How effective is virtual reality technology in palliative care? A systematic review and meta-analysis

Extended Reality Head-Mounted Displays Are Likely to Pose a Significant Risk in Medical Settings While Current Classification Remains as Non-Critical

Extended reality (XR) devices, including virtual and augmented reality head-mounted displays (HMDs), are increasingly utilised within healthcare to provide clinical interventions and education. Currently, XR devices are utilised to assist in reducing pain and improving psychological outcomes for immunocompromised patients in intensive care units, palliative care environments and surgical theatres. However, there is a paucity of research on the risks of infection from such devices in healthcare settings. Identify existing literature providing insights into the infection control risk XR HMDs pose within healthcare facilities and the efficacy of current infection control and cleaning procedures. Three databases (PubMed, Embase and CINAHL) in addition to Google Scholar were systematically searched. A total of seven studies were identified for this review. Microorganisms, including pathogenic bacteria (e.g., Staphylococcus aureus and Pseudomonas aeruginosa), were found to be present on XR HMDs. Published cleaning and infection control protocols designed to disinfect XR HMDs and protect users were heterogeneous in nature. Current cleaning protocols displayed varying levels of efficacy with microbial load affected by multiple factors, including time in use, number of users and XR HMD design features. In healthcare settings, fitting XR HMDs harbouring microorganisms near biological and mucosal entry points presents an infection control risk. An urgent revision of the Spaulding classification is required to ensure flexibility that allows for these devices to be reclassified from 'Non-critical' to 'Semi-Critical' depending on the healthcare setting and patient population (surgery, immunocompromised, burns, etc.). This review identified evidence supporting the presence of microorganisms on XR HMDs. Due to the potential for HMDs to contact mucosal entry points, devices must be re-considered within the Spaulding classification as 'Semi-critical'. The existence of microbial contaminated XR HMDs in high-risk medical settings such as operating wards, intensive care units, emergency departments, labour and delivery wards and clinical areas with immunosuppressed patients requires urgent attention. Public health authorities have a duty of care to develop revised guidelines or new recommendations to ensure efficient sanitation of such devices.

Immersive virtual reality and psychological well-being in adult chronic physical illness: systematic review

INTRODUCTION

Individuals with chronic physical illness are at increased risk of negative psychological sequelae. Immersive virtual reality (VR) is an emerging treatment that might reduce these negative effects and increase quality of life in individuals with chronic physical illness.

OBJECTIVE

To systematically review literature examining the use of immersive VR in adult populations with chronic physical illness to understand: (1) how immersive VR is used to improve psychological well-being of adults with chronic physical illness (2) what effect this immersive VR has on the psychological well-being of adults with chronic physical illness.

DESIGN

Systematic literature review and meta-analysis. Searches of Ovid Medline/PubMed, PsycINFO, Embase, Web of Science and Scopus between July 1993 and March 2023 inclusive.

RESULTS

12 811 texts were identified; 31 met the inclusion criteria. Relaxing and engaging immersive VR interventions were shown to be acceptable and feasible among adults with cancer, dementia, cardiovascular disease, kidney disease and multiple sclerosis. Many of the studies reviewed were feasibility or pilot studies and so the evidence about effectiveness is more limited. The evidence, mostly from studies of people with cancer, suggests that immersive VR can have a positive effects on anticipatory anxiety symptoms and pain.

CONCLUSIONS

Environment-based and game-based relaxing immersive VR offer novel interventions, with beneficial effects among people with cancer and, potentially, beneficial effects in those with other long-term physical illness.

Personalised virtual reality in palliative care: clinically meaningful symptom improvement for some

OBJECTIVES

This study examined the effects of virtual reality (VR) among palliative care patients at an acute ward. Objectives included evaluating VR therapy benefits across three sessions, assessing its differential impact on emotional versus physical symptoms and determining the proportion of patients experiencing clinically meaningful improvements after each session.

METHODS

A mixed-methods design was employed. Sixteen palliative inpatients completed three personalised 20 min VR sessions. Symptom burden was assessed using the Edmonton Symptom Assessment Scale-Revised and quality of life with the Functional Assessment of Chronic Illness Therapy (FACIT-Pal-14). Standardised criteria assessed clinically meaningful changes. Quantitative data were analysed using linear mixed models.

