Using Virtual Reality Exposure Therapy in Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Efficacy of virtual reality hypnosis versus conscious sedation with nitrous oxide in the management of dental anxiety in pediatric dentistry: protocol for a prospective randomized controlled trial

BACKGROUND

Dental anxiety is defined as a persistent and excessive fear of dental treatment. It often leads to interruptions during procedures and, frequently, avoidance of dental care. For patients over the age of 7, nitrous oxide-oxygen inhaled sedation (NOIS) represents one of the most effective and well-established pharmacological approaches to reducing anxiety and pain during dental treatment. Meanwhile, medical hypnosis offers an interesting non-pharmacological alternative by inducing a hypnotic state, potentially serving as a means of sedation to alleviate anxiety or pain. The advancement of virtual reality (VR) technology makes medical hypnosis more accessible to dental practitioners, yielding promising outcomes. To our knowledge, no clinical trial has evaluated the efficacy of medical hypnosis associated with 3D immersive virtual reality devices for pediatric dental procedures.

METHODS

This prospective, controlled, single-blind clinical study including anxious patients aged 7 to 10 years old aims to demonstrate non-inferiority of virtual reality approach. Using a split-mouth design, each patient will attend two separate visits for two comparable conservative dental procedures. At the first procedure, they will randomly be assigned to receive either hypnosis via VR or NOIS. The alternative method will be administered during the second visit. The primary outcome is the sedation success based on the completion of the dental procedure. A score of 3 or higher on the Modified Venham Scale noted more than twice ends the session and qualifies as a sedation failure. The secondary outcomes involve assessing children's tolerance and the temperament influence on sedation success.

DISCUSSION

This study will evaluate the efficacy of a novel non-pharmacological sedation for the management of anxious children in a dental setting. The results may help practitioners choose the appropriate anxiolytic therapeutic option, based on different psychometric and temperament parameters.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05167331. Registered on December 22, 2021.

The Efficacy of Virtual Reality on the Rehabilitation of Musculoskeletal Diseases: Umbrella Review

BACKGROUND

Musculoskeletal disorders cause pain, disability, and financial burdens, with rising prevalence. Virtual reality (VR) offers immersive, digital rehabilitation potential, improving motor functions and pain management.

OBJECTIVE

To evaluate the impact of VR on the rehabilitation of musculoskeletal disorders and to assess the consistency of evidence provided by existing systematic reviews and meta-analyses, this study focuses on musculoskeletal disorders, which encompass conditions affecting the locomotor system, such as arthritis, joint deformities, and injuries. VR therapy leverages immersive digital environments to enhance rehabilitation through digital exercises and simulations.

METHODS

The PubMed or MEDLINE, Embase, and Cochrane Library databases were systematically searched for relevant papers published up to April 2024. Literature screening, quality assessment, and data extraction were conducted according to predefined inclusion and exclusion criteria. The methodological quality of the included meta-analyses was evaluated using the Measurement Tool to Assess Systematic Reviews 2. The Grading of Recommendations Assessment, Development, and Evaluation system was used to classify the evidence level for each outcome as high, moderate, low, or very low. Additionally, the evidence was categorized into 5 levels based on classification criteria: I (convincing), II (highly suggestive), III (suggestive), IV (weak), and nonsignificant.

RESULTS

This umbrella review synthesized data from 14 meta-analyses published between 2019 and 2024, involving a total of 13,184 patients. In total, 7 meta-analyses received high Measurement Tool to Assess Systematic Reviews 2 ratings, 7 were rated moderate, and the remainder were rated low. VR demonstrated promising results in musculoskeletal rehabilitation, significantly reducing knee pain (mean difference [MD] -1.38, 95% CI -2.32 to -0.44; P=.004; I2=94%) and improving balance. For patients with fibromyalgia syndrome, VR effectively reduced pain (standardized mean difference [SMD] -0.45, 95% CI -0.70 to -0.20; P<.001), fatigue (SMD -0.58, 95% CI -1.01 to -0.14; P=.01), anxiety (SMD -0.50, 95% CI -0.908 to -0.029; P=.04), and depression (SMD -0.62, 95% CI -0.76 to -0.15; P=.003) while also enhancing quality of life. In individuals with back pain, VR alleviated pain-related fears (MD -5.46, 95% CI -9.40 to -1.52; P=.007; I2=90%) and reduced pain intensity (MD -1.43, 95% CI -1.86 to -1.00; P<.001; I2=95%). After arthroplasty, VR improved knee functionality (MD 8.30, 95% CI 6.92-9.67; P<.001; I2=24%) and decreased anxiety (MD -3.95, 95% CI -7.76 to -0.13; P=.04; I2=0%).

CONCLUSIONS

VR demonstrates significant potential in the rehabilitation of various musculoskeletal conditions. It effectively alleviates pain, enhances psychological well-being, and facilitates the recovery of motor function in patients.

TRIAL REGISTRATION

PROSPERO CRD42024538469; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024538469.

The application of metaverse in mental health

Rapid technological progress is reshaping human existence globally. The metaverse, a 3D digital realm merging virtual reality (VR) with physical space, exemplifies this fusion. Users can replicate and customize real-world elements within this immersive environment. Over the past decade, VR, augmented reality (AR), and mixed reality (MR) have become effective tools for addressing mental health conditions, offering solutions to the shortage of mental health professionals and limited access to care. However, extensive participation in 3D immersive gaming and social media can lead to insecurity, anxiety, depression, and addictive behaviors, particularly among young adults. This engagement may also impair attention spans, exacerbating symptoms in adolescents with attention deficit hyperactivity disorder. This research examines the impact of expanding metaverse applications on mental health, exploring both risks and benefits.

Do Extended Reality Interventions Benefit Patients Undergoing Elective Cardiac Surgical and Interventional Procedures? A Systematic Review and Meta-analysis

BACKGROUND

Extended reality (XR) interventions have the potential to benefit patients undergoing elective cardiac surgical and interventional procedures. However, there are no systematic reviews with meta-analyses to guide clinical care.

AIM

To critically evaluate the evidence on the effectiveness of XR interventions on patient anxiety and pain and other associated outcomes.

DESIGN

Systematic review and meta-analysis following the PRISMA 2020 statement.

DATA SOURCES

A systematic search of five databases (CENTRAL, CINAHL, MEDLINE, PsycInfo, Scopus) from inception to July 2023.

METHODS

Screening and data extraction was conducted independently by multiple reviewers. Stata (Version 17) was used to conduct meta-analyses for patient anxiety and pain. Secondary patient outcomes were summarised in a synthesis. The Cochrane Risk of Bias (Version 2) tool was applied to trials and the NHLBI Study Quality Assessment tools to all other study designs.

RESULTS

Of the 3372 records identified, 22 were included, 10 of which were eligible for inclusion in the meta-analyses. Fifty-seven percent of randomised trials were rated as high risk of bias. Virtual reality (VR) was the only XR technology evaluated. VR significantly reduced pre-procedural anxiety (standardised mean difference: -1.29; 95% confidence interval - 1.96, -0.62, p < 0.001), and peri-procedural anxiety (standardised mean difference: -0.50; 95% confidence interval - 0.83, -0.18, p < 0.003) but did not reduce pain levels, compared with usual care. VR increased pre-procedural knowledge and postsurgical physical and pulmonary function. VR interventions may also improve emotional wellbeing, care delivery and physiological outcomes, but evidence was inconsistent.

