ESRA19-0696 Non-pharmacological methods for comfort and pain management (virtual reality, musicotherapy, hypnosis,……)

Acute pain must be treated as soon as possible to avoid the development of chronic pain which is highly prevalent worldwide and is considered as a socio-economical and health problem due to secondary disability and comorbidities such as anxiety, depression and the high rate of dependency on opioids and painkillers. Epidemic increases in opioids use highlights the need for effective adjuvant therapies that help to reduce pain and the need for drugs. In this context, music, virtual reality and hypnosis have been evaluated. Music Music and acute pain: Music intervention has shown statistically significant effects in decreasing pain (10%), emotional distress from pain, anesthetic use, opioid and non-opioid intakes and has shown an anxiolytic effect.1 2 a greater effect on pain was shown when music was delivered before surgery, when anxiety is the highest than during or after. Moreover, perioperative soft music may reduce later postoperative pain (day 7) and fatigue (days 1,7) by decreasing the surgical stress response after laparoscopic cholecystectomy.3 Music and chronic pain: Music reduced self-reported chronic pain, anxiety and depressive symptoms with a greater effect when the patient chose himself the music. This effect may be related to familiarity and the feeling of control and pleasure.4 Music in obstetrics: In comparison to a control group (no music), mothers in the music therapy group had a lower level of pain and anxiety at all stages of labor and decreased significantly their analgesics requirements in the postpartum period.5 6Music seems to decrease early postpartum depression rate.6 Music and neurophysiology: Music-induced analgesia results in the release of opioids engaging the descending pain modulation system.7Dobek investigated the neural mechanisms by applying a well-defined painful stimulus while participants listened to either their favorite music or to no music. Pain rating scores were significantly lower with music playing than without it (10% reduction of pain). Brain regions associated with enjoyable music listening include limbic, frontal, auditory regions and also dorsolateral prefrontal cortex, periaqueductal gray matter, rostral ventromedial medulla and dorsal gray matter of the spinal cord, different areas related to pain modulation.8 How to choose music? : Selecting music might be very difficult because of music’s complexity and variety. Music characteristics such as musical organization, rhythm, volume are rarely described by the authors of clinical trials and therefore, no analyses or conclusions can be done. Despite this, music without lyrics seems to be effective to alleviate pain. Duration of music intervention should not exceed 30 min per session and if administered for several days, 14–30 days appear to be effective.8 Virtual Reality (VR) VR allows a complete immersion in an artificial three-dimensional environment. the device consists of a video headset, associated with a smartphone or connected to a computer, headphones. the headset has sensors that can track the movements of the user’s head to give the illusion of movement in virtual space. a feeling of real immersion is given through visual and auditory stimuli.9 VR and acute pain The use of VR to reduce pain and anxiety has been most widely studied in the treatment of burns in both adults and children. It seems that VR would be reversible and short lived and thus that VR would not have a persistent effect in the clinical context.10 the analgesic effects of immersive VR distraction has been evaluated in volunteers receiving thermal pain stimulation and exposed to opioid administration, VR, or opioid and VR. Combined opioid and VR reduced pain reports more effectively than did opioid alone on all subjective pain measures.11 The ability of VR to reduce pain has mostly been attributed to active distraction. Indeed, attention is required for pain and exists in limited supply. If the attention is diverted, resources available for processing pain will be reduced.12 VR seems to be much more effective compared to traditional techniques because of its highly immersive nature giving a sense of presence in the virtual world.12 VR and neurophysiology: In patients using VR and exposed to a painful stimulus, fMRI studies have shown, a reduction of more than 50% in pain-related brain activity in five areas of the brain including the periqueductal grey matter, the anterior cingulate gyrus and the orbital-frontal cortex.13 VR and chronic pain: Hoffman studied the value of VR during repeated physical therapy sessions in burn victims and showed significantly lower pain scores (30–35%), when patients were immersed in virtual reality. In addition, VR maintains its efficacy over repeated sessions.14 VR technology: the technical quality of virtual reality and the degree of immersion generated are directly correlated with the quantity of analgesia provided. the use of a ‘high-tech’ video headset with a high number of pixels also contributes to the amplification of immersion and, consequently, to a greater analgesic effect.15 16 In the future, it should be possible to offer a personified virtual world, taking into account the individual characteristics of the patient, (gender, personal interests) in order to increase the analgesic effect sought. Hypnosis ‘Hypnosis is a state of consciousness involving focus attention and reduced peripheral awareness characterized by enhanced capacity for response to suggestion’. 