RESULTS

Quality of life improved significantly pre-VR to post-VR with a large effect size (Cohen's d: 0.98). Total symptom burden decreased after 20 min VR sessions (Cohen's d: 0.75), with similar effect sizes for emotional (Cohen's d: 0.67) and physical symptoms (Cohen's d: 0.63). Over 50% of patients experienced clinically meaningful improvements per session, though substantial individual variability occurred.

CONCLUSIONS

This study reveals the nuanced efficacy of personalised VR therapy in palliative care, with over half of the patients experiencing meaningful benefits in emotional and physical symptoms. The marked variability in responses underscores the need for realistic expectations when implementing VR therapy.

A Rapid Review of the Role of Virtual Reality in Care Delivery of Palliative Care and Hospice

Virtual reality (VR) is an emerging technology that can provide a nonpharmacological approach to symptom management for those with serious illnesses. The VR platform offers a unique perspective to connect patients with places and experiences they might otherwise miss. This rapid review aims to present the current literature on the uses and benefits of VR for palliative care and hospice patients. Through a systematic process, we identified 14 articles published between 2018 and 2023 that used VR as an interventional strategy for symptom management. The VR equipment includes a head-mounted display, such as the Oculus Go, and sometimes requires hand controllers or joysticks. Virtual reality software was contained exclusively in the head-mounted displays or required a laptop. Nature scenes, memorable locations, and the solar system are examples of options patients could select for the VR experience. Assessments of the intervention were measured before, during, after, and several hours afterward to evaluate benefits and potential adverse effects. Pain was the predominant symptom assessed in the studies. Overall, most of the studies focused on establishing the safety, efficacy, and feasibility of VR using a single-arm interventional method. Future research should implement randomized controlled trials, increase sample size, and expand to pediatric populations.

Virtual Reality in Clinical Nursing Practice Over the Past 10 Years: Umbrella Review of Meta-Analyses

Background

Virtual reality (VR) has shown promising levels of effectiveness in nursing education, pain management, and rehabilitation. However, meta-analyses have discussed the effects of VR usage in nursing unilaterally and inconsistently, and the evidence base is diffuse and varied.

Objective

We aimed to synthesize the combined evidence from meta-analyses that assessed the effects of nurses using VR technology on nursing education or patient health outcomes.

Methods

We conducted an umbrella review by searching for meta-analyses about VR intervention in clinical nursing practice on Web of Science, Embase, Cochrane, and PubMed, and in reference lists. Eligible studies were published in English between December 1, 2012, and September 20, 2023. Meta-analyses of ≤2 intervention studies and meta-analyses without 95% CI or heterogeneity data were excluded. Characteristic indicators, population information, VR intervention information, and 95% CIs were extracted. A descriptive analysis of research results was conducted to discern relationships between VR interventions and outcomes. I2 and P values were used to evaluate publication bias. AMSTAR (A Measurement Tool to Assess Systematic Reviews) 2 and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) checklist were used to appraise literature quality.

Results

In total, 768 records were identified; 74 meta-analyses were included for review. The most reported VR study conditions were neuronursing (25/74, 34%), pediatric nursing (13/74, 18%), surgical and wound care (11/74, 15%), oncological nursing (11/74, 15%), and older adult nursing (10/74, 14%). Further, 30% (22/74) of meta-analyses reported publication bias, and 15% (11/74) and 8% (6/74) were rated as "high" based on AMSTAR 2 and the GRADE checklist, respectively. The main outcome indicators among all included meta-analyses were pain (37/214, 17.3%), anxiety (36/214, 16.8%), cognitive function (17/214, 7.9%), balance (16/214, 7.5%), depression (16/214, 7.5%), motor function (12/214, 5.6%), and participation in life (12/214, 5.6%). VR treatment for cognition, pain, anxiety, and depression was effective (all P values were <.05), while the utility of VR for improving motor function, balance, memory, and attention was controversial. Adverse effects included nausea, vomiting, and dizziness (incidence: range 4.76%-50%). The most common VR platforms were Pico VR glasses, head-mounted displays, the Nintendo Wii, and the Xbox Kinect. VR intervention duration ranged from 2 weeks to 12 months (typically ≥4 wk). VR session length and frequency ranged from 5 to 100 minutes and from 1 to 10 times per week, respectively.

