Can we safely manage pain using virtual reality (VR)?

Virtual reality (VR) has evolved beyond entertainment to enter the healthcare field with various applications such as medical training, health education, patient treatment, and pain management (Pillai and Mathew, 2019Pillai A.S. Mathew P.S. Impact of virtual reality in healthcare: A review.Virtual and augmented reality in mental health treatment. 2019; : 17-31https://doi.org/10.4018/978-1-5225-7168-1.CH002Crossref Google Scholar; Javaid and Haleem, 2020Javaid M. Haleem A. Virtual reality applications toward medical field.Clinical Epidemiology and Global Health. 2020; 8: 600-605https://doi.org/10.1016/J.CEGH.2019.12.010Abstract Full Text Full Text PDF Scopus (0) Google Scholar). VR has become less expensive and more widespread by virtue of the technological revolution and competitive marketing (Dymitrowski and Mielcarek, 2021Dymitrowski A. Mielcarek P. Business model innovation based on new technologies and its influence on a company's competitive advantage.Journal of Theoretical and Applied Electronic Commerce Research. 2021; 16 (2021, Vol. 16, Pages 2110-2128): 2110-2128https://doi.org/10.3390/JTAER16060118Crossref Google Scholar). While advanced VR systems need a highly-developed computer system, other devices only require a smartphone and downloadable applications, making them accessible for many (Gerschütz et al., 2019Gerschütz B. Fechter M. Schleich B. Wartzack S. A review of requirements and approaches for realistic visual perception in virtual reality.Proceedings of the Design Society: International Conference on Engineering Design. 2019; 1: 1893-1902https://doi.org/10.1017/DSI.2019.195Crossref Google Scholar). VR is a three-dimensional technology-generated environment that people can experience with their synchronized senses, making them feel as if they are immersed in their surroundings. There are different kinds of VR, each requiring specific displaying equipment (Vince, 2004Vince J. Introduction to virtual reality. Springer Science & Business Media, 2004Crossref Google Scholar). Non-immersive monitor-based VR allows the user to control activities within the system software, but the environment doesn't interact back. Video games are a non-immersive type where all actions within the game are performed by the player. Semi-immersive projector-based VR types allow the user to move on their own with some environmental back interaction where images are displayed on walls of a room (CAVE), screens, or large computer monitors. Virtual home tour applications are semi-immersive VR. In contrast, fully-immersive VR is another type where the user is fully present and interacts with the simulated environment by sensors using wearable headsets head-mounted display, gloves, or handheld devices. Medical complex training VR applications like neurosurgery applications are fully immersive VR (Bamodu and Ye, 2013Bamodu O. Ye X.M. Virtual reality and virtual reality system components.Advanced Materials Research. 2013; 765–767: 1169-1172https://doi.org/10.4028/WWW.SCIENTIFIC.NET/AMR.765-767.1169Crossref Google Scholar; Gerschütz et al., 2019Gerschütz B. Fechter M. Schleich B. Wartzack S. A review of requirements and approaches for realistic visual perception in virtual reality.Proceedings of the Design Society: International Conference on Engineering Design. 2019; 1: 1893-1902https://doi.org/10.1017/DSI.2019.195Crossref Google Scholar). A headset of VR or head-mounted display (HMD) allows complete immersion in the virtual world through stereoscopic lenses, stereo sound, and user's head tracking sensors to match the virtual camera with his eye positions. VR uses these synchronized senses to manipulate human perception and create what is called sense of presence where the user perceives himself as a part of this simulated environment (Chen et al., 2021Chen Y. Wang X. Xu H. Human factors/ergonomics evaluation for virtual reality headsets: a review.CCF Transactions on Pervasive Computing and Interaction. 2021; 3: 99-111https://doi.org/10.1007/S42486-021-00062-6/FIGURES/2Crossref Google Scholar). This virtual environment alters one's ability to perceive and respond to noxious stimuli by diverting the mind out of the real world and blocking the gate of the pain pathways leading the user to perceive less pain. This mechanism is considered a cognitive distraction, the primary mechanism of VR pain reduction that creates VR analgesia (Gupta et al., 2018aGupta A. Scott K. Dukewich M. Innovative technology using virtual reality in the treatment of pain: Does it reduce pain via distraction, or is there more to it?.Pain Medicine (Malden, Mass.). 