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

Equity implications of extended reality technologies for health and procedural anxiety: a systematic review and implementation-focused framework

OBJECTIVES

Extended reality (XR) applications are gaining support as a method of reducing anxieties about medical treatments and conditions; however, their impacts on health service inequalities remain underresearched. We therefore undertook a synthesis of evidence relating to the equity implications of these types of interventions.

MATERIALS AND METHODS

Searches of MEDLINE, Embase, APA PsycINFO, and Epistemonikos were conducted in May 2023 to identify reviews of patient-directed XR interventions for health and procedural anxiety. Equity-relevant data were extracted from records (n = 56) that met these criteria, and from individual trials (n = 63) evaluated within 5 priority reviews. Analyses deductively categorized data into salient situation- and technology-related mechanisms, which were then developed into a novel implementation-focused framework.

RESULTS

Analyses highlighted various mechanisms that impact on the availability, accessibility, and/or acceptability of services aiming to reduce patient health and procedural anxieties. On one hand, results showed that XR solutions offer unique opportunities for addressing health inequities, especially those concerning transport, cost, or mobility barriers. At the same time, however, these interventions can accelerate areas of inequity or even engender additional disparities.

DISCUSSION

Our "double jeopardy, common impact" framework outlines unique pathways through which XR could help address health disparities, but also accelerate or even generate inequity across different systems, communities, and individuals. This framework can be used to guide prospective interventions and assessments.

CONCLUSION

Despite growing positive assertions about XR's capabilities for managing patient anxieties, we emphasize the need for taking a cautious, inclusive approach to implementation in future programs.

To see or not to see: Does foot visualization in immersive virtual reality influence gait parameters of youths with neuromotor impairments when performing walking-related activities?

BACKGROUND

Immersive virtual reality (VR) experienced through a head-mounted display (HMD) offers the possibility to practice real-world situations in a safe and motivating way in pediatric neurorehabilitation. As the HMD blocks the view of the physical world, patients lack visual feedback of their body parts. Foot visualization in the virtual environment could inform patients about their feet's position during walking-related activities.

RESEARCH QUESTION

How does foot visualization affect spatial gait parameters of youths with neuromotor gait impairments during everyday walking tasks with an immersive VR-HMD?

METHODS

In this cross-sectional study, 15 youths with neuromotor gait impairments (mean age 12.3 years) performed four walking-related tasks wearing the VR-HMD Meta Quest 2. Walking through the virtual environment, they had to place their feet as accurately as possible on bollards, step over a plank, balance over a beam, and cross a gap. We used a Vicon motion capture system to assess spatial gait parameters when the participants could not see their feet and when a real-time virtual model of their feet was integrated into the virtual environment.

RESULTS

In the bollard task, foot visualization had a large positive effect (Hedges' g = 0.82) on the foot placement accuracy, with a reduction in deviation from the bollard center from 12.1 cm (IQR: 16 cm) to 6.5 cm (IQR: 5.1 cm) (p < 0.001). Further, the maximum step height of the leading foot when overstepping the plank decreased by 2.9 cm (g = 0.4, p = 0.05). Foot visualization did not influence the spatial gait parameters when balancing over a beam or crossing a gap.

SIGNIFICANCE

Pediatric patients who practice walking-related activities with an immersive VR-HMD can benefit from foot visualization, as it increases foot placement accuracy for certain tasks. However, technical solutions have to become simpler for the clinical implementation of foot visualization.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

A randomised controlled clinical trial.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

REPORTING METHOD

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

Effects of Virtual Reality on Pain, Anxiety and Fear Among Emergency Department Patients: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

To explore the effects of virtual reality (VR) interventions in reducing pain, anxiety, and fear in child and adult emergency departments (EDs).

DESIGN

A meta-analysis of randomized controlled trials.

DATA SOURCES

Articles were searched from PubMed, Embase, The Cochrane Library, and Web of Science (up to 18 October 2024).