CONCLUSIONS

XR potentially benefits cardiac patients undergoing elective invasive procedures and surgery by reducing pre- and peri-procedural anxiety and increasing procedural knowledge and physical function.

RELEVANCE TO CLINICAL PRACTICE

Cardiac nurses' role can be supported by VR interventions to improve the patient experience and several aspects of patient care.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable as this is a systematic review.

Novel Insights into Addiction Management: A Meta-Analysis on Intervention for Relapse Prevention

Background and Objectives: Addiction and relapse prevention of alcohol and drug users is a real problem globally. Studies report different pharmacological and non-pharmacological methods in preventing relapse with varying ranges of results across the time of relapse. The study aims to identify novel insights into relapse prevention for high-risk alcohol and drug addiction across diverse global populations, ages, and intervention types during detoxification. Materials and Methods: This meta-analysis followed PRISMA guidelines, synthesizing 12 eligible studies published between 2013 and 2023, totaling 2162 participants. Data extraction and statistical analysis were conducted using Python-based libraries. Regression models were applied to examine the influence of age, gender, and intervention type on the mean relapse period. Results: 12 studies with 2162 patients were identified. These studies examined substances, interventions, and demographics, highlighting male predominance in addictive behaviors. OSL regression assessed factors influencing mean relapse periods, finding that age explained 44.2% of the variability (p = 0.0131). The male percentage explained 17.1%, but the significance was inconclusive, as was the female gender's negligible impact (14.7% variability). Intervention types significantly influenced relapse periods, supported by a large F-statistic. Linear regression showed no consistent trend in relapse periods, with declining research post-2018. Forest plots indicated disparities in relapse periods due to treatment or methodology. Most participants were high-risk drug users, though alcohol use was also represented. A declining trend in publication rates after 2018 was observed. Conclusions: Age and intervention type were identified as key factors influencing relapse duration, while gender and substance-specific effects require further study. The findings underscore the need for more targeted, gender-sensitive, and context-aware treatment strategies.

A glutamatergic innervation from medial area of secondary visual cortex to lateral posterior thalamic nucleus facilitates nociceptive and neuropathic pain

Neuropathic pain involves complex cortical mechanisms, yet the role of the medial secondary visual cortex (V2M) remains poorly understood. We hypothesized that glutamatergic neurons in V2M (V2MGlu) contribute to pain modulation and explored their functional involvement in both normal and neuropathic pain states. Here, we found that V2MGlu could be activated by peripheral stimulation under normal conditions. Optical inhibition or activation of unilateral V2MGlu respectively decreased or increased bilateral nociceptive sensitivity, with activation also inducing aversive emotions. Tracing experiments revealed that V2MGlu sends dense synaptic projections to the lateral posterior thalamic nucleus (LP) and lateral dorsal thalamic nucleus (LD). Notably, only optical manipulation of V2MGlu terminals in LP, rather than LD, affected bilateral pain perception. Following partial sciatic nerve ligation (PSL), V2MGlu exhibited hyperactivity, including increased spontaneous spike frequency and heightened responses to stimulation. Inhibiting V2MGlu alleviated PSL-induced mechanical allodynia, thermal hyperalgesia, and negative affective states related to pain. Inhibition of V2MGlu terminals in LP mitigated neuropathic pain. Here, we identified V2MGlu and its circuits to LP as part of the endogenous pain modulatory network, hyperactive after peripheral nerve injury and contributing to neuropathic pain. Our findings support targeting V2MGlu and related circuits as potential therapeutic strategies for neuropathic pain.

Virtual Reality Exposure for Treating PTSD Due to Military Sexual Trauma

Virtual reality exposure therapy (VRE) has been used in the treatment of combat-related PTSD since the late 1990s and was recently adapted to treat PTSD due to military sexual trauma (MST). With content specifically tailored to MST-related contexts, we present the case study of a military veteran who participated in the open clinical trial examining the feasibility of VRE in the treatment of MST-related PTSD (Loucks et al. 2019). We illustrate VRE's use in activating the trauma memory to facilitate therapeutic emotional processing across sessions and overall symptom reduction. The case study includes common challenges that may occur during VRE and relevant recommendations. The discussion will include lessons learned from the case study and the open clinical trial, recommendations for the flexible application of VRE, and the ongoing developments in the latest version of the VRE system, informed by feedback acquired from the clinicians and patients who experienced it in the initial clinical trial.

Extended Reality Analgesia Evidence Reviews Often Lack Sufficient Intervention Detail

Background

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

Method

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

Results

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

Conclusion

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

Clinical Efficacy of Bisphosphonates in Treating Osteoporosis in Diabetes Patients: A Meta-Analysis

The aim of the study was to explore the clinical efficacy of bisphosphonates in patients with osteoporosis in diabetes patients by meta-analysis. Six databases were systematically searched from inception to January 30,2023. Studies evaluating the treatment of diabetic osteoporosis with bisphosphonates were included. Key outcome measures, such as bone mineral density (BMD), bone metabolism markers, pain improvement, and safety assessments, were extracted and analyzed. STATA MP V17.0 was used to calculate the combined effect size. After searching Chinese and English databases, 15 studies met the inclusion criteria of this study. The results of the meta-analysis showed that the BMD of patients with osteoporosis in diabetes increased significantly after bisphosphonate treatment, and the lumbar BMD increased by 0.08 g/cm² (95% CI: 0.05-0.11). Femoral neck BMD increased by 0.06 g/cm² (95% CI: 0.01-0.11); Ward's triangle BMD increased 0.07 g/cm² (95% CI: 0.04-0.09); and trochanter BMD increased by 0.06 g/cm² (95% CI: 0.04-0.08). In addition, bone alkaline phosphatase increased 1.95 μg/l (95% CI: 1.18-2.72), while serum tartrate-resistant acid phosphatase-5b decreased 1.28 U/l (95% CI: -1.81-0.75). Moreover, improvements in pain were statistically significant. The effects of bisphosphonates on osteocalcin (MD: -0.07; 95% CI: -1.12-1.25), serum calcium (MD: 0.01; 95% CI: -0.03-0.04), serum phosphorus (MD: 0.04; 95% CI: -0.03-0.10) and medication safety (OR: 1.75; 95% CI: 1.29-2.37) were not statistically significant. Bisphosphonates have a significant positive effect on bone mineral density and bone metabolism in patients with osteoporosis in diabetes and have good safety.

The Role of Virtual Reality in the Management of Irritable Bowel Syndrome

PURPOSE OF REVIEW

Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction that significantly impacts health-related quality of life (HRQOL). This article explores the potential role of virtual reality (VR)-based cognitive behavioral therapy (CBT) in treating patients with IBS.

