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

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).

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.


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