key: cord-0750923-yy186um5
authors: Alqudimat, Mohammad; Mesaroli, Giulia; Lalloo, Chitra; Stinson, Jennifer; Matava, Clyde
title: State of the Art: Immersive Technologies for Perioperative Anxiety, Acute, and Chronic Pain Management in Pediatric Patients
date: 2021-07-14
journal: Curr Anesthesiol Rep
DOI: 10.1007/s40140-021-00472-3
sha: 6c92d0cf76d07b2bb383738ff8c10af89b29a892
doc_id: 750923
cord_uid: yy186um5

PURPOSE OF REVIEW: This review summarizes and provides a comprehensive narrative synthesis of the current evidence on immersive technology’s (i.e., virtual and augmented Reality) use for perioperative anxiety, acute, and chronic pain in pediatrics. RECENT FINDINGS: Researchers have increasingly studied immersive technology as a non-pharmacological alternative for perioperative anxiety, acute, and chronic pain management. We found several research studies published over the last 3 years: almost all studies examined the use of virtual reality for perioperative anxiety and pain; only one case report was about the use of augmented reality for preoperative anxiety. Most studies showed that virtual reality intervention is effective and safe for perioperative anxiety, acute, and chronic pain. However, the studies are heterogeneous with relatively small sample sizes. SUMMARY: This review shows that more high-quality studies (i.e., randomized controlled trials with larger sample sizes and standardized methods for measuring and reporting outcomes) are needed to examine the effectiveness and adverse effects of virtual reality intervention on perioperative anxiety, acute, and chronic pain in pediatrics.

Anesthesia and surgical procedures impose a potential stressor for pediatric patients, leading to significant perioperative fear and distress. Up to 64% of children experience a high level of preoperative anxiety [1] [2] [3] [4] [5] . Before surgery, pediatric patients may feel threatened by the expected parental separation, unfamiliar environment, new faces with masks on, alarm sounds, and high level of parental anxiety, which can be because of the procedure or their children's fear [3, 4, [6] [7] [8] [9] . Ineffective preoperative anxiety management may increase postoperative pain, delirium, analgesic consumption, general anxiety, behavioral problems, and difficulty sleeping [5, 8, 10] . Therefore, alleviating children's preoperative anxiety can improve recovery, mitigate postoperative pain, and improve the overall perioperative experience. Further, up to 30-40% of children experience moderate to severe postoperative pain [11] [12] [13] and are at risk for transition to chronic pain, a debilitating and costly public health problem [14] [15] [16] [17] . Unrelieved or undertreated pediatric pain can negatively impact all domains of health-related quality of life and also interferes with normative developmental tasks [18] [19] [20] [21] [22] .

Recent research shows that immersive technology, particularly virtual reality (VR), is an effective intervention to alleviate perioperative anxiety and pain in children [23] [24] [25] [26] [27] [28] [29] [30] [31] . Immersive technology, namely VR and augmented reality (AR), refers to technology that aims to extend an individual's sensory environment by emulating or simulating physical reality through technology [32] . VR transposes users to an alternative setting and or a fully digital three-dimensional visualization, which creates a sense of immersion by allowing them to interact with the virtual environment [33, 34] . AR enhances an existing physical environment with additional virtual objects embedded in that space (i.e., additional digital information layers) [32, 35] .

Over the past years, several review studies have been published about the effect of VR intervention on anxiety, acute, and chronic pain in the pediatric population. These reviews incorporate various medical procedures (e.g., dental care, burn, venipuncture, chemotherapy administration, and various surgical procedures) [29, 44, 45] , focus on preoperative anxiety in adult and pediatrics [30] , or assess the use of VR distraction interventions for children with acute pain in any healthcare setting [36•] . None of these reviews concentrated on the perioperative anxiety, acute, and chronic pain in children. In this review [46] , we summarize the findings of the most recent evidence, i.e., studies that have been published in the past 3 years, on the effect of immersive technology on perioperative anxiety, acute, and chronic pain in pediatric patients.