RECENT FINDINGS

While CBT is a proven, skills-based therapy approach that modifies behaviors and alters dysfunctional thinking patterns to influence the gut-brain axis and improve IBS symptoms, it is rarely prescribed given a paucity of CBT-trained clinicians. We developed a novel VR program that delivers a standardized CBT program over an 8-week period to help patients manage their symptoms. In initial qualitative validation testing, patients expressed positive perceptions about using VR CBT for IBS. Home-based, standardized VR CBT has the potential to be an effective and scalable treatment option for patients with IBS. While initial studies have shown proof-of-concept definitive randomized controlled trials are needed to demonstrate the efficacy of self-administered VR CBT in IBS.

The efficacy of socially assistive robots in improving children's pain and negative affectivity during needle-based invasive treatment: A systematic review and meta-analysis

BACKGROUND

The ability of socially assistive robots (SARs) to treat dementia and Alzheimer's disease has been verified. Currently, to increase the range of their application, there is an increasing amount of interest in using SARs to relieve pain and negative emotions among children in routine medical settings. However, there is little consensus regarding the use of these robots.

OBJECTIVE

This study aimed to evaluate the effect of SARs on pain and negative affectivity among children undergoing invasive needle-based procedures.

DESIGN

This study was a systematic review and meta-analysis of randomized controlled trials that was conducted in accordance with the Cochrane Handbook guidelines.

METHODS

The PubMed, CINAHL, Web of Science, Cochrane Library, Embase, CNKI, and WanFang databases were searched from inception to January 2024 to identify relevant randomized controlled trials (RCTs). We used the Cochrane Risk of Bias tool 2.0 (RoB2.0) to assess the risk of bias among the included studies, and we used RevMan 5.4 software to conduct the meta-analysis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used to assess the quality of the evidence.

RESULTS

Ten RCTs involving 815 pediatric subjects were selected for this review and reported outcomes related to pain and emotions during IV placement, port needle insertion, flu vaccination, blood sampling, and dental treatment. Children undergoing needle-related procedures with SARs reported less anxiety (SMD= -0.36; 95% CI= -0.64, -0.09) and fewer distressed avoidance behaviors (SMD= -0.67; 95% CI= -1.04, -0.30) than did those receiving typical care. There were nonsignificant differences between these groups in terms of in pain (SMD = -0.02; 95% CI = - 0.81, 0.78) and fear (SMD = 0.38; 95% CI= -0.06, 0.82). The results of exploratory subgroup analyses revealed no statistically significant differences based on the intervention type of robots or anesthetic use.

CONCLUSIONS

The use of SARs is a promising intervention method for alleviating anxiety and distress among children undergoing needle-related procedures. However, additional high-quality randomized controlled trials are needed to further validate these conclusions.

TRIAL REGISTRATION

The protocol of this study has been registered in the database PROSPERO (registration ID: CRD42023413279).

Analgesic Use of Virtual Reality for Burn Dressing Changes in Low- and Middle-income Countries: A Feasibility Study

Background

The paucity of pain management options in resource-limited settings is a significant and systemically unaddressed problem. To improve global health equity, it is important to bridge this gap in care without introducing the peril of opioid dependence. We present a proof-of-concept case series wherein virtual reality (VR) was successfully used to manage discomfort in patients undergoing burn dressing changes in sub-Saharan Africa.

Methods

Nine patients presenting with burn injuries of variable severity underwent routine stabilization and dressing as part of standard-of-care treatment. During dressing changes, a VR intervention consisting of the Dream Flight interactive game displayed on an Oculus Quest 2 headset was offered to patients. Patient mood scores were collected before VR initiation and at the conclusion of the dressing change by a translator using the Youth Feelings Scale.

Results

There were no adverse events associated with use of the VR headset and no patients elected to terminate the VR during their procedure. Patients and physicians subjectively reported satisfaction with the device's utility in the procedure. Before VR initiation, the 95% confidence interval for patient mood score was 4.89 ± 1.725. After VR initiation, the 95% confidence interval for patient mood score was 8.78 ± 1.40.

Conclusions

Our results of this proof-of-concept case series to suggest both feasibility of use and positive influence on patient discomfort and periprocedural satisfaction. We propose that VR should be explored as an analgesic alternative and/or adjunct to narcotics in resource-limited countries, particularly for high-pain, low-duration procedures.

Virtual Reality Combined with Mind-Body Therapies for the Management of Pain: A Scoping Review

When used separately, virtual reality (VR) and mind-body therapies (MBTs) have the potential to reduce pain across various acute and chronic conditions. While their combination is increasingly used, no study offers a consolidated presentation of VR and MBTs. This study aims to propose an overview of the effectiveness of VR combined with MBTs (i.e., meditation, mindfulness, relaxation, and hypnosis) to decrease the pain experienced by healthy volunteers or patients. We conducted a scoping review of the literature using PubMed, Science Direct and Google Scholar and included 43 studies. Findings across studies support that VR combined with MBTs is a feasible, well-tolerated, and potentially useful to reduce pain. Their combination also had a positive effect on anxiety, mood, and relaxation. However, insufficient research on this VR/MBTs combination and the lack of multidimensional studies impede a comprehensive understanding of their full potential. More randomized controlled studies are thus needed, with usability evaluation protocols to better understand the effects of VR/MBTs on patients wellbeing and to incorporate them into routine clinical practice.

Virtual reality-based analgesia: towards a novel framework for the biopsychosocial management of chronic pain

Virtual reality (VR) holds unmeasured potential as a multicomponent tool for managing chronic pain by adapting conventional in-person biopsychosocial pain management strategies into one virtual space. We review recent evidence showcasing the successful integration of cognitive behavioural therapy, mindfulness-based stress reduction, embodiment techniques, and physical therapy into VR environments, demonstrating positive outcomes in patients with chronic pain. We propose that future clinical and basic research build on this by integrating pain neuroscience techniques to help better understand pathophysiological pain mechanisms and treatment response. This could help facilitate early assessment and personalised treatment of chronic pain using a VR-based biopsychosocial approach.

Effects of virtual reality and nature sounds on pain and anxiety during hysterosalpingography: a randomized controlled trial

OBJECTIVE

The objective of this study was to determine the effects of listening to nature sounds alone and virtual reality plus listening to nature sounds on pain and anxiety in hysterosalpingography.

METHODS

This three-arm parallel randomized controlled trial included 135 (45 in each group) women who underwent hysterosalpingography in Turkey. The virtual reality+nature sounds group viewed a nature video with virtual reality glasses and listened to nature sounds during hysterosalpingography, whereas the nature sounds group only listened to nature sounds. The control group received only routine care.

RESULTS

During hysterosalpingography, women in virtual reality+nature sounds group experienced less pain than those in control group (p=0.009). After hysterosalpingography, pain levels were lower in both virtual reality+nature sounds group and nature sounds group than in control group (p=0.000 and p=0.000, respectively), anxiety levels were lower in virtual reality+nature sounds group than in nature sounds group and control group (p=0.018 and p=0.000, respectively), and anxiety levels were lower in nature sounds group than in control group (p=0.013).

