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NIHR Signal Virtual reality can help reduce the pain and anxiety of stressful medical procedures for children

Published on 15 August 2019

doi: 10.3310/signal-000806

Virtual reality shows promise in helping to distract children from self-reported pain and anxiety during medical procedures. Younger children in particular may benefit from the intervention.

This review of seventeen trials looked at virtual reality interventions tested in trials with children receiving treatment for burns, dental and tumour related health needs, and during needle insertion for intravenous access. Results suggested a marked impact on pain and anxiety of children from these immersive distractions, but research was of mixed quality and individual trials were small.

Fear of medical interventions is a commonly recognised problem in children and can be very acute in younger children. Virtual reality as a distraction may offer a safe solution in counteracting this.

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Why was this study needed?

Medical procedures commonly evoke pain and feelings of anxiety. The experience of pain can be further exacerbated by the fear of it. In children these feelings are often elevated leading to resistive behaviours towards healthcare. Poor engagement can result in less favourable health outcomes, and interventions to improve this are needed.

Distractions such as music, games and TV have been shown to reduce pain and anxiety in children effectively during medical procedures. Virtual reality can however offer a more immersive experience resulting in greater levels of distraction.

A number of individual studies have been published, but this is the first systematic review to bring the evidence on anxiety in children together. This study aimed to improve the evidence-base for children undergoing medical procedures.

What did this study do?

The review included seventeen recently conducted randomised controlled trials, with 859 participants who were age 21 years or younger.

The studies evaluated pain and anxiety levels whilst using virtual reality with children as a form of distraction during medical procedures. These were mostly in burns care but also included venous, dental, and tumour related care. All studies considered virtual reality in comparison with usual care although in many cases “usual” was not well described. This could include other distractions such as watching television or playing music to none at all.

Most trials were small and of mixed quality. Some aspects of this are unavoidable – it is impossible for children and staff to be unaware of whether they are using virtual reality devices or not. Differences in health conditions, medical procedures and virtual reality software limited the review to some extent due to the difficulty in combining results across such varied contexts.

What did it find?

  • Virtual reality reduced patient-reported pain with a large effect compared with treatment as usual during medical procedures (standardised mean difference [SMD] 1.30, 95% confidence interval [CI] 0.68 to 1.91; 749 participants, 14 trials).
  • Patient-reported anxiety was also likely to be reduced to a large extent by virtual reality, though reliability of this result is lower (SMD 1.32, 95% CI 0.21 to 2.44; 460 participants, 7 trials).
  • The positive effect of virtual reality on reducing pain was also observed by caregivers (SMD 2.08, 95% CI 0.55 to 3.61) and health professionals (SMD 3.02, 95% CI 0.79 to 2.25).
  • Virtual reality is potentially more effective in younger children than older children.

What does current guidance say on this issue?

Virtual reality is a relatively new development in healthcare and there are no national guidelines that focus on its use in distracting children from pain and anxiety during medical procedures. A general set of recommendations for best practice in the clinical implementation of virtual reality has recently been developed in the US, but at present there is nothing comparable in the UK.

The Royal College of Paediatrics and Child Health acknowledge virtual reality in some of its guidelines but not in the context of distraction. This may be a consideration for future guideline development.

What are the implications?

Interventions to divert a child’s attention away from stressful procedures can reduce levels of pain and anxiety. Virtual reality can distract the child more entirely than other methods by total immersion in another world, and is safe and simple to administer.

Virtual reality may, however, carry greater cost implications than other interventions and with adequate pain management distractions might not be necessary. Nevertheless, virtual reality provides a promising option that could reduce reliance on pain relieving drugs and improve the experience of difficult medical procedures, particularly for younger children.

The findings will be useful to paediatric healthcare practitioners and may also be helpful to parents and caregivers.

Citation and Funding

Eijlers R, Utens E, Staals  LM et al. Systematic review and meta-analysis of virtual reality in pediatrics: effects on pain and anxiety. Anesth Analg. 2019; May 29. doi: 10.1213/ane.0000000000004165. [Epub ahead of print].

This research was funded by the Zilveren Kruis Foundation (a Dutch health insurance company) and the Coolsingel Foundation (a Rotterdam-based research grant funding body). The authors declare no conflicts of interest.

Bibliography

Aitken JC, Wilson S, Coury D and Moursi AM. The effect of music distraction on pain, anxiety and behavior in pediatric dental patients. Pediatr Dent. 2002;24(2):114–8.