We searched PubMed, Google Scholar and Google (for gray literature), and the Cochrane database using the following search terms: "immersive technology," "perioperative," "perioperative care," "anxiety," "pain management," "pediatric or pediatrics or paediatric or Paediatrics," "children," "children surgery," "child," "child surgery," "immersive technology*," "virtual reality*," "augmented reality*," "perioperative*," "preoperative*," "postoperative*," "surgery* or after surgery*," "anxiety*," "pain*," "pain management*," "pediatric*," "paediatric*," and "Child." We reviewed papers that have published since January 1, 2017. Articles were also identified through the authors' reference lists of selected articles (e.g., systematic review and meta-analysis) found in the literature search. Papers published in English were reviewed. The final reference list was generated based on originality and relevance to this narrative review's broad scope.

We identified eight RCTs that investigated the effect of VR on alleviating preoperative anxiety in pediatrics from 5 countries: South Korea (n=4), Iran=(n=1), Netherlands (n=1), The USA (n=1), and Japan (n=1) ( Table 1 ). In six RCTs [28, [37] [38] [39] [40] 47] , researchers used VR as exposure (i.e., VR tour of the operating room) to allow pediatric patients to become familiar with the operating room before induction of anesthesia. Two RCT examined the use of VR as a distraction tool [48, 49] . Hashimoto et al. (2020) asked pediatric patients (n=29) to practice how to use the VR headset the day before the surgery by watching their favorite cartoon animation, and on the day of the surgery, the researchers ask them to use the VR headsets again while staying in the pre-anesthetic holding area until after the induction of anesthesia. In the other RCTs, researchers asked the participants to use VR just before the surgery, of which, the exact timing was reported in three RCTs as 1 h before entering the OR [37, 38, 47] . In most RCTs (7/8), the modified Yale Preoperative Anxiety Scale [50] was used to measure the preoperative anxiety, while in one RCT, the Yale Preoperative Anxiety Scale [51] was used.

Almost all RCTs compared VR (i.e., intervention group) with care as usual (i.e., control group), except for one RCT [47] . In that RCT, Park et al. examined the effectiveness of VR as exposure to the operating room on preoperative anxiety for both patients and their parents. The researchers asked parents (n=40) in the intervention group to watch a 4-min VR tour concurrently with their children (i.e., mirroring display) while escorted from the pre-anesthetic holding area to the operating room. Parents and children were able to talk with each other and discuss what they were seeing. The results showed that the preoperative anxiety scores for children and their parents were significantly lower in the intervention group than the control group (i.e., children watched the same tour alone; n=40).

Although the reviewed RCTs are heterogeneous (i.e., content and duration of VR intervention, timing of administering the intervention, sample size, different mechanisms of VR, and type of surgery), almost all RCTs (7/8) showed that the preoperative anxiety score was significantly lower in the VR groups than in the control groups. Several limitations were reported in these studies including most of the RCT was open-label or not blinded [39, 48, 49] and repeated measures analysis of variance (i.e., ANOVA) was not used for comparison groups in all studies since the data was not normally distributed, technical issues (e.g., battery depletion), and small sample sizes. Only one RCT by Eijlers et al. showed that there was no significant difference in preoperative anxiety scores between the intervention group (i.e., VR exposure tour to the operating room) and the control group (i.e., "care as usual"). The researchers highlighted in the limitation section that 22% (21/94) of children in the intervention group discontinued the VR by frequently taking off the headset. Most of these children (15/21) were 4 or 5 years old, and the headset may have been large and heavy on them.

We identified two case studies from the USA [52, 53] and one game development study from Belgium [54] . Libaw et al. described the use of AR as a distraction technique during the induction of general anesthesia in a case study of three children (mean age=8.7). The AR software was designed to show the real operating room with an avatar that encourages patients to take deep breaths during mask induction. The researchers reported that patients felt less anxiety in comparison with their Rooms, which allowed a 10-year-old patient (n=1) and his mother to play and interact together virtually during patient transportation from the preoperative area to the operating room. The patient and his mother were able to hear and talk to each other. The researchers concluded that this approach of using VR reduced the child's preoperative anxiety by keeping the childparent connection until anesthesia induction. Finally, Vrancken et al. developed and tested a game, "HospiAvontuur," to help children (4-7 years) and their parents prepare for elective surgery admission.

The current evidence showed that immersive technology (i.e., VR and AR) is a promising intervention to alleviate preoperative anxiety in children. Further RCTs with larger sample sizes and standardized protocol (e.g., multicenter RCT) are needed to establish evidence (i.e., with high-certainty) on immersive technology and its effect and adverse effects on preoperative anxiety. This is crucial since suboptimal management of preoperative anxiety can intensify postoperative pain.