CONCLUSION

Virtual reality with nature content plus listening to nature sounds and only listening to nature sounds are effective in reducing pain and anxiety related to hysterosalpingography procedures in women. Compared with only listening to nature sounds, virtual reality plus listening to nature sounds further reduced hysterosalpingography-related pain and anxiety.

Virtual Reality as a Pain Control Adjunct in Orthopedics: A Narrative Review

Orthopedic surgeons typically prescribe opioids for postoperative pain management as they are effective in managing pain. However, opioid use can lead to issues such as overdose, prescription excess, inadequate pain management, and addiction. Virtual reality (VR) therapy is an alternative route for postoperative pain management that has grown in popularity over the years. VR therapy involves immersing patients in a virtual 3D experience that is anticipated to alleviate pain. In this review article, we summarized the findings of numerous PubMed studies on the effectiveness of VR therapy for postoperative pain control. VR therapy is beneficial for reducing anxiety, pain, and opioid use after surgical procedures across various specialties. Further studies should explore VR therapy in orthopedic procedures.

The Effectiveness of Virtual and Augmented Reality in Surgical Pain Management: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Satisfactory management of postoperative pain remains challenging. Nonpharmacological modalities such as virtual and augmented reality (VR/AR) offer potential benefits and are becoming increasingly popular. This systematic review evaluates the effectiveness and safety of VR/AR interventions on postoperative pain and recovery.

METHODS

MEDLINE, Embase, CINAHL, Web of Science, and CENTRAL databases were searched from inception to July 27, 2023, for randomized controlled trials (RCTs), published in English, evaluating the use of VR/AR interventions for surgical pain relief. Study selection and data extraction were performed by pairs of reviewers independently and in duplicate, and potential risk of bias was determined using the Risk of Bias-version 2 (RoB 2) tool. Our outcomes included pain relief, reduction of anxiety, satisfaction, and adverse effects. Due to substantial heterogeneity, a narrative synthesis without meta-analysis was performed.

RESULTS

We included 35 trials among 2257 citations, categorized as surgery (n = 12), minor procedures (n = 15), and postoperative physiotherapy (n = 8). Surgical group included various surgeries, with 11 using immersive VR predominantly in the postoperative period, and most reporting no differences in pain, but potential for reduced anxiety and sedation requirements. In the minor procedures group, most studies reported decreased pain and anxiety during the procedural performance. Two studies reported increased heart rate, while 2 others reported better hemodynamic stability. Home-based AR physiotherapy achieved (n = 6) similar pain and functional outcomes after knee replacement, with 1 large study (n = 306) reporting reduction of mean costs by $2745 for provision of 12 weeks physiotherapy. There were some concerns around potential bias for most studies, as the nature of interventions make it challenging to blind assessors and participants. No important adverse effects were noted using VR/AR technology.

CONCLUSIONS

Evidence from RCTs indicates that the use of immersive VR during minor procedures may reduce procedural pain, decrease anxiety, and improve satisfaction. However, small studies, inconsistent effect, and variation in the application of interventions are important limitations. Evidence to support the application of AR/VR for major surgeries is limited and needs to be further investigated. Use of home-based physiotherapy with AR likely has economic advantages, and facilitates virtual care for appropriate patients who can access and use the technology safely.

The effectiveness of extended reality on relieving pain after total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Patients with total knee arthroplasty (TKA) often suffer from severe postoperative pain, which seriously hinders postoperative rehabilitation. Extended reality (XR), including virtual reality, augmented reality, and mixed reality, has been increasingly used to relieve pain after TKA. The purpose of this study was to evaluate the effectiveness of XR on relieving pain after TKA.

METHODS

The electronic databases including PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov were searched for studies from inception to July 20, 2023. The outcomes were pain score, anxiety score, and physiological parameters related to pain. Meta-analysis was performed using the Review Manager 5.4 software.

RESULTS

Overall, 11 randomized control trials (RCTs) with 887 patients were included. The pooled results showed XR had lower pain scores (SMD = - 0.31, 95% CI [- 0.46 to - 0.16], P < 0.0001) and anxiety scores (MD = - 3.95, 95% CI [- 7.76 to - 0.13], P = 0.04) than conventional methods. The subgroup analysis revealed XR had lower pain scores within 2 weeks postoperatively (SMD = - 0.49, 95% CI [- 0.76 to - 0.22], P = 0.0004) and XR had lower pain scores when applying XR combined with conventional methods (SMD = - 0.43, 95% CI [- 0.65 to - 0.20], P = 0.0002).

CONCLUSION

This systematic review and meta-analysis found applying XR could significantly reduce postoperative pain and anxiety after TKA. When XR was combined with conventional methods, postoperative pain can be effectively relieved, especially within 2 weeks after the operation. XR is an effective non-pharmacological analgesia scheme.

Effects of Virtual Reality on Pain, Anxiety, Patient Satisfaction in Coronary Angiography: A Randomized Trial

BACKGROUND

Since patients are conscious during the coronary angiography procedure, they may experience pain and anxiety regarding possible complications and an uncertain outcome.

AIM

This study was conducted to determine the effects of virtual reality application on pain severity, anxiety level, and patient satisfaction in patients who undergo coronary angiography.

METHOD

This randomized controlled study was conducted with a total of 70 patients, including 35 patients in the intervention and 35 patients in the control group. Apart from their routine treatment, virtual reality glasses application was used in the intervention group patients during the procedure. The patients in the control group were given only routine treatment. Data were collected by using "Descriptive Information Form", "Visual Analogue Scale (VAS)", Anxiety Assessment Scale (AAS), "Physiological Symptoms of Anxiety Follow-up Form", and "Virtual Reality Glass Application Satisfaction Form".

RESULTS

Mean post-intervention scores of VAS, AAS, heart rate, diastolic and systolic blood pressure, respiratory rate of the intervention group decreased significantly compared with the control group, while O2 saturation value was found to increase significantly.

CONCLUSIONS

In this study, it was found that virtual reality application was effective in reducing pain and anxiety, increasing patient satisfaction, and normative regulation of vital signs in patients who undergo coronary angiography.

A novel acupuncture technique at the Zusanli point based on virtual reality and EEG: a pilot study

Introduction

Acupuncture is a Traditional Chinese Medicine (TCM) method that achieves therapeutic effects through the interaction of neurotransmitters and neural regulation. It is generally carried out manually, making the related process expert-biased. Meanwhile, the neural stimulation effect of acupuncture is difficult to track objectively. In recent years, virtual reality (VR) in medicine has been on the fast lane to widespread use, especially in therapeutic stimulation. However, the use of related technologies in acupuncture has not been reported.

Methods

In this work, a novel acupuncture stimulation technique using VR is proposed. To track the stimulation effect, the electroencephalogram (EEG) is used as the marker to validate brain activities under acupuncture.

Results and discussion

After statistically analyzing the data of 24 subjects during acupuncture at the "Zusanli (ST36)" acupoint, it has been determined that Virtual Acupuncture (VA) has at least a 63.54% probability of inducing similar EEG activities as in Manual Acupuncture (MA). This work may provide a new solution for researchers and clinical practitioners using Brain-Computer Interface (BCI) in acupuncture.

