Korean J Pain.  2021 Jun;34(3):304-314. 10.3344/kjp.2021.34.3.304.

Effectiveness of virtual reality immersion on procedure-related pain and anxiety in outpatient pain clinic: an exploratory randomized controlled trial

• Joo Y
• Kim EK
• Song HG
• Jung H
• Park H
• Moon JY

• KMID: 2517514
• DOI: http://doi.org/10.3344/kjp.2021.34.3.304

Abstract

Background
The study investigated virtual reality (VR) immersion in alleviating procedure-related pain in patients with chronic pain undergoing fluoroscopy-guided minimally-invasive intervention in a prone position at an outpatient clinic.
Methods
In this prospective randomized controlled study, 38 patients undergoing lumbar sympathetic ganglion block were randomized into either the VR or the control group. In the VR group, procedure-related pain was controlled via infiltration of local anesthetics while watching a 30-minute VR hypnotic program. In the control group, the skin infiltration alone was used, with the VR device switched off. The primary endpoint was an 11-point score on the numerical rating scale, indicating procedure-related pain. Patients’ satisfaction with pain control, anxiety levels, the need for additional local anesthetics during the procedure, hemodynamic stability, and any adverse events were assessed.
Results
Procedure-related pain was significantly lower in the VR group (3.7 ± 1.4) than in the control group (5.5 ± 1.7; P = 0.002). Post-procedural anxiety was lower in the VR group than in the control group (P = 0.025), with a significant reduction from pre-procedural anxiety (P < 0.001). Although patients’ satisfaction did not differ significantly (P = 0.158) between the groups, a higher number of patients required additional local anesthetics in the control group (n = 13) than in the VR group (n = 4; P = 0.001). No severe adverse events occurred in either group during the study.
Conclusions
VR immersion can be safely used as a novel adjunct to reduce procedural pain and anxiety during fluoroscopic pain intervention.

Keyword

Ambulatory Care Facilities; Anxiety; Autonomic Nerve Block; Chronic Pain; Ganglia; Sympathetic; Hypnotics and Sedatives; Minimally Invasive Surgical Procedures; Pain Perception; Pain; Procedural; Virtual Reality; Virtual Reality Exposure Therapy

Figure

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  Fig. 1 Photographs of a person wearing the virtual reality device in a prone position to undergo the lumbar sympathetic ganglion block.

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  Fig. 2 Images of NUVO program by Oncomfort SA, Wavre, Belgium.

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  Fig. 3 Consolidated Standards of Reporting Trials (CONSORT) flow diagram. LSGB: lumbar sympathetic ganglion block, VR: virtual reality.

Reference

1. Castañeda AM, Lee CS, Kim YC, Lee D, Moon JY. 2018; Addressing opioid-related chemical coping in long-term opioid therapy for chronic noncancer pain: a multicenter, observational, cross-sectional study. J Clin Med. 7:354. DOI: 10.3390/jcm7100354. PMID: 30322212. PMCID: PMC6210168.

2. Semeru GM, Halim MS. 2019; Acceptance versus catastrophizing in predicting quality of life in patients with chronic low back pain. Korean J Pain. 32:22–9. DOI: 10.3344/kjp.2019.32.1.22. PMID: 30671200. PMCID: PMC6333577.

3. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Lancet Low Back Pain Series Working Group. 2018; Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 391:2368–83. DOI: 10.1016/S0140-6736(18)30489-6. PMID: 29573872.

4. Kim EJ, Moon JY, Park KS, Yoo da H, Kim YC, Sim WS, et al. 2014; Epidural steroid injection in Korean pain physicians: a national survey. Korean J Pain. 27:35–42. DOI: 10.3344/kjp.2014.27.1.35. PMID: 24478899. PMCID: PMC3903799.

5. Ryu JH, Lee CS, Kim YC, Lee SC, Shankar H, Moon JY. 2018; Ultrasound-assisted versus fluoroscopic-guided lumbar sympathetic ganglion block: a prospective and randomized study. Anesth Analg. 126:1362–8. DOI: 10.1213/ANE.0000000000002640. PMID: 29189275.