2018; 19: 151-159https://doi.org/10.1093/PM/PNX109Crossref PubMed Scopus (0) Google Scholar; Wiech et al., 2010Wiech K. Lin C.S. Brodersen K.H. Bingel U. Ploner M. Tracey I. Anterior insula integrates information about salience into perceptual decisions about pain.The Journal of Neuroscience: The Official Journal of the Society for Neuroscience. 2010; 30: 16324-16331https://doi.org/10.1523/JNEUROSCI.2087-10.2010Crossref PubMed Scopus (334) Google Scholar). In addition, VR alters the user's sensation of chronic pain through interrupting the physiological means of detecting pain (Gold et al., 2007Gold, J. I., Belmont, K. A., & Thomas, D. A. (2007). The neurobiology of virtual reality pain attenuation. Http://Www.Liebertpub.Com/Cpb, 10(4), 536–544. https://doi.org/10.1089/CPB.2007.9993Google Scholar). The analgesic mechanism of VR has brought it to the attention of the acute and persistent pain management field (Smith et al., 2020Smith V. Warty R.R. Sursas J.A. Payne O. Nair A. Krishnan S. da Silva Costa F. Wallace E.M. Vollenhoven B. The effectiveness of virtual reality in managing acute pain and anxiety for medical inpatients: Systematic review.J Med Internet Res. 2020; 22 (2020;22(11):E17980 Https://Www.Jmir.Org/2020/11/E17980): e17980https://doi.org/10.2196/17980Crossref PubMed Scopus (42) Google Scholar). Considerable evidence illustrates the positive acute pain outcomes of VR in adults. Two systematic review and meta-analysis studies demonstrated the efficacy of VR analgesia for acute procedural and post-surgical pain conducted by Chan et al. (2018) and Ding et al., 2020Ding L. Hua H. Zhu H. Zhu S. Lu J. Zhao K. Xu Q. Effects of virtual reality on relieving postoperative pain in surgical patients: A systematic review and meta-analysis.International Journal of Surgery. 2020; 82: 87-94https://doi.org/10.1016/J.IJSU.2020.08.033Crossref PubMed Scopus (0) Google Scholar, respectively. VR reduced pain in a variety of clinical settings including pain from burns, pain from chemotherapy port access (Li et al., 2011Li, A., Montaño, Z., Chen, V. J., & Gold, J. I. (2011). Virtual reality and pain management: current trends and future directions. Http://Dx.Doi.Org/10.2217/Pmt.10.15, 1(2), 147–157. https://doi.org/10.2217/PMT.10.15Google Scholar), lumbar puncture pain (Sander et al., 2001Sander, S., Boggan, B., Eshelman, D., Guzzetta, C. E., & Wills Alcoser, P. (2001). Effects of distraction with use of virtual reality glasses during lumbar punctures in adolescents with cancer. Http://Dx.Doi.Org/10.1177/104345420101800244, 18(2), 83–83. https://doi.org/10.1177/104345420101800244Google Scholar), gastrointestinal endoscopy (Luis Mosso Vázquez et al., 2017Luis Mosso Vázquez J. Wiederhold B.K. Miller I. Mosso Lara D. Wiederhold M.D. Virtual Reality Assisted Anesthesia (VRAA) during Upper Gastrointestinal Endoscopy: Report of 115 Cases-Analysis of Physiological Responses. 5. 2017Google Scholar), labor pain (Akin et al., 2021Akin B. Yilmaz Kocak M. Küçükaydın Z. Güzel K. The effect of showing images of the foetus with the virtual reality glass during labour process on labour pain, birth perception and anxiety.Journal of Clinical Nursing. 2021; 30: 2301-2308https://doi.org/10.1111/JOCN.15768Crossref PubMed Google Scholar), and fibromyalgia (Gupta et al., 2018bGupta A. Scott K. Dukewich M. Innovative technology using virtual reality in the treatment of pain: Does it reduce pain via distraction, or is there more to it?.Pain Medicine. 2018; 19: 151-159https://doi.org/10.1093/PM/PNX109Crossref PubMed Scopus (0) Google Scholar). VR was found to minimize treatment avoidance (e.g., dental care) (Sweta et al., 2019Sweta V.R. Abhinav R.P. Ramesh A. Role of virtual reality in pain perception of patients following the administration of local anesthesia.Annals of Maxillofacial Surgery. 2019; 9: 110https://doi.org/10.4103/AMS.AMS_263_18Crossref PubMed Google Scholar) and the anxiety symptoms associated with acute pain (Smith et al., 2020Smith V. Warty R.R. Sursas J.A. Payne O. Nair A. Krishnan S. da Silva Costa F. Wallace E.M. Vollenhoven B. The effectiveness of virtual reality in managing acute pain and anxiety for medical inpatients: Systematic review.J Med Internet Res. 2020; 22 (2020;22(11):E17980 Https://Www.Jmir.Org/2020/11/E17980): e17980https://doi.org/10.2196/17980Crossref PubMed Scopus (42) Google Scholar). More recently, a systematic review of VR for acute pain management found reduced pain intensity in 83% of 19 studies when comparing VR to a non-VR group in settings of wound care, procedure-induced pain, physical or occupational therapy, dental treatment or generalized acute pain (Dreesmann et al., 2022Dreesmann N.J. Su H. Thompson H.J. A systematic review of virtual reality therapeutics for acute pain management.Pain Management Nursing. 