Designing and developing a nature-based virtual reality with heart rate variability biofeedback for surgical anxiety and pain management: evidence from total knee arthroplasty patients

OBJECTIVES

Total knee arthroplasty (TKA) is one of the most common joint surgeries, with over a million procedures performed annually in the US. Over 70% of patients report moderate to high pain and anxiety surrounding TKA surgery, and 96% are discharged with an opioid prescription. This population requires special attention as approximately 90% of TKA patients are older adults and one of the riskiest groups prone to misusing opioids. This study aimed to develop and compare the efficacy of nature-based virtual reality (VR) with heart rate variability biofeedback (HRVBF) to mitigate surgical pain and anxiety.

METHODS

This randomized control trial recruited 30 patients (mean age = 66.3 ± 8.2 years, 23 F, 7 M) undergoing TKA surgery and randomly assigned to a control, 2D video with HRVBF, or VR with HRVBF group. A visual analog scale (VAS) was used to measure pain levels before and after the intervention. In addition, a second VAS and the State-Trait Anxiety Inventory (STAI) were used to measure anxiety before and after the intervention. Electrocardiogram (ECG) was used to continuously measure HRV and respiration rate in preoperative and postoperative settings.

RESULTS

VR and 2D-video with HRVBF decreased pain and anxiety post-intervention compared with the control group, p's <.01. On analyzing physiological signals, both treatment groups showed greater parasympathetic activity levels, and VR with HRVBF reduced pain more than the 2D video, p < .01.

CONCLUSIONS

Nature-based VR and 2D video with HRVBF can mitigate surgical pain and anxiety. However, VR may be more efficacious than 2D video in reducing pain.

Virtual reality as a non-medical tool in the treatment of anxiety, pain, and perception of time in children in the maintenance phase of acute lymphoblastic leukemia treatment

Introduction

Management of pediatric cancer patients involves invasive procedures such as punctures, injections, catheter placements, and chemotherapy which can generate fatigue, nausea, vomiting, anxiety, and pain. Virtual Reality (VR) is a nonpharmacological intervention classified as a cognitive-behavioral method to relieve symptoms.

Methods

We designed a crossover protocol and included 20 patients between 9 and 12 years old; ten were male. All patients had acute lymphoblastic leukemia diagnosis and were treatedwith St. Jude's XV protocol in the maintenance phase. Pain and anxiety were measured with validated scales in the pediatric population.

Results

Although we used a small group of patients, we found statistical difference in the reduction of anxiety and perception of time.

Discussion

These results open a window to non-pharmacological treatments and show a strategy to improve quality of life in children inside the hospital.

Gait patterns during overground and virtual omnidirectional treadmill walking

BACKGROUND

Omnidirectional treadmills (ODTs) offer a promising solution to the virtual reality (VR) locomotion problem, which describes the mismatch between visual and somatosensory information and contributes to VR sickness. However, little is known about how walking on ODTs impacts the biomechanics of gait. This project aimed to compare overground and ODT walking and turning in healthy young adults.

METHODS

Fifteen young adults completed forward walk, 180° turn, and 360° turn tasks under three conditions: (1) overground, (2) on the Infinadeck ODT in a virtual environment without a handrail, and (3) on the ODT with a handrail. Kinematic data for all walking trials were gathered using 3D optical motion capture.

RESULTS

Overall, gait speed was slower during ODT walking than overground. When controlling for gait speed, ODT walking resulted in shorter steps and greater variability in step length. There were no significant differences in other spatiotemporal metrics between ODT and overground walking. Turning on the ODT required more steps and slower rotational speeds than overground turns. The addition of the stability handrail to the ODT resulted in decreased gait variability relative to the ODT gait without the handrail.

CONCLUSION

Walking on an ODT resembles natural gait patterns apart from slower gait speed and shorter step length. Slower walking and shorter step length are likely due to the novelty of physically navigating a virtual environment which may result in a more conservative approach to gait. Future work will evaluate how older adults and those with neurological disease respond to ODT walking.

Transforming medicine: artificial intelligence integration in the peripheral nervous system

In recent years, artificial intelligence (AI) has undergone remarkable advancements, exerting a significant influence across a multitude of fields. One area that has particularly garnered attention and witnessed substantial progress is its integration into the realm of the nervous system. This article provides a comprehensive examination of AI's applications within the peripheral nervous system, with a specific focus on AI-enhanced diagnostics for peripheral nervous system disorders, AI-driven pain management, advancements in neuroprosthetics, and the development of neural network models. By illuminating these facets, we unveil the burgeoning opportunities for revolutionary medical interventions and the enhancement of human capabilities, thus paving the way for a future in which AI becomes an integral component of our nervous system's interface.

Virtual Reality Therapy for the Management of Chronic Spinal Pain: Systematic Review and Meta-Analysis

BACKGROUND

The effectiveness of virtual reality (VR) therapy in adults with chronic spinal pain (CSP) is unclear.

OBJECTIVE

This study was conducted to compare the effectiveness of VR therapy and other therapies in adults with CSP, especially patients with inflammation-related pain.

METHODS

PubMed, Web of Science, Cochrane Library, Embase, and CINAHL databases were searched up to November 11, 2023. Randomized controlled trials (RCTs) comparing adults with CSP receiving VR therapy with those receiving other therapies were included. The trial registration platform as well as the reference lists of included studies and previous systematic reviews and meta-analyses were manually searched. Two independent reviewers performed study selection, data extraction, risk-of-bias assessment, and evaluation of the quality of the evidence. The weighted mean difference (WMD) was used as the effect size used to synthesize the outcome measure.

RESULTS

In total, 16 RCTs involving 800 participants were included in this meta-analysis. The pooled data from 15 (94%) RCTs including 776 (97%) participants showed that VR therapy was superior in improving pain intensity (WMD=-1.63, 95% CI -2.11 to -1.16, P<.001, I2=90%) and reducing inflammatory markers, including C-reactive protein (WMD=-0.89, 95% CI -1.07 to -0.70, P<.001, I2=0%), tumor necrosis factor-alpha (WMD=-6.60, 95% CI -8.56 to -4.64, P<.001, I2=98%), and interleukin-6 (WMD=-2.76, 95% CI -2.98 to -2.53, P<.001, I2=0%). However, no significant differences were found in terms of the spinal range of motion (ROM), disability level, or fear of movement. In addition, 10 (63%) of the included RCTs had a high risk of bias.

CONCLUSIONS

VR therapy may be an effective and safe intervention for reducing symptoms in patients with CSP, as it is shown to exert significant analgesic effects and beneficial improvements in inflammatory factor levels. However, this approach may not have significant effects on the spinal ROM, disability level, or fear of movement. Notably, the quality of the evidence from the RCTs included in this study ranged from moderate to low. Therefore, we recommend that readers interpret the results of this study with caution.

TRIAL REGISTRATION

PROSPERO CRD42022382331; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=382331.

Effects of non-pharmacological interventions on pain in wound patients during dressing change: A systematic review

BACKGROUND

Changes to the wound dressing frequently cause pain. Some adverse side effects of pharmacologic pain management may cause problems or even impede wound healing. There is no systematic study of non-pharmacologic therapies for pain during wound dressing changes, despite the gradual promotion of non-pharmacologic pain reduction methods.