Conclusions

VR in nursing has positive effects-relieving patients' pain, anxiety, and depression and improving cognitive function-despite the included studies' limited quality. However, applying VR in nursing to improve patients' motor function, balance, memory, and attention remains controversial. Nursing researchers need to further explore the effects and standard operation protocols of VR in clinical practice, and more high-quality research on VR in nursing is needed.

Integrating knowledge, skills, and attitudes: professional training required for virtual reality therapists in palliative care

Fully immersive virtual reality (VR) is an advanced technology increasingly studied and used in palliative care for symptom management. While the findings shed a positive light on its therapeutic potential, VR carries adverse effects, leading to ethical concerns. Based on the clinical experiences of a registered clinical psychologist who is also a certified thanatologist, we put forward a perspective on the importance of professional training for VR therapists in view of the possible risks posed by VR in palliative care. We propose professional trainings on knowledge, skills, and attitudes to ensure patients' safety while maximizing the therapeutic benefits of VR. Given the scarcity of reports on such an area, we hope this perspective article opens up discussions and contributes to current understanding and emerging future directions to ensure quality and ethical delivery of VR in palliative care.

Virtual Reality for Anxiety Reduction in Women Undergoing Colposcopy: A Randomized Controlled Trial

OBJECTIVE

To test whether headset-delivered virtual reality (VR) content affects satisfaction and/or anxiety in women with cervical squamous intraepithelial lesions undergoing colposcopy and colposcopically guided cervical biopsy.

METHODS

In this single-center, randomized trial, the authors measured overall satisfaction (100-mm visual analog scale) and situation-specific anxiety (STAI-S) in 247 women with suspected cervical squamous intraepithelial lesions wearing either no VR headset (arm 1, control) or a VR headset before (arm 2) or before and during colposcopy (arm 3). Secondary endpoints were pain, discomfort, and anxiety during colposcopy, heart rate, and 72-hour follow-up parameters: overall satisfaction, bleeding severity, bleeding duration, pain, and use of analgesics. Analysis was by intention to treat.

RESULTS

Median values for overall satisfaction were 100 (interquartile range, 90-100) in controls (n = 83), 100 (95-100) in arm 2 (n = 82), and 100 (95-100) in arm 3 (n = 82), respectively ( p = .92). The median Δ of situational anxiety (baseline vs after colposcopy) was -8 (-13 to -3), -8 (-16.5 to -4), and -10 (-20.5 to -4.5), respectively ( p = .09). The secondary endpoints pain during colposcopy (20 [10-50] vs 20 [10-40] vs 30 [10-50]; p = .65), discomfort during colposcopy (30 [10-50] vs 30 [10-50] vs 20 [10-50]; p = .46), and anxiety during colposcopy (20 [0-50] vs 10 [0-40] vs 10 [0-30]; p = .44), were not different between arms. Follow-up data showed no improvement in the 2 VR arms compared with controls (overall satisfaction, p = .37; bleeding severity, p = .09; pain level, p = .89; duration of pain; p = .23; and use of analgesics; p = .39). Per-protocol analysis did not change the results.

CONCLUSIONS

A VR headset showing a 360-degree surround vision film has no effect on satisfaction or anxiety in women undergoing colposcopy.

Positive Psychological Intervention Delivered Using Virtual Reality in Patients on Hemodialysis With Comorbid Depression: Protocol and Design for the Joviality Randomized Controlled Trial

BACKGROUND

Depression is highly prevalent in individuals on hemodialysis, but it is infrequently identified and remains undertreated. In this paper, we present details of the methodology of a randomized controlled trial (RCT) aimed at testing the feasibility and preliminary efficacy of a 5-week positive psychological intervention in individuals on hemodialysis with comorbid depression delivered using immersive virtual reality (VR) technology.

OBJECTIVE

We aim to describe the protocol and design of the Joviality trial whose main objectives are 2-fold: determine the feasibility of the Joviality VR software through metrics capturing rates of recruitment, refusal, retention, noncompliance, and adherence, as well as end-user feedback; and assess preliminary efficacy for outcomes measures of depressive symptoms, psychological well-being and distress, quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalizations.

