prospective randomized comparison study

ObjectiveTo evaluate the efficacy of virtual reality distraction (VR) during intravenous line (IV) placement in a pediatric emergency department to increase first-attempt IV success. Secondary endpoints included median time to successful IV placement, patient pain and anxiety scores, and an evaluation of characteristics of patients in whom VR is well tolerated.Study designThis was a randomized controlled trial at a tertiary pediatric emergency department, enrolling patients aged 4–17 years who required IV placement. Patients were enrolled only when child life specialists were unavailable. The primary endpoint was first attempt IV success.ResultsA total of 116 subjects were enrolled, 58 were randomly assigned to the VR group and 58 were assigned to the standard of care (SOC) group. 115 subjects completed the trial and were analyzed. First attempt IV success rates were similar between the groups (VR = 81%, standard = 84.2%, p = .65). Number of IV attempts and changes in pain and anxiety scores were also similar between the groups. The median time to successful IV placement was shorter in the VR group (78 vs 104 seconds) but this difference was not statistically significant (p = .21). Overall the VR headset was tolerated by 79% of subjects assigned to that group. The only significant predictor of headset tolerance was older age (P = .02).ConclusionsVR distraction for IV placement in the Pediatric Emergency Department shows similar efficacy to standard distraction techniques and appears to be well tolerated.     

虚拟现实技术在减轻儿童操作性疼痛中的应用进展

近年来,基于虚拟现实技术分散注意力的方法逐渐被应用到儿童操作性疼痛管理中。该文对虚拟现实技术在儿童操作性疼痛中的应用现状进行综述,包括操作性疼痛的常见原因、虚拟现实技术的分类、虚拟现实技术在减轻儿童操作性疼痛中应用方法及效果等,总结了相关不足并提出了展望,以期为临床实践提供指导。     

Virtual reality pain control during burn wound debridement in the hydrotank

OBJECTIVE: Most burn-injured patients rate their pain during burn wound debridement as severe to excruciating. We explored the adjunctive use of water-friendly, immersive virtual reality (VR) to distract patients from their pain during burn wound debridement in the hydrotherapy tank (hydrotank). SETTING: This study was conducted on inpatients at a major regional burn center. PATIENTS: Eleven hospitalized inpatients ages 9 to 40 years (mean age, 27 y) had their burn wounds debrided and dressed while partially submerged in the hydrotank. INTERVENTION: Although a nurse debrided the burn wound, each patient spent 3 minutes of wound care with no distraction and 3 minutes of wound care in VR during a single wound care session (within-subject condition order randomized). OUTCOME MEASURES: Three 0 to 10 graphic rating scale pain scores (worst pain, time spent thinking about pain, and pain unpleasantness) for each of the 2 treatment conditions served as the primary dependent variables. RESULTS: Patients reported significantly less pain when distracted with VR [eg, "worst pain" ratings during wound care dropped from "severe" (7.6) to "moderate" (5.1)]. The 6 patients who reported the strongest illusion of "going inside" the virtual world reported the greatest analgesic effect of VR on worst pain ratings, dropping from severe pain (7.2) in the no VR condition to mild pain (3.7) during VR. CONCLUSIONS: Results provide the first available evidence from a controlled study that immersive VR can be an effective nonpharmacologic pain reduction technique for burn patients experiencing severe to excruciating pain during wound care. The potential applications of VR analgesia to other painful procedures (eg, movement or exercise therapy) and other pain populations are discussed.     

Can virtual reality reduce pain and anxiety in pediatric emergency care and promote positive response of parents of children? A quasi-experimental study

AimTo evaluate the effectiveness of virtual reality to reduce pain and anxiety in pediatric patients during venipuncture procedure in emergency care and the behavioral response of their parents/companions.BackgroundVirtual reality is being used as a source of distraction in children undergoing invasive procedures.MethodsQuasi-experimental study with 458 children (from 2 to 15 years) who attended a pediatric emergency service from September 2019 to April 2021. An intervention based on virtual reality as a distraction method during venipuncture procedure was applied. The level of pain and anxiety of children and attitude of parents/companions were assessed. Ordinal and binary logistic regressions were applied.ResultsA protective effect of using virtual reality was observed in the intervention group both for the absence of pain (−4.12; 95 % CI: −4.85 to −3.40) and anxiety (−1.71; 95 % CI: −2.24 to −1.17) in children aged between 2 and 15 years. A significant reduction in the blocking response of the accompanying parents (−2.37; 95 % CI: −3.017 to −1.723) was also observed.ConclusionsVR is effective in reducing pain and anxiety in children during venipuncture in emergency care. A positive attitude of the parents during the invasive procedure to their children was found.     