METHODS

The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane Collaboration Risk of Bias Tool, and the Revman version 5.4 software was used to assess the risk of bias in the included studies. Two researchers independently screened eligible articles. The effects of VR on pain, anxiety, or fear in ED patients were estimated with a standardized mean difference (SMD) and 95% confidence interval (CI). Egger's test and the funnel plot were used to evaluate the publication bias. All data analysis was conducted utilizing STATA software version 18.0.

RESULTS

Sixteen randomized controlled trials (RCTs) involving 1449 participants were included. In this meta-analysis, VR reduced the severity of pain (SMD = -0.82; 95% CI: -1.11 to -0.53; p < .001), anxiety (SMD = -1.13; 95% CI: -1.74 to -0.52; p < .001), and fear (SMD = -0.82: 95% CI: -1.51 to -0.12; p = .022).

CONCLUSIONS

The results of this meta-analysis indicate that VR can effectively reduce pain, anxiety, and fear in ED patients. Therefore, VR shows promise as a valuable complementary pain, anxiety, and fear management intervention for ED patients.

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.

Influence of the Olfatín Project on the reduction of pain related to intranasal influenza vaccination, as part of a school influenza vaccination program

PURPOSE

To evaluate the influence of viewing the Olfatín Project video on the assessment of school LAIV-associated pain in three and four-year-old children through the Wong Baker Faces® pain classification scale.

DESIGN AND METHODS

A three-arm randomized multicenter clinical trial with a placebo control group was carried out. The main variable measured was pain, assessed through the score on the Wong Baker Faces® Pain Rating Scale. There were a total population of 4591 children three and four-year-olds (born in 2019 and 2020) and who attended the 1st and 2nd year of early childhood education. Before the school vaccination, researchers randomly assigned participant schools corresponding to each of the basic health areas to each of the three study groups: Olfatín's video viewing, a control video viewing not related to influenza and no video viewing.

RESULTS

No significant differences according to sex, age or the minor's grade according to the assigned intervention were detected. 72.3% of those vaccinated assigned a 0 from the Wong Baker Faces® scale: 75.4% of those who watched Olfatín's video, 68.3% for those in Drilo's group and 72.8% for those who didn't watch any video, but without significant differences (p = 0.08). There were no significant differences either stratifying by sex.

CONCLUSION

LAIV is a painless vaccine for children, which has to be taken into account by the health authorities when planning the pediatric influenza vaccination campaign.

PRACTICE IMPLICATIONS

Olfatín's cartoon video can be used by professionals to create a greater experience for children and therefore a better acceptance.

Technology versus nostalgia; A randomized controlled trial of the effect of virtual reality and kaleidescop on pediatric pain, fear and anxiety management during immunization

BACKGROUND

Routine vaccination procedures, while crucial for public health, can induce pain, fear, and anxiety in children. Distraction techniques such as virtual reality and kaleidoscope have been proposed to alleviate these negative experiences during vaccinations.

OBJECTIVE

This study aimed to compare the effectiveness of virtual reality and kaleidoscope as distraction methods in reducing pain, fear, and anxiety during routine vaccination in children aged 48 months.

DESIGN

This randomized controlled trial allocated children aged 48 months receiving the measles-mumps-rubella vaccine into three groups: virtual reality (n = 42), kaleidoscope (n = 42), and control (n = 42).

SETTING(S)

The study was conducted in a pediatric clinic.

PARTICIPANTS

The study included a total of 126 children aged 48 months.

METHODS

Pain and fear levels were assessed by both researchers and children before and after the vaccination procedure, while anxiety was evaluated by children after vaccination. Pain was measured using the Wong Baker Faces Pain Rating Scale, fear with the Children's Fear Scale, and anxiety with the Child Anxiety Scale-State Version.

RESULTS

Post-vaccination pain, fear, and anxiety scores were significantly lower in the kaleidoscope group compared to both the virtual reality and control groups (p < .05).