METHODS

This 2-arm RCT is scheduled to enroll 84 individuals on hemodialysis with comorbid depression from multiple outpatient centers in Chicago, Illinois, United States. Enrollees will be randomized to the following groups: VR-based Joviality positive psychological intervention or sham VR (2D wildlife footage and nature-based settings with inert music presented using a head-mounted display). To be eligible, individuals must be on hemodialysis for at least 3 months, have Beck Depression Inventory-II scores of ≥11 (ie, indicative of mild-to-severe depressive symptoms), be aged ≥21 years, and be fluent in English or Spanish. The Joviality VR software was built using agile design principles and incorporates fully immersive content, digital avatars, and multiplex features of interactability. Targeted skills of the intervention include noticing positive events, positive reappraisal, gratitude, acts of kindness, and mindful or nonjudgmental awareness. The primary outcomes include metrics of feasibility and acceptability, along with preliminary efficacy focused on decreasing symptoms of depression. The secondary and tertiary outcomes include quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalization rates. There are 4 assessment time points: baseline, immediately after the intervention, 3 months after the intervention, and 6 months after the intervention. We hypothesize that depressive symptoms and hemodialysis-related markers of disease will substantially improve in participants randomized to the VR-based Joviality positive psychology treatment arm compared with those in the attention control condition.

RESULTS

This RCT is funded by the National Institute of Diabetes and Digestive and Kidney Diseases and is scheduled to commence participant recruitment in June 2023.

CONCLUSIONS

This trial will be the first to test custom-built VR software to deliver a positive psychological intervention, chairside, in individuals on hemodialysis to reduce symptoms of depression. Within the context of an RCT using an active control arm, if proven effective, VR technology may become a potent tool to deliver mental health programming in clinical populations during their outpatient treatment sessions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05642364; https://clinicaltrials.gov/ct2/show/NCT05642364.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45100.

A Review of Chronic Pain and Device Interventions: Benefits and Future Directions

Chronic pain is a debilitating condition with a growing prevalence both in the USA and globally. The complex nature of this condition necessitates a multimodal approach to pain management that extends beyond the established pharmaceutical interventions currently employed. A variety of devices comprising both invasive and noninvasive approaches are available to patients, serving as adjuvants to existing regimens. The benefits of these interventions are notable for their lack of addiction potential, potential for patient autonomy regarding self-administration, minimal to no drug interaction, and overall relative safety. However, there remains a need for further research and more robust clinical trials to assess the true efficacy of these interventions and elucidate if there is an underlying physiological mechanism to their benefit in treating chronic pain or if their effect is predominantly placebo in nature. Regardless, the field of device-based intervention and treatment remains an evolving field with much promise for the future chronic pain management.

Virtual reality use and patient outcomes in palliative care: A scoping review

Objective

Virtual reality is increasingly used in healthcare settings. Potentially, it's use in palliative carecould have a positive impact; however, there is limited evidence on the scope, purpose and patient outcomes relating to virtual reality use in this context. The objective of this scoping review is to chart the literature on virtual reality use in palliative care, identifying any evidence relating to biopsychosocial patient outcomes which could support its use in practice.

Methods

A scoping review of the literature, involving . a systematic search across 10 electronic bibliographic databases in December 2021, . Eligibility criteria were primary research studies, of any research designwithin a 10-year timeframe, which reported on virtual reality use and patient outcomes in palliative care. A total of 993 papers were identified, andcomprehensive screening resulted in 10 papers for inclusion.

Results

This scoping review identified 10 papers addressing virtual reality in palliative care, published within a three-year timeframe 2019-2021. Research methodologies included mixed methods, quantitative and qualitative. The evidence highlightsvirtual reality use with patients receiving palliative care in a variety of settings, and data around useability, feasibility and acceptability is positive. However, the evidence regarding biopsychosocial patient outcomes linked to virtual reality use is limited.

Conclusion

Virtual reality is gathering momentum in palliative care and is potentially a helpful intervention; however more research is needed to underpin the evidence base supporting its application, particularly in understanding the impact on biopsychosocial patient outcomes and ascertaining the best approach for measuring intervention effectiveness.