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Three Part Question

in [adults undergoing painful procedures] does [virtual reality] [decreased acute pain perception] compared to [no distraction techniques]?

Clinical Scenario

A 47 year old female presents to the ED with a 6 cm superficial laceration on her forearm. She sustained the injury while cutting wood to build an outdoor patio set. She is very anxious and complaining of severe pain making it difficult to exam the entire wound or provide local anesthetic. You wonder how to proceed with irrigation and closure.

Distraction methods are commonly used in paediatric emergency departments to ease anxiety and reduce pain perception in children undergoing painful procedures. Can distraction methods, specifically virtual reality, be effective in decreasing pain perception in adults undergoing painful procedures?

Search Strategy

Medline 1996-Feb/20 using the OVID interface

([virtual reality.mp. or exp Virtual Reality/ or exp Computer Simulation/ or Imaging, Three-Dimensional/ or Therapy, Computer-Assisted/] or [virtual reality.ti,ab,kf.] or [enhanced reality.mp.]) AND ([exp Acute Pain/ or exp Pain Perception/ or exp Pain Management/ or exp Pain Measurement/] or [pain outcome.mp.] or [painful procedure.mp]) LIMIT to all adult (19 plus years) and english language

Search Outcome

323 papers of which 284 were deemed irrelevant to answering the clinical question, 16 were excluded as the participants underwent painful stimulus (heat/thermal, cold pressor, mild electric shock) and not a painful procedure, 6 were excluded as we found that undergoing a painful experience (physical therapy session in burn victims, labor) did not fit under the term “painful procedure”, 2 papers were excluded as they were case studies