OBJECTIVES

To give clinical wound pain management a new direction, locating and assessing non-pharmacological interventions regarding pain brought on by wound dressing changes are necessary.

METHOD

The researchers conducted a comprehensive literature review on non-pharmacological interventions for pain during wound dressing changes across five databases: PubMed, Web of Science, Medline, Embase, and the Cochrane Library spanning the period from January 2010 to September 2022. The evaluation of literature and data extraction was carried out independently by two researchers, and in cases of disagreement, a third researcher participated in the deliberation. To assess the risk of bias in the literature, the researchers utilised the Cochrane Handbook for Reviews of Interventions, version 5.1.0.

RESULTS

In total, 951 people were involved in 11 investigations covering seven non-pharmacological therapies. For pain triggered by dressing changes, virtual reality (VR) distraction, auditory and visual distractions, foot reflexology, religious and spiritual care, and guided imaging demonstrated partially positive effects, with hypnosis therapy and jaw relaxation perhaps having a weak effect.

CONCLUSION

The key to managing wounds is pain management. According to our review, there is some indication that non-pharmacologic interventions can help patients feel less discomfort when having their wound dressings changed. However, the evidence supporting this view is weak. It needs to be corroborated by future research studies with multicentre and large samples. To promote and use various non-pharmacologic interventions in the future, it is also necessary to build standardised and homogenised paths for their implementation.

Virtual reality's impact on children with type 1 diabetes: a proof-of-concept randomized cross-over trial on anxiety, pain, adherence, and glycemic control

AIMS

 Assess the effectiveness of virtual reality (VR) technology, in reducing pain and anxiety, and improving adherence and glycemic control among children with type 1 diabetes (T1D).

METHODS

Children with T1D, managed with continuous glucose monitoring and insulin pumps, were recruited for a randomized cross-over trial. Children were randomized to one of two interventions for diabetes management: group 1 used VR glasses first and group 2 listened to vocal-guided affective imagery first (audio). After 1 month, the interventions were crossed over. The outcome measures included pain and anxiety assessment, adherence, glycemic control, and patient-reported outcome measures (PROMs) of VR satisfaction and effectiveness.

RESULTS

 Forty children, mean age 11.4 ± 1.8 years, were participated. During the VR part, the monthly mean pain score compared to the baseline improved in both groups by 30% (p = 0.03). A 14% reduction in the state anxiety score was observed from baseline to 1 month in both groups (p = 0.009). Glycemic control measures including time in range, time above range, and glucose management indicator improved in both groups during VR part (p < 0.004 for all), compared to audio part. After one month, the patient-reported outcome measure (PROM) of satisfaction and effectiveness was sixfold higher after 1 month in group 1 compared to group 2 (p = 0.002). Adherence improved for both groups.

CONCLUSIONS

VR was shown to be effective in reducing pain and anxiety, improving adherence, PROM, and glycemic control among children with T1D. We suggest incorporating VR technology in pediatric diabetes clinics to facilitate and improve coping and management of diabetes.

TRIAL REGISTRATION

Trial registration number and date of registration for prospectively registered trials:ClinicalTrials.gov Identifier: NCT05883267, May 10th, 2023.

Using functional near-infrared spectroscopy to study effects of virtual reality intervention for adolescents with depression in a clinical setting in China: study protocol for a prospective, randomised, controlled trial

INTRODUCTION

Adolescent depression has been shown to be associated with many devastating psychosocial outcomes. However, there are many barriers that may prevent depressed individuals from receiving specialised treatment. Virtual reality (VR) technology has shown promise as one avenue for overcoming these challenges. This study first aims to evaluate the effectiveness of VR intervention on adolescent depression symptoms, and second, to determine the intervention's underlying mechanism of effect using functional near-infrared spectroscopy (fNIRS).

METHODS AND ANALYSIS

This is a single-centre, prospective, randomised controlled clinical trial. Sixty-six eligible adolescents aged 12-18 years with a diagnosis of depression will be randomised in a 1:1 ratio to either the VR treatment group or the conventional treatment group. All patients for both groups will receive usual treatment during a 4-week intervention period. In addition, patients randomised to VR treatment group (n=33) will complete three 20 min VR sessions including attention, executive function and relaxation training per week. Moreover, 33 healthy adolescents will be recruited as the general population. Primary outcome (ie, depressive symptoms) and secondary outcomes (ie, anxiety symptoms, executive function, treatment emergent symptoms, haemoglobin changes measured by fNIRS) will be collected at preintervention, immediately postintervention and at 4 weeks follow-up. The data assessor and analyst will be blinded to group membership.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Ethics Committee of Lishui Second People's Hospital. Written informed consent will be obtained for all participants. Results will be disseminated through peer-reviewed journals, national or international conference presentations, media outlets, the internet and various community activities.

TRIAL REGISTRATION NUMBER

ChiCTR2300067747.

A systematic review and meta-analysis of randomized controlled trials on the effectiveness of immersive virtual reality in cancer patients receiving chemotherapy

PURPOSE

Immersive virtual reality (IVR) shows promise in cancer care, especially for chemotherapy patients. This systematic review and meta-analysis assesses IVR's impact on adult and pediatric cancer patients undergoing chemotherapy.

METHODS

We searched PubMed, Cochrane Library, Embase, Scopus, Web of Science, and Google Scholar for relevant randomized controlled trials (RCTs). We focused on anxiety, depression, fatigue, pain, and anxiety in adults and pain and anxiety in pediatric patients.

RESULTS

Fifteen trials were included, enrolling 607 adult and 257 pediatric cancer patients. IVR significantly reduced anxiety (SMD = -1.89, 95% CI = -2.93 to -0.85), depression (SMD = -1.85, 95% CI = -3.14 to -0.55), fatigue (SMD = -3.40, 95% CI = -5.54 to -1.26), and systolic blood pressure (MD = -3.54, 95% CI = -6.67 to -0.40) in adults. In pediatric patients, IVR significantly lowered pain (SMD = -1.17, 95% CI = -1.84 to -0.50) and anxiety (SMD = -1.18, 95% CI = -1.77 to -0.59) but not heart rate (MD = 0.48, 95% CI = -2.38 to 3.34).

CONCLUSION

IVR effectively reduces anxiety, depression, fatigue, systolic blood pressure, pain, and anxiety in cancer patients. More robust RCTs are needed for further IVR research.

Use of Virtual Reality in Interdisciplinary Multimodal Pain Treatment With Insights From Health Care Professionals and Patients: Action Research Study

BACKGROUND

Chronic pain is a widespread global health problem. Interdisciplinary multimodal pain treatment (IMPT) is a treatment option for people with chronic pain. Virtual reality (VR) could be used to broaden IMPT programs. However, despite the advantages of VR, it is rarely used in daily clinical practice.

OBJECTIVE

This research aimed to explore how, when, and with whom VR can be used meaningfully during IMPT, either as an addition or substitution as a component of IMPT.