17 Usually, hypnosis is induced by a progressive muscle relaxation followed by guided imagery to experience oneself in a safe place chosen by the patient and followed by suggestions which can vary depending on the goal: analgesia and comfort for a surgery, more specific changes in the context of chronic pain. Finally, post-hypnotic suggestions are made to prolong the effect of hypnosis after the session including sometimes instruction to practice self-hypnosis at home (with or without audio recordings of the session). Hypnosis and acute pain: a systematic review and meta-analysis of 85 controlled experimental trials (3632 participants) showed that hypnosis produced moderate to large overall analgesia for all pain outcomes in the context of painful medical procedures (42 to 29% reduction of pain intensity for respectively high hypnotic suggestibility and medium hypnotic suggestibility) with a higher tolerance with a higher pain threshold when direct suggestion of pain relief were used.18 the importance of hypnotazibility as a determinant of hypnotically achievable analgesia might be true in laboratory studies but in clinical studies, however, in spite of the lack of selection, most patients are ‘hypnotizable enough’ to benefit from hypnotic intervention.17 ‘If confidence, motivation and then cooperation are present, everybody can reach the hypnotic state’. 19 In the pre-operative period, hypnosis can be used to decrease anxiety and catastrophizing thoughts, predictive of increased postoperative pain and maybe chronic pain.19A significant reduction in pain scores, analgesic consumption, post-operative nausea were found when hypnosis and local anaesthesia (hypnosedation) were compared with general anaesthesia.20 21 Less fatigue, improved recovery rates, decreased inflammatory response (IL-6) one day after surgery were also found.22 Hypnosis has been proven beneficial during invasive procedures by decreasing pain, anxiety and shortening operating times which is cost effective.17 19 23 In the postoperative period, hypnosis can be used to optimize patient’s comfort. Hypnosis combined with relaxing music was superior to relaxing music alone24 and hypnosis produced better results than distraction.17 Hypnosis and chronic pain: Hypnosis has been evaluated in a large number of chronic pain conditions (fibromyalgia, multiple sclerosis, irritable bowel syndrome, headache, sickle cell disease cancer-related pain). Intensity, duration, frequency of pain as well as the use of analgesics were reduced compared with standard care or supportive therapy.25 Effective protocols for pain management includes a minimum of 20 minutes time length, 4 or more sessions for hypnosis treatment and recommendations for home practice.25 Hypnosis in obstetrics: Beneficial effects of hypnosis on pain was shown reducing the overall use of analgesia during labour but not epidural use.26 Hypnosis and neurophysiology: Hypnosis suggestions produces a modification of activity in key regions of the brain involved in pain regulation, ACC, prefrontal and insular cortices.20 Combination of music, virtual reality and hypnosis A new line of VR research has emerged with the combination of music, virtual reality and hypnosis. VR technology is used with an audio recording of hypnotic induction, suggestions of wellbeing, pain relief and posthypnotic suggestions. Patterson evaluated the effect of VR distraction on a thermal pain stimulus in volunteers who received a hypnosis session or not before VR session distraction or no VRD. Hypnosis combined with VRD reduced by 22–25% subjective worst pain and unpleasantness more than VRD alone. Combination therapies including VR as a method for delivering hypnosis training may be promising to manage pain.9 the ability to instantly transport the patient into a virtual world for the purpose of distraction, to slow breathing and to deliver hypnosis suggestions makes VR a tremendously powerful tool. Studies are needed to compare the efficacy of VR hypnosis to hypnosis delivered by a therapist. Conclusions Music analgesia, VR and hypnosis produce alleviation of pain and can be considered as a complementary pain management strategy for both acute and chronic pain. Moreover, hypnosis can substitute general anesthesia in association with local anesthesia. Finally, the combination of music, virtual reality and hypnosis represents a promising association to help the management of anxiety and pain in medical conditions. References Hyung Lee. The effect on music on p