CONCLUSIONS

Using kaleidoscope during vaccination in 48-month-old children effectively reduced pain, fear, and anxiety. Integrating kaleidoscope as a distraction method during routine vaccination procedures may enhance the vaccination experience and potentially improve adherence to vaccination schedules.

REGISTRATION

Clinical trials number is NCT0611XXXX.

Virtual Reality Distraction for Needle-Related Pain and Distress in Children: A Multicenter Randomized Controlled Trial

This international multicenter randomized controlled trial aimed to compare the effectiveness of virtual reality (VR) distraction with an identical non-VR game in reducing needle-related pain and anxiety in children undergoing venous blood draw. The study involved 304 children aged 5-9 years undergoing a blood draw procedure, randomly allocated to one of three groups: VR distraction, non-VR distraction, and control group (usual care). The distraction task was based on the Multiple Object Tracking (MOT) paradigm, and the game was identical in design and gameplay for both VR and non-VR distraction groups. The primary outcome was self-reported pain intensity using the Faces Pain Scale-Revised (FPS-R). Secondary outcomes included child distress, attention/distraction to the blood draw, and parent and medical staff satisfaction with procedure. Analyses were conducted using analysis of variance and multivariable linear regression models. The results showed that VR distraction and non-VR distraction performed similarly, showing large effect sizes compared with standard care. There was no significant difference between the two types of distraction. The study's findings suggest that VR and non-VR distraction are similarly effective in reducing needle-related pain and anxiety in children undergoing venous blood draw. This is the first well-powered study comparing modern VR distraction with an identical task displayed on a smartphone or monitor screen. The study's results have important implications for using VR in clinical settings and suggest that investing in expensive VR equipment for acute pain management may not be necessary. The study protocol was pre-registered on Open Science Framework at https://osf.io/frsyc.

Virtual reality applications in pediatric surgery

Virtual reality modeling (VRM) is a 3-dimensional (3D) simulation. It is a powerful tool and has multiple uses and applications in pediatric surgery. Patient-specific 2-dimensional imaging can be used to generate a virtual reality model, which can improve anatomical perception and understanding, and can aid in preoperative planning for complex operations. VRM can also be used for realistic training and simulation. It has also proven effective in distraction for pediatric patients experiencing pain and/or anxiety. We detail the technical requirements and process required for VRM generation, the applications, and future directions.

An Exposure-Based Video Game (Dr. Zoo) to Reduce Needle Phobia in Children Aged 3 to 6 Years: Development and Mixed Methods Pilot Study

BACKGROUND

Needle phobia, which affects 19% of children aged 4 to 6 years, prevents many children from receiving necessary or preventive medical treatments. Digital interventions have been made to target needle phobia but currently rely on distraction rather than evidence-based exposure.

OBJECTIVE

We designed and evaluated a serious exposure-based mobile game called Dr. Zoo to reduce the fear of needles in children aged 3 to 6 years, where players administered shots to cartoon animals.

METHODS

We conducted a mixed methods study with 30 parents (mean age 35.87, SD 4.39 years) and their 36 children (mean age 4.44, SD 1.11 years) who played the game for 5 days leading to a scheduled appointment that included an injection (eg, influenza vaccination). After the study, parents completed exit surveys and participated in semistructured interviews to evaluate ease of use, acceptability, and preliminary effectiveness of the game and to provide insights on their experience with the game to inform future developments. Interview transcripts were analyzed by 3 independent coders following an open coding process and subsequently coded and discussed to reach consensus.