METHODS

This research used an action research design to help health care professionals and patients learn how, when, and with whom they can use VR. Data were collected through reflection sessions with health care professionals and semistructured interviews with patients in 2 specialized centers that provide IMPT for chronic pain. Two researchers performed direct content analyses.

RESULTS

In total, 4 physiotherapists, 1 occupational therapist, 3 psychologists, and 22 patients participated in this research. Three iteration cycles, including 9 reflection sessions and 8 semistructured interviews, were performed. Both health care professionals and patients considered VR to be useful in therapy as an addition but not a substitution. VR was used as a diagnostic and intervention tool with all patients at the rehabilitation center or home. VR was used to gain insight into patients' pain beliefs, cognitions, and irrational cognitions about additional damage and physical abilities. Considering VR as an intervention tool, the health care professionals had 3 goals: balancing relaxation and competition, grading activities, and exposure in vivo.

CONCLUSIONS

VR could be a valuable addition to IMPT for both patients with chronic pain and health care professionals. More research should be performed to assess the additional effects of VR on patients' participation in daily life.

Patients' Use of Virtual Reality Technology for Pain Reduction during Outpatient Hysteroscopy: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To summarize evidence from randomized controlled trials (RCTs) on the effectiveness of virtual reality technology (VRT), as used by patients, for reducing pain during outpatient hysteroscopy.

DATA SOURCES

Electronic databases and clinical registers were searched until June 21, 2023. The review protocol was registered in PROSPERO before the data extraction (CRD42023434340).

METHODS OF STUDY SELECTION

We included RCTs of patients receiving VRT compared with controls receiving routine care during outpatient hysteroscopy.

TABULATION, INTEGRATION, AND RESULTS

The primary outcome was average pain during hysteroscopy. Pooled results were expressed as mean differences (MDs) with 95% confidence interval (CI). Sources of heterogeneity were investigated through sensitivity and subgroups analysis. Five RCTs were included (435 participants). The comparison between the intervention and control groups showed a borderline difference in perceived pain during hysteroscopy (MD -0.88, 95% CI -1.77 to 0.01). Subgroup analysis based on the type of VRT (active or passive) indicated that active VRT potentially reduced the perception of pain (MD -1.42, 95% CI -2.21 to -0.62), whereas passive VRT had no effect (MD -0.06, 95% CI -1.15 to 1.03).

CONCLUSION

Patients' use of active VRT may be associated with a reduction in pain during outpatient hysteroscopy (evidence Grading of Recommendations Assessment, Development, and Evaluation 2/4). Future research should focus on conducting methodologically robust studies with larger sample sizes and more homogeneous populations.

Beyond the Pain: A Systematic Narrative Review of the Latest Advancements in Fibromyalgia Treatment

Fibromyalgia is a complex chronic pain disorder that significantly impacts the quality of life of affected individuals. The etiology of fibromyalgia remains elusive, necessitating effective treatment options. This review aims to provide an overview of current treatment options for fibromyalgia and highlight recent updates in managing the condition. The methodology employed in this systematic review comprised the following key steps. We conducted a comprehensive search across various databases to identify pertinent studies published between 2000 and 2023. Inclusion criteria were defined to specifically target studies involving adult individuals diagnosed with fibromyalgia, with a focus on both pharmacological and non-pharmacological interventions for managing the condition. The review encompassed a range of study types, including randomized controlled trials, observational studies, and systematic reviews. To ensure the quality of the selected studies, we employed appropriate assessment tools, and data extraction and synthesis adhered to established guidelines. This rigorous approach allowed for a robust analysis of the literature on fibromyalgia management. In the course of our review, it became evident that a spectrum of treatment approaches holds significant promise in the management of fibromyalgia. Specifically, pharmacological interventions, including selective serotonin-norepinephrine reuptake inhibitors, anticonvulsants, cannabinoids, tropisetron, and sodium oxybate, have exhibited substantial potential in alleviating fibromyalgia symptoms. Concurrently, non-pharmacological strategies, such as cognitive-behavioral therapy, exercise regimens, and complementary and alternative therapies, have yielded positive outcomes in improving the condition's management. Recent developments in the field have introduced innovative pharmacological agents like milnacipran and pregabalin, in addition to non-pharmacological interventions like mindfulness-based stress reduction and aquatic exercise, expanding the array of options available to enhance fibromyalgia care and alleviating patient symptoms. Fibromyalgia necessitates a multidisciplinary approach to treatment, encompassing both pharmacological and non-pharmacological interventions. Recent updates in fibromyalgia management offer additional options to alleviate symptoms and improve the quality of life for individuals with fibromyalgia. Healthcare professionals should remain informed about these advancements to provide evidence-based care, addressing the complex symptoms associated with fibromyalgia and enhancing patient outcomes.

Effect modifiers of virtual reality in pain management: a systematic review and meta-regression analysis

ABSTRACT

There is a rapidly growing body of evidence for the application of virtual reality (VR) in pain management, however, with varying effectiveness. Little is known about patient-related and VR-related factors affecting efficacy of VR. A systematic review and meta-analysis was performed including 122 randomised controlled trials (9138 patients), reporting on subjectively reported pain scores comparing an immersive VR intervention to a non-VR control group. Virtual reality significantly reduced pain in the pooled analysis (standardized mean difference = -0.65, 95% CI -0.76 to -0.54, P < 0.001). Subgroup analyses showed no significant differences between type of pain, ie, VR effects were similar in acute, chronic, and procedural pain conditions. Univariate and multivariate meta-regression analyses were performed to investigate the effect of intervention, patient, and pain characteristics on VR. Virtual reality effectively reduced pain, especially in patients reporting moderate to severe pain and in younger subjects. Studies comparing VR with a control group receiving no distraction methods were associated with higher effect sizes. The effect of VR was not related to a specific frequency or duration of use. Type of software and interaction level were related to VR effects in the univariable, but not in the multivariable, meta-regression analysis. Heterogeneity was considerable for all meta-analyses, and risk of bias was moderate to high in most included studies. Studies on mechanisms behind VR analgesia in younger patients and patients reporting moderate to severe pain are recommended to confirm our hypotheses while taking into account risk of bias and the comparator. Optimal application of VR using treatment modules for long-term pain conditions are an important issue for future research.

Efficacy of smartphone-based virtual reality relaxation in providing comfort to patients with cancer undergoing chemotherapy in oncology outpatient setting in Indonesia: protocol for a randomised controlled trial

INTRODUCTION

Patients with cancer undergoing chemotherapy experience various physical and psychological problems and discomfort. Virtual reality (VR) can be used in technology-based non-pharmacological therapy that can serve as a potential distractor in the symptom management of patients with cancer undergoing chemotherapy. We propose a smartphone-based virtual reality relaxation (S-VR) technique as a complementary modality to provide comfort to patients with cancer, and we will evaluate its effect on patients with cancer undergoing chemotherapy.

