Virtual Reality in Pediatric Pain Management

Virtual Reality: An Emerging Intervention for Pediatric Acute and Chronic Pain Management

By Charles K. Lee, Sam Rodriguez, MD, and Thomas Caruso, MD, MEd
Division of Pediatric Anesthesiology
Department of Anesthesiology, Perioperative, and Pain Medicine
Stanford University School of Medicine
Stanford, California

Introduction
Virtual Reality (VR) is a promising tool with many clinical applications. The utility of VR was once limited primarily to entertainment or laboratory-based research, but the technology has become sufficiently affordable, portable, and versatile for routine clinical use (1). Multiple clinician scientists have explored VR as a tool to ameliorate pain and anxiety (2, 3). In this article, we review evidence for the use of VR in pediatric acute and chronic pain management.

Periprocedural Acute Care with Virtual Reality 
Needle phobia among children is common, some estimating it to be as high as 63% (4). Chan et al. conducted two randomized controlled trials of the use of VR in facilitating needle-based procedures in children in the emergency room and outpatient pathology clinic (5). While undergoing intravenous cannulation or venipuncture, four to 11-year-old children using the VR intervention had a significantly lower rise in pain scores compared to standard of care (5). In another study, caregivers and phlebotomists also had higher levels of satisfaction with blood draw experiences when children were engaged in VR (6).

VR may also be helpful in addressing needle anxiety during routine vaccinations. In 2018, Chad et al. demonstrated that VR decreased pain and fear in children receiving routine immunizations, though the results were not powered to show statistical significance (7). More recently, Ellertonet al. developed a protocol for a randomized controlled trial to assess the effectiveness of VR in reducing pain in 100 four-year-old children undergoing routine vaccination, yet the results of the study have not been published (8).

Aside from needle-based procedures, VR may reduce pain in patients undergoing wound dressing changes, which often cause severe pain for children with chronic injuries. Hua et al. showed that VR significantly relieved pain and anxiety during wound changes and shortened the duration of dressing changes for children with chronic wounds on lower limbs compared with standard distraction methods such as toys, television, books, and parental comfort (9).  VR has also been studied in patients requiring dressing changes due to burns. Hoffman et al. conducted a randomized controlled trial of pediatric patients with burns and compared a VR intervention (SnowWorld - an interactive VR of 3D snowy canyon) with standard of care during wound cleaning procedures (10). Patients in the VR group reported lower “worst pain” ratings in the ICU on Day 1 and subsequent wound care sessions, compared with those in the standard of care group (10). In addition, Schmitt et al. found that immersive VR made the previously painful physical therapy sessions more fun and lessened pain up to 44% for burn patients, with these benefits being maintained over subsequent sessions (11).

Not all VR interventions are equal in efficacy, however. Another randomized control study found that off-the-shelf, non-customized VR interventions did not significantly reduce subjective pain scores and duration of dressing changes in burn patients compared with standard distraction (such as TV or music), though the VR intervention significantly reduced the dosage of rescue analgesic medicine (12). Authors noted that the results may be explained by the gate control theory of pain (13), emphasizing that pain relief is correlated with how immersive the VR experience is. The study used a non-customized VR that may not have adequately engaged participants’ attention (12).

Different medical procedures may necessitate different types of VR applications, particularly with regard to active and passive experiences. For example, pediatric oncology patients undergoing port access experienced less pain and stress when they concurrently used an application called Virtual Gorilla that required the use of a computer mouse to control movements (14). However, this program would be ill-suited for medical procedures that require both arms to be available for healthcare practitioners (such as IV placements); in these instances, gaze-controlled movements or passive applications would be more appropriate (15).

Virtual Reality for Chronic Pain
VR is now being used for chronic pain relief in children and adults. One of the most common uses of VR for these patients is as a physical therapy adjunct to facilitate patient engagement in their exercise programs. The Stanford Chariot Program created the Pain Rehabilitation Virtual Reality Program (PR-VR) in collaboration with Dr. Laura Simons and the team of pediatric pain specialists at Lucile Packard Children’s hospital (16), which is now clinically used in multiple hospitals throughout North America and has been adapted for home use. Multiple clinical trials are underway to evaluate the efficacy and feasibility of VR for pediatric chronic pain given the numerous reported successes (17, 18).

VR uses for children with chronic pain have also focused on exposure therapy for complex regional pain syndrome (18) and mirror therapy (19). With these treatments, clinicians and therapists craft a customized VR treatment plan for each patient’s clinical needs and preferences. A typical session might include 10 to 20 minutes of a therapeutic virtual experience requiring patients to reach or stand, followed by 10 minutes of a commercially available game like TiltBrush (Google) where patients can paint 3D scenes in a virtual environment. Finally, VR has been used to teach coping strategies such as deep breathing (20) and guided meditation (21), which many chronic pain patients benefit from. In our clinical experience, the meditation and breathing exercises have been most effective for children 12 years and older.

Side Effects
Fortunately, children seem to have fewer side effects from VR than adults (22). Our group showed that with proper screening, the most common side effect of VR in kids is “increased anxiety,” likely from not being able to see their surroundings or caretakers (23). The incidence of nausea and motion sickness, with appropriate selection of content, is far lower than cited in the adult literature (22).