RESULTS

Parents rated their child's difficulty in completing the game as very low on average (scale 1-5; mean 1.76, SD 0.82) and were highly likely to recommend Dr. Zoo to other parents (scale 1-5; mean 4.41, SD 0.87), suggesting Dr. Zoo's strong ease of use and high acceptability. In the exit survey, parents rated their child's fear as significantly lower after participating in the study (scale 1-5; mean 3.09, SD 1.17) compared with that before participating (scale 1-5; mean 4.37, SD 0.81; z score=-4.638; P<.001). Furthermore, 74% (26/35) of the parents reported that the game had a positive impact on their child's fear or perception of needles (only 2 parents reported a negative impact). Qualitative analysis of the interview transcripts revealed potentially important features of the game in this positive impact, such as the game's interactive design, as observed in 69% (24/35) of our participants.

CONCLUSIONS

The results suggest that an evidence-based serious mobile game can be an easy-to-use, acceptable, and potentially effective intervention for changing young children's fear and perceptions of needles. Leveraging digital interventions may be a potential solution to needle anxiety as a public health concern.

Fathers' Experiences of Childhood Cancer: A Phenomenological Qualitative Study

Research has shown differences in how fathers and mothers respond to a child's cancer diagnosis. Previous studies have highlighted that sociocultural norm shape fathers' experiences of their child's cancer diagnosis. Our phenomenological qualitative study aimed to examine the lived experiences of fathers whose children have been diagnosed with cancer and explore the impact of sociocultural gender roles. Fathers whose children were currently receiving treatment or had completed treatment in the previous 15 months were recruited from across Australia. Twenty-one fathers were interviewed. Five themes were identified: (a) Your world falls apart: Diagnosis and treatment; (b) Care for the child: Just the way it is; (c) Keeping strong: Finding ways to cope; (d) Employment: Practical and emotional support at work; and (e) Guilt, relief, and grief: Facing death. This study demonstrates the profound impact of a child's diagnosis on fathers and demonstrates that societal-cultural norms influence fathers' experience of childhood cancer.

Development of a Virtual Reality Tool for the Treatment of Pediatric Patients in the ICU

Prolonged stays in the intensive care unit (ICU) cause difficulties in rehabilitation and other disorders for patients. This problem is exacerbated in the case of pediatric patients. The use of virtual reality can help with the lack of external stimuli and contribute as potential nonpharmacological therapies in some patient rehabilitation processes. To this end, we have developed a virtual reality application for use in the pediatric ICU as a tool for the treatment and rehabilitation of delirium. The tool consists of two applications: an immersive environment for a virtual reality headset used by the patient, and a web application managed by a therapist with which they can customize, control, adapt, and analyze in real time everything that happens in the patient's virtual world. Our application has been designed jointly with a university center and a hospital, and initial evaluations indicate the results to be promising.

Immersive and Non-Immersive Virtual Reality for Pain and Anxiety Management in Pediatric Patients with Hematological or Solid Cancer: A Systematic Review

Invasive and painful procedures, which often induce feelings of anxiety, are necessary components of pediatric cancer treatment, and adequate pain and anxiety management during these treatments is of pivotal importance. In this context, it is widely recognized that a holistic approach, including pharmacological and non-pharmacological modalities, such as distraction techniques, should be the standard of care. Recent evidence suggested the use of virtual reality (VR) as an effective non-pharmacological intervention in pediatrics. Therefore, this systematic review aims to analyze previously published studies on the effectiveness of VR for the management of pain and/or anxiety in children and adolescents with hematological or solid cancer. Medline, SCOPUS, Web of Science, ProQuest, CINAHL, and The Cochrane Central Register of Controlled Trials were used to search for relevant studies in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Randomized controlled trial, crossover trial, cluster randomized trial, and quasi-experimental studies were included. Thirteen studies, published between 1999 and 2022, that fulfilled the inclusion criteria were included. Regarding the primary outcomes measured, pain was considered in five studies, anxiety in three studies, and the remaining five studies analyzed the effectiveness of VR for both pain and anxiety reduction. Our findings suggested a beneficial effect of VR during painful vascular access procedures. Limited data are available on the reduction of anxiety in children with cancer.