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Alshatrat et al. 2018 USA	50 subjects in good physical health undergoing scaling and root planning procedures	RCT	Time spent thinking about pain	Time spent thinking about pain was less using VR (p=0.004) r= 0.29)	Outcomes were not presented using median score or exact scales (1-10), only presented as mean rank difficult to interpret what their p values were representing, there was bias without blinding, similarity of sides was no assessed (severity of peritonitis)
			How unpleasant was the dental care	More unpleasant dental care without VR (p<0.05) r=0.39)
			Worst pain	Worst pain was lower using VR (p<0.05, r=0.4)
			Average pain	Average pain score lower using VR (p<0.05 r=0.4)
			Pain perception	Less perception that teeth and gum bothered them using VR(p<0.05 r=0.43)
Faber, Patterson, & Bremer. 2013 Netherlands	36 patients with burns undergoing bandage change and wound cleaning	NRCT	Pain	Compared with pain during no VR baseline day 0, pain rating during wound debridement were statistically lower when patients were using VR on days 1,2,3 P<0.05 but had no significant beyond 3 days Day 1: VR (3.5) vs non VR (4.7) Day 2: VR (3.8) vs non VR (4.7) Day 3: VR (3.9) vs non VR (4.95)	All participants received baseline Tylenol and analgesia opioid at standard mean procedural dose of 0.16 mg/kg, could have impacted results Predominant male population, small population, not all participants underwent all 7 days (drop to n=7 after day 3) No specific scale on diagram, no calculation of specific p values of each No randomization in terms of sequence of (VR vs no VR) all patient first underwent painful procedure without VR followed by VR
Furman et al,. 2009 USA	38 patients in good mental and physical health undergoing periodontal scaling and root planning procedure	RCT	Visual analog scale assessing pain (0-10) and questionnaire consisted of 11 items related to pain,	The mean (± SD) VAS pain scores for items 1 through 5 combined were 1.76 (± 1.4) for VR, 2.57 (± 1.8) for the movie and 3.95 (± 2.1) for the control condition (p < 0.001)	Small sample size
Ford et al., 2017 USA	10 adult participants undergoing burn injury care	Mixed-methods pilot study; quantitate and qualitative approach	Qualitative pain assesment	Not at all 8.33% A little bit 16.66% Some 58.33% A lot 16.66%= with 60% achieving meaningful associated pain reduction	Small sample, no control or comparison, mostly qualitative outcomes, did not report on statistical significance Patient stopped/started VR at different times of procedure, some used audio other did not
Hoxhallari et al., 2019 USA	40 patients undergoing wide-awake local anesthesia no tourniquet surgery	Single Blind, randomized prospective study	Pain using Likehart scale	In pain outcome, the only statistically relevant (decreased between VR and control was in patients with pre-existing anxiety during the injection of lidocaine (p=0.02) else the pain score were not significantly different at time of local anesthetic injection, mid procedure, or at the end of procedure	Small group, did not describe randomization process or confounders
McSherry et al,. 2018 USA	18 participants deep or partial thickness burn wound or necrotizing fasciitis or decubitus ulcers undergoing dressing change	RCT	Pain	Small, nonsignificant differences in pain and levels were found between the IVR and no IVR wound procedures (p > 0.05)	Not all participants participated in both arms of the study (6 only one or the other), majority male and co commitment substance use which may impact scores
Glennon et al., 2018 USA	97 adults in outpatient cancer center undergoing bone marrow aspiration and biopsy procedures	Quasi-experimental study	Pain score	No statistically significant differences were noted between the groups for pain values (p < 0.05)	No control (no distraction techniques)- however this is not standard of practice at their institution, different providers doing procedure, weak randomization (every other patient), multiple confounders possible
Guo, Deng, & Yang., 2015 China	98 patients undergoing hang injury dressing change	RCT	Visual analog scale scoring pain	The average VAS score at the end of the dressing was 2.63 +/- 1.27 in the experimental group and 7.64 +/- 3.41 in the control group. This showed significant after the dressing change (t = -30.792, p < 0.01).	The control group had a higher mean pain score before the dressing change compared to experimental group
Higgins et al., 2019 USA	109 patients undergoing Mohs procedure	Prospective interventional study	Pain outcomes	Most patients reported that the VR experience did not subjectively improve surgical pain they may have been experiencing and pain was not significantly improved by the VR experience	Lack of control group Selection bias
Hoffman et al., 2008 USA	11 hospital inpatients had their burn wounds debrided and dressed while partially submerged in hydrotank	RCT	Worse pain	Mean pain ratings were lower during VR than in the control condition (no distraction) for all 3 pain measures, and the differences were all statistically significant (p= 0.015, p=0.017, p<0.001)	Small sample size, no blinding of care giver
			thinking about pain and pain unpleasantness rated on a 0-10 graphic	Patients reported significantly less pain when distracted with VR ratings during wound care dropped from ‘‘severe’’ (7.6) Mean pain ratings were lower during VR than in the control condition (no distraction) for all 3 pain measures, and the differences were all statistically significant (p= 0.015, p=0.017, p<0.001) Patients reported significantly less pain when distracted with VR 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.
Karaman et al., 2018 Turkey	117 volunteer adult students underwent experimental pain during the application of blood pressure cuff	Randomized single blind quasi-experimental study	Pain levels using visual analog scale	mean pain score of the individuals in the experimental group was 2.62±1.82, and that of individuals in the control group was 5.75±1.65. Results of the statistical analysis showed a statistically significant difference between the mean pain scores of the individuals in the experimental and control groups (p<0.001)
Maani et al., 2011 USA	12 patients receiving wound debridement	RCT	Pain scored of 0-10 Graphic Rating Scale	Patients reported significantly less pain when distracted with VR. “Worst pain” (pain intensity) dropped from 6.25 of 10 to 4.50 of 10. “Pain unpleasantness” ratings dropped from “moderate” (6.25 of 10) to “mild” (2.83 of 10). “Time spent thinking about pain” dropped from 76% during no VR to 22% during VR.	Single blinding. Short/small number of treatments. Use of pharmacological agents, and did not study if amount of oral pain medication was reduced or significantly different
Van Twilert, Bremer & Faber 2009 Netherlands	19 inpatients undergoing wound dressing	NRCT	Pain using visual analog thermometer score	VR and distraction techniques significantly improved pain scores (F =13.2; p < .01)., VR was superior to television but not in statistical significance	Not blinded Small sample Individuals did not choose other distraction techniques until after experienced VR, could have affected results
Walker et al., 2014 USA	45 adult men referred for cystoscopy	RCT	Pain	No data endpoints showed a statistically significant difference between the 2 groups
			Time spending thinking about pain	No data endpoints showed a statistically significant difference between the 2 groups
JahaniShoorab et al., 2015 Iran	30 primiparous parturient women having labor and needing episiotomy repair	RCT	Pain measured using the Numeric Pain Rating Scale	The pain score at different stages of the episiotomy in both groups was analyzed and compared by repeated measures ANOVA. A significant difference between the groups, based group effect (p=0.038) and different stages (p<0.0001). Less pain during hymen repair mean(VR=9 vs non VR 23) , during skin repair (VR 16 vs non VR 39), after repair (VR 6 vs non VR 25) and1 hr post repair (VR 4.2 vs no VR 10)	Significant differences on episiotomy incision depths between the intervention group and the group receiving standard care

Comment(s)

All 15 studies included were experimental studies comparing pain scales of patients undergoing procedures with adjunct VR headsets or non-distraction. Eight studies showed improved pain scores with statistically significant results. Five RCTs showed no statistically significant between the two groups. Two studies, although in support of VR, were based on qualitative responses. The major limitation of these studies were small sample sizes, non randomization, non blinding, and use of analgesics as a confounder. Some reasons against VR include minor side effects of nausea during simulation and the fact that some adults would prefer observing the procedure or interacting with the physician/caregiver.