METHODS AND ANALYSIS

We will recruit 80 patients from the One Day Chemotherapy 'Tulip' Center of Dr. Sardjito General Hospital, Yogyakarta, Indonesia. This will be a two-arm parallel randomised controlled trial, with a 1:1 allocation and the primary outcome assessor blinded. This study will be divided into two groups: (1) an intervention group, with participants receiving 360° panoramic video content and music relaxation intervention through a VR device (head-mounted display) placed on their head during chemotherapy for ±10 min plus standard care and (2) a control group, with participants receiving guided imagery relaxation therapy in the form of a leaflet plus standard care. We will measure the outcomes after one chemotherapy cycle for each participant. The primary outcome is the effectiveness of the S-VR in improving the comfort of patients. The secondary outcome is the effect of the S-VR on the patients' symptom management self-efficacy, pain, anxiety, blood pressure (systolic blood pressure and diastolic blood pressure) and pulse rate.

ETHICS AND DISSEMINATION

This study was approved by the Medical and Health Research Ethics Committee of the Faculty of Medicine, Public Health and Nursing of Universitas Gadjah Mada-Dr. Sardjito General Hospital, Yogyakarta, Institutional Review Board (approval number: KE/FK/0301/EC/2023). Written informed consent will be obtained from all participants who enrol in the study. Dissemination will be conducted through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05756465.

Cancer Pain Management: A Narrative Review of Current Concepts, Strategies, and Techniques

Pain is frequently reported during cancer disease, and it still remains poorly controlled in 40% of patients. Recent developments in oncology have helped to better control pain. Targeted treatments may cure cancer disease and significantly increase survival. Therefore, a novel population of patients (cancer survivors) has emerged, also enduring chronic pain (27.6% moderate to severe pain). The present review discusses the different options currently available to manage pain in (former) cancer patients in light of progress made in the last decade. Major progress in the field includes the recent development of a chronic cancer pain taxonomy now included in the International Classification of Diseases (ICD-11) and the update of the WHO analgesic ladder. Until recently, cancer pain management has mostly relied on pharmacotherapy, with opioids being considered as the mainstay. The opioids crisis has prompted the reassessment of opioids use in cancer patients and survivors. This review focuses on the current utilization of opioids, the neuropathic pain component often neglected, and the techniques and non-pharmacological strategies available which help to personalize patient treatment. Cancer pain management is now closer to the management of chronic non-cancer pain, i.e., "an integrative and supportive pain care" aiming to improve patient's quality of life.

Virtual reality for pain management: an umbrella review

Background and objective

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

Methods

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

Results

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

Discussion and conclusions

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

Effect of Virtual Reality on Pediatric Pain and Fear During Procedures Involving Needles: Systematic Review and Meta-analysis

BACKGROUND

Virtual reality (VR) is used as a distraction measure during painful clinical procedures associated with the use of needles. These procedures include vaccinations, blood draws, or the administration of medications, which can cause children to feel increased levels of pain and fear.

OBJECTIVE

The objective of this study was to collect and analyze the current evidence regarding the effectiveness of VR as a tool to distract children from pain and fear during needle procedures as compared to that of standard techniques.

METHODS

A systematic review and meta-analysis was performed. We included randomized clinical trials (RCTs) or quasi-RCTs with participants younger than 21 years who underwent needle procedures in which the main distraction measure used was VR and where the main outcome measure was pain. The databases searched included the PubMed, Web of Science, Scopus, PsycINFO, CINAHL, and Cochrane libraries. In this systematic review, the studies were analyzed by applying the Critical Appraisal Skills Program guide in Spanish and the Jadad scale. In the meta-analysis, the effect size of the studies was analyzed based on the results for pain and fear in children.

RESULTS

From 665 unique search results, 21 studies were included in this systematic review, most of which reported low methodological quality. The study sample cohorts ranged from a minimum of 15 participants to a maximum of 220 participants. Ten studies were included in the meta-analysis. The global effect of using VR as a distraction measure was a significant reduction in pain (inverse variance [IV] -2.37, 95% CI -3.20 to -1.54; Z=5.58; P<.001) and fear (IV -1.26, 95% CI -1.89 to -0.63; Z=3.92; P<.001) in children in the experimental groups.

CONCLUSIONS

The quality of the studies was mostly low. The main limitations were the impossibility of blinding the participants and health care personnel to the VR intervention. Nonetheless, the use of VR as a distraction measure was effective in reducing pain and fear in children during procedures involving needles.

Effect of the Application of Virtual Reality on Pain Reduction and Cerebral Blood Flow in Robot-Assisted Gait Training in Burn Patients

Burn injuries and their treatment are extremely painful. This study aimed to determine whether virtual reality (VR) could reduce pain during robot-assisted gait training (RAGT) in burn patients by analyzing the cerebral blood flow (CBF) in the prefrontal cortex over time using functional near-infrared spectroscopy (fNIRS). The patients included in this study complained of a pain score ≥5 on a visual analog scale (VAS) during RAGT, which was performed 10 times for 2 weeks. Each session consisted of 15 min of VR application, with a 2-min break, and 15 min without VR. The average values of oxyhemoglobin and deoxyhemoglobin concentrations in the prefrontal cortex on fNIRS were calculated at four stages: temporal delay time with only RAGT, RAGT without VR, temporal delay time with RAGT and VR, and RAGT with VR. The pain scores and CBF were evaluated in sessions 1, 5, and 10 of the RAGT. The mean VAS pain scores were significantly lower (p < 0.05) in the experimental condition than in the control condition. Oxyhemoglobin in the prefrontal lobe significantly increased when RAGT was performed with VR. In conclusion, VR may be a strong nonpharmacological pain reduction technique for burn patients during physical therapy.

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.

Efficacy of Listening to Music on Pain Reduction during Colposcopy-Directed Cervical Biopsy: A Randomized, Controlled Trial

Background and Objective: To investigate the efficacy of listening to music on pain reduction during colposcopy-directed cervical biopsy (CDB). Materials and Methods: From June 2020 to November 2021, 240 women undergoing CDB were enrolled. The participants were randomized into three groups: Group 1, colposcopic examination while wearing headphones and listening to music; Group 2, colposcopy while wearing headphones but not listening to music; Group 3 (control group), colposcopy while neither listening to music nor wearing headphones. All participating women completed a 10 cm visual analog scale for subjective pain at three time points: baseline, immediately after cervical biopsy, and 15 min after the procedure. The primary endpoint was the biopsy pain score. Result: Of the 240 women, a sample size of 80 was randomly assigned per group. The clinical–pathological and procedure-related characteristics of the participants in all groups were similar. The mean baseline pain score between each group was not significantly different (2.83 in the music group, 2.54 in group 2, and 2.94 in the control group, p = 0.47). There were no significant differences between each group in terms of mean biopsy pain score (4.21 in the music group, 4.24 in group 2, and 4.30 in the control group, p = 0.98). The differences in changes between the baseline pain score and the biopsy pain score were not statistically significant (1.39 in the music group, 1.70 in group 2, and 1.36 in the control group, p = 0.69). In the multiple comparison analysis, the differences in changes between the biopsy pain score and the baseline pain score between each group were also not statistically significant. There were no complications with the intervention observed. Conclusion: This study demonstrated that there was no beneficial effect of listening to music on pain reduction during colposcopy-directed cervical biopsies.