Conclusion
Undertreated pain can progress to persistent medical complications including chronic pain (24), highlighting the importance of early intervention. VR is a promising acute pain management tool, especially for needle phobia, routine vaccination, and wound care. VR treatments have also been effectively used for patients with chronic pain, particularly as a rehabilitation adjunct and for mirror therapy (16-18, 25). While the recent price reduction of VR headsets has allowed for the successful integration of VR in some clinical settings, further studies investigating its cost-effectiveness and utility in addressing pediatric pain could lead to even wider clinical integration.

References

  1. J. Dascal et al., Virtual Reality and Medical Inpatients: A Systematic Review of Randomized, Controlled Trials. Innov Clin Neurosci 14, 14-21 (2017).
  2. R. Eijlers et al., Systematic Review and Meta-analysis of Virtual Reality in Pediatrics: Effects on Pain and Anxiety. Anesth Analg 129, 1344-1353 (2019).
  3. A. M. Iannicelli et al., Does virtual reality reduce pain in pediatric patients? A systematic review. Ital J Pediatr 45, 171 (2019).
  4. A. Taddio et al., Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine 30, 4807-4812 (2012).
  5. E. Chan et al., Virtual Reality for Pediatric Needle Procedural Pain: Two Randomized Clinical Trials. J Pediatr 209, 160-167 e164 (2019).
  6. J. I. Gold, N. E. Mahrer, Is Virtual Reality Ready for Prime Time in the Medical Space? A Randomized Control Trial of Pediatric Virtual Reality for Acute Procedural Pain Management. J Pediatr Psychol 43, 266-275 (2018).
  7. R. Chad, S. Emaan, O. Jillian, Effect of virtual reality headset for pediatric fear and pain distraction during immunization. Pain Manag 8, 175-179 (2018).
  8. K. Ellerton et al., The VRIMM study: Virtual Reality for IMMunisation pain in young children-protocol for a randomised controlled trial. BMJ Open 10, e038354 (2020).
  9. Y. Hua, R. Qiu, W. Y. Yao, Q. Zhang, X. L. Chen, The Effect of Virtual Reality Distraction on Pain Relief During Dressing Changes in Children with Chronic Wounds on Lower Limbs. Pain Manag Nurs 16, 685-691 (2015).
  10. H. G. Hoffman et al., Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study. Front Hum Neurosci 13, 262 (2019).
  11. Y. S. Schmitt et al., A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns. Burns 37, 61-68 (2011).
  12. B. Kipping, S. Rodger, K. Miller, R. M. Kimble, Virtual reality for acute pain reduction in adolescents undergoing burn wound care: a prospective randomized controlled trial. Burns 38, 650-657 (2012).
  13. R. Melzack, P. D. Wall, Pain mechanisms: a new theory. Science 150, 971-979 (1965).
  14. K. Wolitzky, R. Fivush, E. Zimand, L. Hodges, B. O. Rothbaum, Effectiveness of virtual reality distraction during a painful medical procedure in pediatric oncology patients. Psychol Health 20, 817-824 (2005).
  15. J. Piskorz, M. Czub, Effectiveness of a virtual reality intervention to minimize pediatric stress and pain intensity during venipuncture. J Spec Pediatr Nurs 23,  (2018).
  16. A. Griffin et al., Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study. JMIR Rehabil Assist Technol 7, e22620 (2020).
  17. S. Shiri et al., A virtual reality system combined with biofeedback for treating pediatric chronic headache--a pilot study. Pain Med 14, 621-627 (2013).
  18. A. S. Won et al., Two Virtual Reality Pilot Studies for the Treatment of Pediatric CRPS. Pain Med 16, 1644-1647 (2015).
  19. A. Yeves-Lite et al., Conventional and Virtual Reality Mirror Therapies in Upper Obstetric Brachial Palsy: A Randomized Pilot Study. J Clin Med 9,  (2020).
  20. N. E. Cook, N. A. Huebschmann, G. L. Iverson, Safety and Tolerability of an Innovative Virtual Reality-Based Deep Breathing Exercise in Concussion Rehabilitation: A Pilot Study. Dev Neurorehabil, 1-8 (2020).
  21. E. Seabrook et al., Understanding How Virtual Reality Can Support Mindfulness Practice: Mixed Methods Study. J Med Internet Res 22, e16106 (2020).
  22. L. Tychsen, P. Foeller, Effects of Immersive Virtual Reality Headset Viewing on Young Children: Visuomotor Function, Postural Stability, and Motion Sickness. Am J Ophthalmol 209, 151-159 (2020).
  23. T. J. Caruso et al., Retrospective Review of the Safety and Efficacy of Virtual Reality in a Pediatric Hospital. Pediatr Qual Saf 5, e293 (2020).
  24. R. Sinatra, Causes and consequences of inadequate management of acute pain. Pain Med 11, 1859-1871 (2010).
  25. L. D. Morris, Q. A. Louw, K. A. Grimmer, E. Meintjes, Targeting pain catastrophization in patients with fibromyalgia using virtual reality exposure therapy: a proof-of-concept study. J Phys Ther Sci 27, 3461-3467 (2015).

Back to top