Immersive technologies in the pediatric acute and procedural pain setting have largely focused on VR technologies for children undergoing needle pokes, wound, or burn dressing changes [36•] . Distraction and affect modulation are the purported mechanisms that drive the effectiveness of VR interventions in the context of acute and procedural pain. Distraction through VR allows children experiencing pain to shift their attentional resources towards stimuli in VR, producing a hypoalgesic effect. VR can also stimulate a positive affective state, enhancing distraction and hypoalgesia [41••] . In a recent Cochrane review, Lambert et al. reviewed 17 RCTs and concluded that there is little evidence for the use of VR in reducing acute pain in children; the effectiveness of VR intervention on acute pain in children undergoing clinical treatments and procedures has been ranked as low to very low certainty [36•] . Therefore, they highlighted that there is a need for larger high-quality RCTs (i.e., at least 200 participants in each arm) to investigate the effectiveness and the adverse effect of VR intervention in this population.

The role of immersive technologies in pediatric chronic pain is not only to provide distraction from pain, but also uses biofeedback, graded exposure, and motivation [55, 56] . Physical activity for children with chronic pain is often painful and avoided [57] . Engaging in physical activity using immersive technology while distracted from pain may be better tolerated. Graded exposure is utilized to overcome fear of pain and gradually improve physical function over time [58] ; this can be employed through VR with modifiable gaming parameters gradually expose children to exercises. Technology with features such as music, cues, rewards, and performance metrics can provide motivation to perform painful movements. Technology that uses biofeedback provides patients information about a physiological parameter to prompt behavior modification, such as the VR application DEEP [59] . DEEP is a biofeedback, meditative, and psychoactive VR game that is controlled by breathing. Users don the VR headset and following onscreen and biofeedback cues, allow the game to teach them breathing techniques that can relieve stress, anxiety, and mild depression Immersive technologies in pediatric chronic pain are an emerging practice and science, heavily focused on VR. Evidence from studies of VR in adults with chronic pain show promising results. A scoping review (research methodology that provides an overview of the available research evidence without necessarily producing a summary answer to a discrete research question) [60] and systematic review [61] of controlled trials evaluating VR in adults with chronic pain report that VR is effective in pain reduction and functional improvements, but there is insufficient data to show long-lasting effects.

There are a handful of studies evaluating VR in pediatric chronic pain. Won et al. conducted a pilot study evaluating VR for children (n=4) with complex regional pain syndrome [62] . VR was used to engage the children in lower limb exercises (6 sessions) and used motion sensors to track limb movements during the intervention. The authors conclude that VR was well tolerated and feasible to use; however, in the absence of a comparator group, it is unclear whether VR enhanced limb movements compared to traditional forms of exercise. Shiri et al. conducted a pilot feasibility study in children with headaches (n=9) using VR (10 sessions) for biofeedback targeting relaxation [63] . In addition to feasibility, pre-post measures demonstrated improvements in pain intensity and quality of life post-intervention [63] , although unclear if this differs from other biofeedback technologies.

Griffin et al. conducted a pre-post study of using a customdeveloped VR technology (Fruity Feet) with 17 youths with chronic pain (63 sessions total) in the rehabilitation setting [56] . Fruity Feet uses gaming features to motivate children to engage in physical activity; game settings can be manipulated to target the painful body part. The authors report that VR was safe to use and achieved high levels of patient satisfaction and improvements in pain and function post intervention. Mesaroli et al. (unpublished study) implemented Fruity Feet in Canada with a cohort of youth (n=8) with chronic pain in the context of physiotherapy, and similarly reported high levels of physiotherapist and patient acceptance and feasibility.

Current evidence for VR in pediatric chronic pain, although limited, is promising. Future studies are needed to evaluate the effectiveness of VR in reducing pain or improving function, ideally through controlled trials comparing VR to standard of care. The INOVATE-Pain consortium has outlined guiding principles for VR interventions in pediatric chronic pain with suggested measures and study procedures [41••, 64] . This is critical so comparisons across studies, such as through a systematic review, will be possible. Furthermore, in the context of the COVID-19 pandemic and the shift towards virtual care for chronic pain management [23] , the future of immersive technologies should shift accordingly to remote delivery. Adapting VR for at-home use is currently underway through a collaboration with The Hospital for Sick Children in Toronto, Canada, and Stanford Chariot VR in California, USA, funded by Johnson and Johnson.