Decreasing Pain and Fear in Medical Procedures with a Pediatric Population (DREAM): A Pilot Randomized Within-Subject Trial

BackgroundMany children with injuries, including burns and fractures, experience moderate to severe pain during medical procedures. Recent studies claim that nonpharmacologic pain management using virtual reality (VR) could distract children from procedural pain by engaging multiple senses.AimsThe aims of this pilot randomized clinical trial were to assess the acceptability and feasibility of VR distraction in children with burns or fractures undergoing painful medical procedures, as well as the staff nurses, and assess the preliminary efficacy of VR distraction on pain intensity, pain-related fear, and subsequent recall of both.Materials and MethodA within-subject study design, in which participants served as their own control, was used. A total of 20 children from 7 to 17 years old with an injury were recruited at the surgical-trauma outpatient clinics of the Centre hospitalier universitaire Sainte-Justine (CHU Sainte-Justine). Each participant received both standard and experimental treatments through randomized order. Pain (numerical rating scale) and pain-related fear (Children's Fear Scale) measures were taken before the procedure and after each sequence, followed by a measure of children's (graphic rating scale) and nurses' acceptability of the intervention through their satisfaction level. Recall of pain intensity and pain-related fear were assessed 24 hours after the procedure. Wilcoxon signed-rank tests were used, with a significance level at 0.05.ResultsResults showed that VR distraction was an acceptable and feasible intervention for children and nurses of these outpatient clinics. Preliminary effects showed that, compared to standard of care, children participants reported a significant decrease in pain intensity (p = .023) and pain-related fear (p = .011) during VR as well as less recalled pain-related fear (p = .012) at 24 hours after the procedure. No side effects were reported.ConclusionVR is a promising intervention with children undergoing painful procedures because it is immersive and engages multiple senses. It is a low-cost intervention well accepted by children and nursing staff at this clinical site and is easy to implement in daily practice for procedural pain management.     

Effects of distraction versus spatial discrimination on laser-evoked potentials in migraine

OBJECTIVES: To evaluate whether migraine patients exhibit less inhibition to painful stimuli when distracted from pain as compared to healthy subjects, testing the spatial discrimination of painful stimuli, the performance during the mental arithmetic task used to contrast the discrimination performance and the behavior of N1 and N2-P2 laser-evoked potentials (LEPs) amplitudes during spatial discrimination and during distraction. METHODS: Eight migraine patients and 8 healthy controls were examined. During repetitive series of painful laser stimulation of the hand, they had to (1) perform a spatial discrimination task, contrasted by (2) a mental arithmetic task that served as distraction. RESULTS: Patients made 50% to 100% more mistakes than controls in the spatial discrimination task (P < .001) as well as during mental arithmetic (P < .05). Whereas healthy subjects showed a marked decrease of the LEP vertex potential amplitudes during distraction compared to the discrimination task, no such attenuation of LEPs was seen in migraine patients (group x task interaction, P < .05). N1 amplitude exhibited a left-hemisphere dominance in both groups, significantly smaller amplitude in migraine patients, but no significant task modulation. CONCLUSION: Migraine patients exhibited reduced inhibition by attentional modulation of pain processing, accompanied by impaired spatial discrimination of painful stimuli.     

The use of virtual reality for pain control: A review

Virtual reality (VR) is a relatively new technology that enables individuals to immerse themselves in a virtual world. This multisensory technology has been used in a variety of fi elds, and most recently has been applied clinically as a method of distraction for pain management during medical procedures. Investigators have posited that VR creates a nonpharmacologic form of analgesia by changing the activity of the body’s intricate pain modulation system. However, the effi cacy of VR has not been proven and the exact mechanisms behind VR’s action remain unknown. This article presents a comprehensive review of the literature to date exploring the clinical and experimental applications of VR for pain control. The review details specifi c research methodologies and popular virtual environments. Limitations of the research, recommendations for improvement of future studies, and clinical experiences with VR are also discussed.     

Virtual reality intervention as a support method during wound care and rehabilitation after burns: A systematic review and meta-analysis

ObjectiveThis systematic review and meta-analysis aimed to analyze and synthesize the evidence on the effectiveness of virtual reality (VR) interventions in the prevention of pain, fear and anxiety during burn wound care procedures.MethodsIn September and October 2021, PubMed, Scopus, Cochrane Library and Web of Science were searched for relevant randomized controlled and crossover studies. Two independent authors described the following inclusion criteria for the search: patients undergoing burn wound care with applied VR treatment compared to any other or non-VR intervention. From a total of 1171 records, 25 met the inclusion criteria. After full-text screening, seven publications were excluded. The risk of bias was assessed for 18 studies by two independent authors. RevMan 5.4 was used for the statistical analysis, meta-analysis and visual presentation of the results.ResultsThe meta-analysis showed a significant difference between VR treatment and standard care when analyzing pain outcome during wound care procedures (SMD = −0.49; 95% CI [−0.78, −0.15]; I² = 41%) and in subgroup analysis when immersive VR was incorporated (SMD = −0.71; 95% CI [−1.07, −0.36]; I² = 0%). No significant differences were found between VR treatment and standard care for range of motion outcome (SMD = 0.44; 95% CI [−0.23, 1.11]; I² = 50%).ConclusionsVR seems to be an effective therapeutic support in burn wound care procedures for reducing pain. However, this systematic review and meta-analysis highlights the need for more research into the use of VR as a distraction method. Studies on larger groups using similar conditions can provide unequivocal evidence of the effectiveness of VR and enable the inclusion of such intervention in standard medical procedures.     