Landolt MA, Marti D, Widmer J and Meuli M. Does cartoon movie distraction decrease burned children’s pain behavior? Journal of Burn Care and Rehabilitation. 2002;23(1):61–5.

Malloy KM, Milling LS. The effectiveness of virtual reality distraction for pain reduction: a systematic review. Clin Psychol Rev. 2010;30(8):1011–8.

Mifflin KA, Hackmann T, Chorney JM. Streamed video clips to reduce anxiety in children during inhaled induction of anesthesia. Anesth Analg. 2012;115(5):1162–7.

Ploghaus A, Narain C, Beckmann CF et al. Exacerbation of pain by anxiety is associated with activity in a hippocampal network. Journal of Neuroscience. 2001;21(24):9896–903.

Whitehead-Pleaux AM, Baryza MJ and Sheridan RL. The effects of music therapy on pediatric patients’ pain and anxiety during donor site dressing change. J Music Ther. 2006;43(2):136–53.

Woo AKM. Depression and anxiety in pain. Rev Pain. 2010;4(1):8–12.

Why was this study needed?

Medical procedures commonly evoke pain and feelings of anxiety. The experience of pain can be further exacerbated by the fear of it. In children these feelings are often elevated leading to resistive behaviours towards healthcare. Poor engagement can result in less favourable health outcomes, and interventions to improve this are needed.

Distractions such as music, games and TV have been shown to reduce pain and anxiety in children effectively during medical procedures. Virtual reality can however offer a more immersive experience resulting in greater levels of distraction.

A number of individual studies have been published, but this is the first systematic review to bring the evidence on anxiety in children together. This study aimed to improve the evidence-base for children undergoing medical procedures.

What did this study do?

The review included seventeen recently conducted randomised controlled trials, with 859 participants who were age 21 years or younger.

The studies evaluated pain and anxiety levels whilst using virtual reality with children as a form of distraction during medical procedures. These were mostly in burns care but also included venous, dental, and tumour related care. All studies considered virtual reality in comparison with usual care although in many cases “usual” was not well described. This could include other distractions such as watching television or playing music to none at all.

Most trials were small and of mixed quality. Some aspects of this are unavoidable – it is impossible for children and staff to be unaware of whether they are using virtual reality devices or not. Differences in health conditions, medical procedures and virtual reality software limited the review to some extent due to the difficulty in combining results across such varied contexts.

What did it find?

  • Virtual reality reduced patient-reported pain with a large effect compared with treatment as usual during medical procedures (standardised mean difference [SMD] 1.30, 95% confidence interval [CI] 0.68 to 1.91; 749 participants, 14 trials).
  • Patient-reported anxiety was also likely to be reduced to a large extent by virtual reality, though reliability of this result is lower (SMD 1.32, 95% CI 0.21 to 2.44; 460 participants, 7 trials).
  • The positive effect of virtual reality on reducing pain was also observed by caregivers (SMD 2.08, 95% CI 0.55 to 3.61) and health professionals (SMD 3.02, 95% CI 0.79 to 2.25).
  • Virtual reality is potentially more effective in younger children than older children.

What does current guidance say on this issue?

Virtual reality is a relatively new development in healthcare and there are no national guidelines that focus on its use in distracting children from pain and anxiety during medical procedures. A general set of recommendations for best practice in the clinical implementation of virtual reality has recently been developed in the US, but at present there is nothing comparable in the UK.

The Royal College of Paediatrics and Child Health acknowledge virtual reality in some of its guidelines but not in the context of distraction. This may be a consideration for future guideline development.

What are the implications?

Interventions to divert a child’s attention away from stressful procedures can reduce levels of pain and anxiety. Virtual reality can distract the child more entirely than other methods by total immersion in another world, and is safe and simple to administer.

Virtual reality may, however, carry greater cost implications than other interventions and with adequate pain management distractions might not be necessary. Nevertheless, virtual reality provides a promising option that could reduce reliance on pain relieving drugs and improve the experience of difficult medical procedures, particularly for younger children.

The findings will be useful to paediatric healthcare practitioners and may also be helpful to parents and caregivers.

Citation and Funding

Eijlers R, Utens E, Staals  LM et al. Systematic review and meta-analysis of virtual reality in pediatrics: effects on pain and anxiety. Anesth Analg. 2019; May 29. doi: 10.1213/ane.0000000000004165. [Epub ahead of print].