Researchers have postulated the effect of VR on perioperative anxiety and pain by two mechanisms: exposure and distraction [30, 36•] . VR can expose patients and their parents to the perioperative settings (e.g., operating room and recovery area), which allows them to become familiar with the physical environment. The findings of recent randomized controlled trials (RCTs) showed that VR was effectively used as exposure therapy to reduce children's preoperative anxiety (5 to 8 years old) [28, [37] [38] [39] [40] . On the other hand, VR can distract and divert pediatric patients' attention away from stressful or painful procedures with engaging materials and direct patients' attention to more pleasant stimulus [36•] . This is because children can be captivated by audiovisual content. In a recent review study [41••] , Trost et al. described the VR approaches to pain and discussed the three interrelated dimensions of VR; these dimensions are frequently described as the three key features or pillars of VR [42] : presence, immersion, and interactivity. Presence is the "subjective experience of being in one place or environment, even when one is physically situated in another" [43] . Immersion refers to the user's sense of being engaged and captivated by the digital audiovisual content [41••] . Interactivity is the user's ability to interact and manipulate the virtual space using the technical configuration [ [41••] . This model indicates that VR pain applications can be investigated from the perspective of having VR hardware and software, which enable the production of the pillars of VR. The pillars of VR moderate and mediate the subsequent changes in the users' cognitive, emotional, social, behavioral, and physiological outcomes (i.e., targets of pain-related therapy), leading to more considerable outcomes such as reduced pain intensity [41••] . Using such a standardized conceptual framework in future research may facilitate reflective and purposeful progress in the immersive technology pain field, which enhances the methodological consistency across studies.

Despite the advance of immersive reality, several challenges exist limiting its use in routine pediatric care [65] . The availability of age-, patient-, and culturally appropriate VR applications, size and weight of the headsets, patient isolation status, and infection control consideration are factors' this group of authors have encountered with clinical and research implementation [65] . The development of VR environments can be costly and requires a team of experts to execute. Pediatric centers may leverage lowcost alternatives such as 360 video environments [65] . Also, the pediatric centers may identify industry partnerships and collaborations to leverage co-design and co-development. The headsets' size may cause headaches and eye aches as most devices' interpupillary distance is designed for older children and adults. As such, most headset developers recommend children over 8 years old to use VR. However, there has been no evidence provided on the effects of VR on younger children. As a result, concerns regarding the use of VR in younger children still exist. The COVID-19 pandemic highlighted the risks of disease transmission and further underlined the importance of infection control during VR among patients. Our institution developed protocols for cleaning devices that include single-use disposable covers, non-fabric headsets, wiping processes, and the use of UV light for disinfecting VR devices and partnering with infection prevention experts was critical. The use of Google Cardboard VR headsets that are single-use can also mitigate infection risk as patients can keep their own devices [65] . Similarly, dedicated reusable devices for the duration of a patient's hospital encounter can be used following consultation with infection control experts and approved cleaning processes.

The current evidence on immersive technology in pediatric perioperative anxiety, acute, and chronic pain is promising despite the limitation of VR technology and current studies. Immersive technology for anxiety and pain in children is a relatively new field driven by rapid technological advancements. Thus, more high-quality RCTs with large sample sizes are needed to investigate the effectiveness and adverse effects of VR intervention on perioperative anxiety, acute, and chronic pain in pediatrics. Further, standardized theoretical frameworks that facilitate the design of VR trials, the measurement, and reporting of outcomes are essential. In addition, these efforts should include the comparison of VR with other types of technology like AR.

Given the COVID-19 pandemic, we also recommend research on the role of immersive technology for managing in pain using remote VR by children at home.

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Acknowledgements SickKids Virtual Reality Program.

Conflict of Interest Mohammad Alqudimat declares that he has no conflict of interest.Giulia Mesaroli is co-investigator on a virtual reality grant funded by Johnson & Johnson, and is co-investigator on a virtual reality grant funded by Physician Services, Inc.Chitra Lalloo is co-investigator on a virtual reality grant funded by Johnson & Johnson, and is co-chair of research for the SickKids Pain Centre. This is an unpaid position and involves leadership of pain-related research initiatives across The Hospital for Sick Children (Toronto, Canada).Jennifer Clyde Matava declares that he has no conflict of interest.