Virtual reality game reduces paediatric patients’ pain during treatment

• Opioids are used in severe burn care, although their long-term use can be linked to addiction.
• Novel nonpharmacological approaches like virtual reality (VR) games offer safe pain management aids.
• At the Nationwide Children’s Hospital, USA, Dr Henry Xiang and his multidisciplinary team are pioneering the use of VR for pain alleviation during painful medical procedures.
• Their research reports significantly lower pain levels in paediatric burn patients with the use of VR games during dressing changes.
• In an extended study, they also found that a potential neurological mechanism other than distraction could enhance pain management when patients play VR games during painful procedures.

A quarter of a million children in the USA experience severe burns every year, and dressing changes during their treatment provoke extreme pain. Pain is traditionally managed using opioids or other strong painkillers, but the repeated use of painkillers has recently been linked to increased risks of long-term opioid use and addiction. Conversely, the psychological effects of ineffectively managed pain can also significantly impact paediatric patients.

Doctors are keen to reduce paediatric painkiller consumption while providing appropriate pain relief through non-pharmacological strategies, such as distracting patients to alleviate the pain during treatment.

Virtual reality pain relief

Virtual reality (VR) is a computer-generated, simulated 3D environment that allows users to experience and interact with a particular scene as though they were inside. It usually requires a headset for visual input and headphones for audio input. The immersive nature of VR makes it an ideal distraction tool, providing paediatric patients with an engaging environment to focus on during a painful medical procedure.

VR-PAT users reported pain levels that were 30% lower, a clinically meaningful decrease compared to patients who followed standard pain-management techniques.

There are various ways to adopt VR while performing procedures such as dressing changes among children.

Passive VR provides an audiovisual environment for patients to experience, whereas active VR also allows them to interact with the environment, usually in the form of an interactive game. This is different in comparison to standard care, where children are given toys and iPads during dressing changes.

VR games for paediatric patients

Dr Henry Xiang, founding Director of the Center for Pediatric Trauma Research and Research Director in the CDC-funded Center for Injury Research and Policy at Nationwide Children’s Hospital, and his multidisciplinary team are making groundbreaking efforts in using VR for pain alleviation during medical procedures. Working closely with VR developers, they have created the VR pain alleviation therapeutic (VR-PAT) that helps manage paediatric burn patient pain during dressing changes. Unlike older VR systems, which relied on large and expensive equipment, VR-PAT requires only a lightweight, low-cost VR headset, a smartphone, and detachable earphones.

Xiang and his colleagues applied this system to paediatric burn patients. As the patients were being treated for burns, the team provided the Virtual River Cruise game with a snow-filled environment for an additional cooling effect. Players could aim at snow-blowing statues from a boat on a river, which was filled up with snow if they aimed correctly. The gameplay required only slight movements of the head to minimise disruption during delicate medical procedures.

During dressing changes, Xiang and his team randomly assigned burn patients, aged 6–17 years, with either the active VR-PAT game, a passive version of the game allowing them to experience the same environment without interacting with it, or standard distraction tools such as iPads, music, and books. The team then interviewed the patients and their guardians about their pain levels and VR experience and asked their nurses to rate the system’s ease of use and helpfulness. The nurses described the system as easy to implement and patients who played the active VR-PAT game reported significantly reduced pain levels compared to those who experienced passive VR or standard care.

Home VR pain management

Xiang and his team also applied the same VR-PAT system to paediatric burn patients during home burn care. Over a week of dressing changes, VR-PAT provided an easily implemented, useful distraction. VR-PAT users reported pain levels that were 30% lower, a clinically meaningful decrease compared to patients who followed standard pain-management techniques. The patients also reported consistent levels of happiness and fun, and that the VR game maintained realism and engagement. Maintaining engagement was a major concern to both developers and clinicians, because if the children become disinterested, they would no longer be distracted from their pain, causing the effectiveness of VR-PAT for pain management to wane.

VR pain relief mechanism

The VR-PAT system provides impressive results, but how does it provide pain relief? The accepted wisdom is that using VR during medical procedures helps alleviate pain because it distracts patients. While this is certainly a significant effect, Xiang and his team proposed that other neurological factors may be at work when a patient focuses on a VR game during a painful procedure.

VR game realism, fun, and engagement are interrelated features that indirectly influence pain perception, while time spent thinking about pain can significantly increase perceived pain.

Xiang and his team found that for paediatric burn patients, engagement with the VR game had a significant effect on reducing pain levels during dressing changes. They also showed that the beneficial effect of VR engagement was stronger than the negative effect of time spent thinking about pain.This suggests that although VR was thought to alleviate pain through distraction, it could also be related to another potentially neurophysiological mechanism, an idea that the team is keen to explore.

The correlation between anxiety and pain

Pain experiences are strongly related to expectations, and anxiety about the pain expected in an upcoming medical procedure can dramatically affect pain levels during treatment.

In a clinical landscape shifting towards the adoption of non-pharmacological pain management approaches, VR presents a strong option that has already shown significant benefits for paediatric burn patients.

Children are more susceptible than adults to anxiety and feeling powerless in unfamiliar settings.

Paediatric burn patients often experience anxiety, particularly after a bad experience with a previous dressing change. The team examined the relationship between pain and anxiety in paediatric burn patients and discovered a strong link between anxiety before burn dressing changes for patients and moderate-to-severe pain levels.

Future of pain management

Age is also a key factor in developing a pain management system. In an ongoing project, Xiang’s team has found that younger children benefit more than older children from VR pain alleviation therapeutic during burn treatment. The team also tested the effectiveness of VR-PAT in lowering the pain levels of adult severe burn patients. Although VR is a useful pain alleviation approach, Xiang stresses that more research is needed to develop strategies that work well for adults, particularly if they have severe burns that require long dressing changes.

In a clinical landscape shifting towards the adoption of non-pharmacological pain management approaches, VR presents a strong option that has already shown significant benefits for paediatric burn patients. Xiang and his colleagues’ ongoing work in promoting and developing VR technologies in the medical setting could help in minimising opioid use in patients with a range of medical conditions, ultimately providing them with a safe aid for pain relief.