6. Angelini G, Ketzler JT, Coursin DB. 2001; Use of propofol and other nonbenzodiazepine sedatives in the intensive care unit. Crit Care Clin. 17:863–80. DOI: 10.1016/S0749-0704(05)70184-6. PMID: 11762265.

7. Shafer A. 1998; Complications of sedation with midazolam in the intensive care unit and a comparison with other sedative regimens. Crit Care Med. 26:947–56. DOI: 10.1097/00003246-199805000-00034. PMID: 9590327.

8. Chuan A, Zhou JJ, Hou RM, Stevens CJ, Bogdanovych A. 2021; Virtual reality for acute and chronic pain management in adult patients: a narrative review. Anaesthesia. 76:695–704. DOI: 10.1111/anae.15202. PMID: 32720308.

9. Won AS, Bailey J, Bailenson J, Tataru C, Yoon IA, Golianu B. 2017; Immersive virtual reality for pediatric pain. Children (Basel). 4:52. DOI: 10.3390/children4070052. PMID: 28644422. PMCID: PMC5532544.

10. Hoffman HG, Doctor JN, Patterson DR, Carrougher GJ, Furness TA 3rd. 2000; Virtual reality as an adjunctive pain control during burn wound care in adolescent patients. Pain. 85:305–9. DOI: 10.1016/S0304-3959(99)00275-4. PMID: 10692634.

11. Brown NJ, Kimble RM, Rodger S, Ware RS, Cuttle L. 2014; Play and heal: randomized controlled trial of Ditto™ intervention efficacy on improving re-epithelialization in pediatric burns. Burns. 40:204–13. DOI: 10.1016/j.burns.2013.11.024. PMID: 24360745.

12. Gold JI, Kim SH, Kant AJ, Joseph MH, Rizzo AS. 2006; Effectiveness of virtual reality for pediatric pain distraction during i.v. placement. Cyberpsychol Behav. 9:207–12. DOI: 10.1089/cpb.2006.9.207. PMID: 16640481.

13. Caruso TJ, George A, Menendez M, De Souza E, Khoury M, Kist MN, et al. 2020; Virtual reality during pediatric vascular access: a pragmatic, prospective randomized, controlled trial. Paediatr Anaesth. 30:116–23. DOI: 10.1111/pan.13778. PMID: 31785015.

14. Yamashita Y, Shimohira D, Aijima R, Mori K, Danjo A. 2020; Clinical effect of virtual reality to relieve anxiety during impacted mandibular third molar extraction under local anesthesia. J Oral Maxillofac Surg. 78:545.e1–6. DOI: 10.1016/j.joms.2019.11.016. PMID: 31862340.

15. Chan PY, Scharf S. 2017; Virtual reality as an adjunctive nonpharmacological sedative during orthopedic surgery under regional anesthesia: a pilot and feasibility study. Anesth Analg. 125:1200–2. DOI: 10.1213/ANE.0000000000002169. PMID: 28598921.

16. Moon JY, Shin J, Chung J, Ji SH, Ro S, Kim WH. 2018; Virtual reality distraction during endoscopic urologic surgery under spinal anesthesia: a randomized controlled trial. J Clin Med. 8:2. DOI: 10.3390/jcm8010002. PMID: 30577461. PMCID: PMC6352098.

17. BinDhim NF, Shaman AM, Alhawassi TM. 2013. Confirming the one-item question Likert Scale to measure anxiety. Internet J Epidemiol [Internet]. 1–4. Available from: https://print.ispub.com/api/0/ispub-article/14525. cited 2018 Sep 11.

18. Matza LS, Morlock R, Sexton C, Malley K, Feltner D. 2010; Identifying HAM-A cutoffs for mild, moderate, and severe generalized anxiety disorder. Int J Methods Psychiatr Res. 19:223–32. DOI: 10.1002/mpr.323. PMID: 20718076. PMCID: PMC6878292.

19. Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, et al. IMMPACT. 2005; Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 113:9–19. DOI: 10.1016/j.pain.2004.09.012. PMID: 15621359.