This research was funded by the Zilveren Kruis Foundation (a Dutch health insurance company) and the Coolsingel Foundation (a Rotterdam-based research grant funding body). The authors declare no conflicts of interest.

Bibliography

Aitken JC, Wilson S, Coury D and Moursi AM. The effect of music distraction on pain, anxiety and behavior in pediatric dental patients. Pediatr Dent. 2002;24(2):114–8.

Landolt MA, Marti D, Widmer J and Meuli M. Does cartoon movie distraction decrease burned children’s pain behavior? Journal of Burn Care and Rehabilitation. 2002;23(1):61–5.

Malloy KM, Milling LS. The effectiveness of virtual reality distraction for pain reduction: a systematic review. Clin Psychol Rev. 2010;30(8):1011–8.

Mifflin KA, Hackmann T, Chorney JM. Streamed video clips to reduce anxiety in children during inhaled induction of anesthesia. Anesth Analg. 2012;115(5):1162–7.

Ploghaus A, Narain C, Beckmann CF et al. Exacerbation of pain by anxiety is associated with activity in a hippocampal network. Journal of Neuroscience. 2001;21(24):9896–903.

Whitehead-Pleaux AM, Baryza MJ and Sheridan RL. The effects of music therapy on pediatric patients’ pain and anxiety during donor site dressing change. J Music Ther. 2006;43(2):136–53.

Woo AKM. Depression and anxiety in pain. Rev Pain. 2010;4(1):8–12.

Systematic Review and Meta-analysis of Virtual Reality in Pediatrics: Effects on Pain and Anxiety

Published on 29 May 2019

Eijlers, R.,Utens, Emwj,Staals, L. M.,de Nijs, P. F. A.,Berghmans, J. M.,Wijnen, R. M. H.,Hillegers, M. H. J.,Dierckx, B.,Legerstee, J. S.

Anesth Analg , 2019

BACKGROUND: Medical procedures often evoke pain and anxiety in pediatric patients. Virtual reality (VR) is a relatively new intervention that can be used to provide distraction during, or to prepare patients for, medical procedures. This meta-analysis is the first to collate evidence on the effectiveness of VR on reducing pain and anxiety in pediatric patients undergoing medical procedures. METHODS: On April 25, 2018, we searched EMBASE, MEDLINE, CENTRAL, PubMed, Web of Science, and PsycINFO with the keywords "VR", "children," and "adolescents". Studies that applied VR in a somatic setting with participants </=21 years of age were included. VR was defined as a fully immersive 3-dimensional environment displayed in surround stereoscopic vision on a head-mounted display (HMD). We evaluated pain and anxiety outcomes during medical procedures in VR and standard care conditions. RESULTS: We identified 2889 citations, of which 17 met our inclusion criteria. VR was applied as distraction (n = 16) during venous access, dental, burn, or oncological care or as exposure (n = 1) before elective surgery under general anesthesia. The effect of VR was mostly studied in patients receiving burn care (n = 6). The overall weighted standardized mean difference (SMD) for VR was 1.30 (95% CI, 0.68-1.91) on patient-reported pain (based on 14 studies) and 1.32 (95% CI, 0.21-2.44) on patient-reported anxiety (based on 7 studies). The effect of VR on pediatric pain was also significant when observed by caregivers (SMD = 2.08; 95% CI, 0.55-3.61) or professionals (SMD = 3.02; 95% CI, 0.79-2.25). For anxiety, limited observer data were available. CONCLUSIONS: VR research in pediatrics has mainly focused on distraction. Large effect sizes indicate that VR is an effective distraction intervention to reduce pain and anxiety in pediatric patients undergoing a wide variety of medical procedures. However, further research on the effect of VR exposure as a preparation tool for medical procedures is needed because of the paucity of research into this field.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Expert commentary

Minimal research has been performed assessing the level of immersion and subsequent clinical benefit with use of the different readily available or purpose built virtual reality solutions (software and hardware).

Combined with the lack of definition of ‘care as usual’ in many of the analysed trials, the selection of virtual solution over other distraction tools in routine clinical practice must be made cautiously and using a patient-centred approach. However, VR distraction interventions are a welcome addition to healthcare professionals’ arsenal for the management of procedural anxiety and pain.

High quality trials are required to assess its use in procedural psychological preparation and identify which patient cohorts benefit most from virtual reality solution use.

Dr Chris Evans, NHS England Clinical Entrepreneur Fellow, Founder of Little Sparks Hospital, Starlight Children's Foundation Trustee

The commentator declares no conflicting interests