Active and Passive Distraction Interventions in a Pediatric Emergency Department to Reduce the Pain and Anxiety During Venous Blood Sampling: A Randomized Clinical Trial

IntroductionDistraction is a method that is easy to use in emergency departments and effective in relieving procedural pain and anxiety. This study aimed to determine the effect of 2 new distraction methods—1 active distraction (rotatable wooden toy) and 1 passive distraction (toy wristband)—on procedural pain, fear, and anxiety in children during venous blood sampling.MethodsThis study was a randomized controlled experimental study. The sample consisted of 216 children aged 6 years to 12 years. They were divided into 3 groups using the block randomization procedure: active distraction group (n = 72); passive distraction group (n = 72); and control group (n = 72). The levels of pain and anxiety in the children were measured before and during the blood sampling by the children themselves, their parents, and the researcher using the Visual Analog Scale, the Wong-Baker FACES Pain Rating Scale, and the Children’s Fear Scale.ResultsThe children and their parents included in the control and experimental groups had similar sociodemographic characteristics. The active distraction group had lower levels of procedural pain, fear, and anxiety than the other groups (children’s visual analog scale score, F = 134.22; P < 0.05; Wong-Baker FACES Pain Rating Scale score, F = 137.54; P < 0.001; and Children’s Fear Scale score, F = 92.44; P < 0.001).DiscussionBoth the toy wristband and rotatable wooden toy interventions can be used to reduce procedural pain, fear, and anxiety in children during blood sampling in emergency departments.     

Efficacy of Cartoon Viewing Devices During Phlebotomy in Children: A Randomized Controlled Trial

PurposeThe purpose of this study was to examine the efficacy of different cartoon viewing devices during phlebotomy in children.DesignThis study was a prospective, randomized controlled trial.MethodsThe study included inpatients from the Biochemical Laboratory of a private university hospital in Turkey and was conducted between September 2017 and April 2018. A computer-based random number generator was used to randomly assign the patients into three groups (virtual reality [VR], tablet, and control) with 40 children each. Data were collected using the Wong-Baker FACES Pain Rating Scale and the Children's Fear Scale. Pain and anxiety scores were reported by children, parents, and observers in tablet and control groups. In the VR group, pain and anxiety were determined only by children's reports.FindingsAccording to the children reports, the VR group reported significantly less pain and anxiety than those in the tablet and control groups (P < .05).ConclusionsThe cartoon distraction performed using a VR device reduced the perception of pain and anxiety during phlebotomy in school-age children.     

Sustained Efficacy of Virtual Reality Distraction

The current study tested whether the effectiveness of distraction using virtual reality (VR) technology in reducing cold pressor pain would maintain over the course of 8 weekly exposures. Twenty-eight adults, 18 to 23 years of age, underwent 1 baseline cold pressor trial and 1 VR distraction trial in randomized order each week. VR distraction led to significant increases in pain threshold and pain tolerance and significant decreases in pain intensity, time spent thinking about pain, and self-reported anxiety, relative to baseline. Repeated exposure did not appear to affect the benefits of VR. Implications for the long-term use of VR distraction as a nonpharmacological analgesic are discussed.PerspectiveThis article addresses the concern that the efficacy of virtual reality–assisted distraction from pain could potentially decrease with repeated exposure. The current finding that efficacy did not diminish over several repeated exposures provides support for the use of virtual reality as an adjuvant treatment of pain.     

预先注射美蓝缓解丙泊酚注射部位疼痛的效果

目的探讨麻醉诱导前预先注射美蓝以缓解注射丙泊酚所致注射部位疼痛的效果。方法 2011年4-8月,方便抽样法抽取绍兴市人民医院行下肢骨科手术的患者120例,按随机数字表法将其分为A、B、C 3组各40例,在麻醉诱导静脉注射丙泊酚前1min,3组患者分别预先注射美蓝25、50mg及生理盐水3ml,评价3组患者注射部位疼痛的程度。结果 B组患者重度疼痛例数明显少于A组(P<0.05),A组和B组发生疼痛的例数均少于C组(均P<0.05);A、B组患者丙泊酚注射部位疼痛的发生率分别为47.5%和40.0%,与C组(90.0%)比较,差异有统计学意义(P<0.05或P<0.01);术后24h随访,患者尿液均未出现蓝色。结论预先静脉注射美蓝能有效缓解麻醉诱导注射丙泊酚所致注射部位疼痛,其中预先注射美蓝50mg缓解注射部位疼痛的效果更好。     

Virtual reality as an adjunctive pain control during burn wound care in adolescent patients

For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16-year-old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17-year-old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care). We contend that VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.