20. Furman E, Jasinevicius TR, Bissada NF, Victoroff KZ, Skillicorn R, Buchner M. 2009; Virtual reality distraction for pain control during periodontal scaling and root planing procedures. J Am Dent Assoc. 140:1508–16. DOI: 10.14219/jada.archive.2009.0102. PMID: 19955069.

21. Solcà M, Krishna V, Young N, Deogaonkar M, Herbelin B, Orepic P, et al. 2021; Enhancing analgesic spinal cord stimulation for chronic pain with personalized immersive virtual reality. Pain. 162:1641–9. DOI: 10.1097/j.pain.0000000000002160. PMID: 33259460.

22. Darnall BD, Krishnamurthy P, Tsuei J, Minor JD. 2020; Self-administered skills-based virtual reality intervention for chronic pain: randomized controlled pilot study. JMIR Form Res. 4:e17293. DOI: 10.2196/17293. PMID: 32374272. PMCID: PMC7381022.

23. Sharar SR, Carrougher GJ, Nakamura D, Hoffman HG, Blough DK, Patterson DR. 2007; Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: preliminary results from 3 ongoing studies. Arch Phys Med Rehabil. 88(12 Suppl 2):S43–9. DOI: 10.1016/j.apmr.2007.09.004. PMID: 18036981.

24. Brown L, Chen ET, Binder DS. 2020; The use of virtual reality for Peri-procedural pain and anxiety at an outpatient spine clinic injection visit: an exploratory controlled randomized trial. Am J Transl Res. 12:5818–26. PMID: 33042461. PMCID: PMC7540157.

25. Walker MR, Kallingal GJ, Musser JE, Folen R, Stetz MC, Clark JY. 2014; Treatment efficacy of virtual reality distraction in the reduction of pain and anxiety during cystoscopy. Mil Med. 179:891–6. DOI: 10.7205/MILMED-D-13-00343. PMID: 25102532.

26. Frey DP, Bauer ME, Bell CL, Low LK, Hassett AL, Cassidy RB, et al. 2019; Virtual reality analgesia in labor: the VRAIL pilot study-a preliminary randomized controlled trial suggesting benefit of immersive virtual reality analgesia in unmedicated laboring women. Anesth Analg. 128:e93–6. DOI: 10.1213/ANE.0000000000003649. PMID: 31094789.

27. Rousseaux F, Bicego A, Ledoux D, Massion P, Nyssen AS, Faymonville ME, et al. 2020; Hypnosis associated with 3D immersive virtual reality technology in the management of pain: a review of the literature. J Pain Res. 13:1129–38. DOI: 10.2147/JPR.S231737. PMID: 32547176. PMCID: PMC7247604.

28. Konstantatos AH, Angliss M, Costello V, Cleland H, Stafrace S. 2009; Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine in patients having burns dressings changes. Burns. 35:491–9. DOI: 10.1016/j.burns.2008.08.017. PMID: 19111995.

29. Solcà M, Ronchi R, Bello-Ruiz J, Schmidlin T, Herbelin B, Luthi F, et al. 2018; Heartbeat-enhanced immersive virtual reality to treat complex regional pain syndrome. Neurology. 91:e479–89. DOI: 10.1212/WNL.0000000000005905. PMID: 29980635.

30. Garcia-Palacios A, Herrero R, Vizcaíno Y, Belmonte MA, Castilla D, Molinari G, et al. 2015; Integrating virtual reality with activity management for the treatment of fibromyalgia: acceptability and preliminary efficacy. Clin J Pain. 31:564–72. DOI: 10.1097/AJP.0000000000000196. PMID: 25551475.

31. Matheve T, Bogaerts K, Timmermans A. 2020; Virtual reality distraction induces hypoalgesia in patients with chronic low back pain: a randomized controlled trial. J Neuroeng Rehabil. 17:55. DOI: 10.1186/s12984-020-00688-0. PMID: 32321516. PMCID: PMC7178732.

32. Beck AT, Steer RA. 1991; Relationship between the Beck anxiety inventory and the Hamilton anxiety rating scale with anxious outpatients. J Anxiety Disord. 5:213–23. DOI: 10.1016/0887-6185(91)90002-B.