Clinical Bottom Line

Based on the presented evidence, there is no strong evidence to favour virtual reality headsets as a means to decreased acute pain perception in adults undergoing medical procedures. Further study into the topic is needed.

References

1. Alshatrat, S., Alotaibi, R., Sirois, M., & Malkawi, Z. The use of immersive virtual reality for pain control during periodontal scaling and root planing procedures in dental hygiene clinic International Journal Of Dental Hygiene 17(1), 71-76
2. Faber, A., Patterson, D., & Bremer, M. Repeated Use of Immersive Virtual Reality Therapy to Control Pain During Wound Dressing Changes in Pediatric and Adult Burn Patients Journal Of Burn Care & Research 34(5), 563-568
3. Furman, E., Jasinevicius, T., Bissada, N., Victoroff, K., Skillicorn, R., & Buchner, M Virtual Reality Distraction for Pain Control During Periodontal Scaling and Root Planing Procedures The Journal Of The American Dental Association 140(12), 1508-1516
4. Ford, C., Manegold, E., Randall, C., Aballay, A., & Duncan, C. Assessing the feasibility of implementing low-cost virtual reality therapy during routine burn care Burns 44(4), 886-895
5. Hoxhallari, E., Behr, I., Bradshaw, J., Morkos, M., Haan, P., Schaefer, M., & Clarkson, J. Virtual Reality Improves the Patient Experience during Wide-Awake Local Anesthesia No Tourniquet Hand Surgery Plastic And Reconstructive Surgery 144(2), 408-414
6. McSherry, T., Atterbury, M., Gartner, S., Helmold, E., Searles, D., & Schulman, C. Randomized, Crossover Study of Immersive Virtual Reality to Decrease Opioid Use During Painful Wound Care Procedures in Adults Journal Of Burn Care & Research
7. Glennon, C., McElroy, S., Connelly, L., Mische Lawson, L., Bretches, A., Gard, A., & Newcomer, L. Use of Virtual Reality to Distract From Pain and Anxiety Oncology Nursing Forum 45(4), 545-552
8. Guo, C., Deng, H., & Yang, J. Effect of virtual reality distraction on pain among patients with hand injury undergoing dressing change Journal Of Clinical Nursing 24(1-2), 115-120
9. Higgins, S., Feinstein, S., Hawkins, M., Cockburn, M., & Wysong, A. Virtual Reality to Improve the Experience of the Mohs Patient—A Prospective Interventional Study Dermatologic Surgery 45(8), 1009-1018
10. Hoffman, H., Patterson, D., Seibel, E., Soltani, M., Jewett-Leahy, L., & Sharar, S. Virtual Reality Pain Control During Burn Wound Debridement in the Hydrotank The Clinical Journal Of Pain 24(4), 299-304
11. Karaman D , Erol F , Yilmaz D , & Dikmen Y Investigation of the effect of the virtual reality application on experimental pain severity in healthy SciElo 65 (3), 446-451
12. Maani, C., Hoffman, H., Morrow, M., Maiers, A., Gaylord, K., McGhee, L., & DeSocio, P. Virtual Reality Pain Control During Burn Wound Debridement of Combat-Related Burn Injuries Using Robot-Like Arm Mounted VR Goggles The Journal Of Trauma: Injury, Infection, And Critical Care 71(supplement), S125-S130
13. van Twillert, B., Bremer, M., & Faber, A Computer-Generated Virtual Reality to Control Pain and Anxiety in Pediatric and Adult Burn Patients During Wound Dressing Changes Journal Of Burn Care & Research 28(5), 694-702
14. Walker, M., Kallingal, G., Musser, J., Folen, R., Stetz, M., & Clark, J. Treatment Efficacy of Virtual Reality Distraction in the Reduction of Pain and Anxiety During Cystoscopy Military Medicine 179(8), 891-896
15. JahaniShoorab N, Zagami S.E , Nahvi A. ,Mazluom S , Golmakani N , Talebi M ,& Ferial Pabarja The Effect of Virtual Reality on Pain in Primiparity Women during Episiotomy Repair: A Randomize Clinical Trial Iranian Journal of Medical Science 40 (3), 219-24