2022; 23 (Epub 2022 Jul 19): 672-681https://doi.org/10.1016/j.pmn.2022.05.004Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). Due to the substantial evidence, VR has recently been approved by the Food and Drug Administration (FDA) for treating persistent low back pain in adults (FDA 2021FDAFDA Authorizes Marketing of Virtual Reality System for Chronic Pain Reduction.FDA. 2021; (|)https://www.fda.gov/news-events/press-announcements/fda-authorizes-marketing-virtual-reality-system-chronic-pain-reductionGoogle Scholar). VR, in combination with opioids, has allowed for decreasing opioid use and, consequently, the associated side effects (Giravi et al., 2022Giravi H.Y. Biskupiak Z. Tyler L.S. Bulaj G. Adjunct digital interventions improve opioid-based pain management: Impact of virtual reality and mobile applications on patient-centered pharmacy care.Frontiers in Digital Health. 4. Frontiers Media S.A., 2022https://doi.org/10.3389/fdgth.2022.884047Crossref Scopus (1) Google Scholar). Moreover, VR showed positive pain outcomes for chronic neck pain (Nusser et al., 2021Nusser M. Kramer M. Knapp S. Krischak G. Effects of virtual reality-based neck-specific sensorimotor training in patients with chronic neck pain: A randomized controlled pilot trial.Journal of Rehabilitation Medicine. 2021; 53https://doi.org/10.2340/16501977-2786Crossref PubMed Scopus (7) Google Scholar). While promising, research in VR managing persistent pain is still scant compared to the larger research body of VR managing acute or procedural pain (Hadjiat and Marchand, 2022Hadjiat Y. Marchand S. Virtual reality and the mediation of acute and chronic pain in adult and pediatric populations: Research developments.Frontiers in Pain Research. 2022; 3https://doi.org/10.3389/fpain.2022.840921Crossref Google Scholar). Some shortcomings of the available evidence include that inconsistent benefits of VR for persistent pain are due to the varied VR dosage used in different studies for adults, as Mallari et al., 2019Mallari B. Spaeth E.K. Goh H. Boyd B.S. Virtual reality as an analgesic for acute and chronic pain in adults: a systematic review and meta-analysis.Journal of Pain Research. 2019; 12: 2053https://doi.org/10.2147/JPR.S200498Crossref PubMed Scopus (125) Google Scholar reported in their systematic review and meta-analysis. They also claimed that the effect of VR was transient (during and immediately after the VR exposure) and doubted the probability of lasting analgesic effect. More randomized control trials are recommended to address the VR analgesic effect, dosage, and equipment types on persistent pain in adult and pediatric populations for better evidence-based research generation (Hadjiat and Marchand, 2022Hadjiat Y. Marchand S. Virtual reality and the mediation of acute and chronic pain in adult and pediatric populations: Research developments.Frontiers in Pain Research. 2022; 3https://doi.org/10.3389/fpain.2022.840921Crossref Google Scholar). Healthcare providers and patients perceive virtual reality as an adjuvant modality that enhances the patient's engagement and individualization in pain management clinical sittings despite its financial (Vincent et al., 2021Vincent C. Eberts M. Naik T. Gulick V. O'Hayer C.V Provider experiences of virtual reality in clinical treatment.PLOS ONE. 2021; 16e0259364https://doi.org/10.1371/JOURNAL.PONE.0259364Crossref Google Scholar), technical, and ethical challenges (Bruno et al., 2022Bruno R.R. Wolff G. Wernly B. Masyuk M. Piayda K. Leaver S. Erkens R. Oehler D. Afzal S. Heidari H. Kelm M. Jung C. Virtual and augmented reality in critical care medicine: the patient's, clinician's, and researcher's perspective.Critical Care. 2022; 26: 1-13https://doi.org/10.1186/S13054-022-04202-X/FIGURES/6Crossref PubMed Google Scholar), which could hinder its further integration and scaling utilization in the health care system (Sarkar et al., 2021Sarkar U. Lee J.E. Nguyen K.H. Lisker S. Lyles C.R. Barriers and facilitators to the implementation of virtual reality as a pain management modality in academic, community, and safety-net settings: Qualitative analysis.J Med Internet Res. 2021; 23 (2021;23(9):E26623 Https://Www.Jmir.Org/2021/9/E26623): e26623https://doi.org/10.2196/26623Crossref PubMed Scopus (6) Google Scholar). Currently, some clinicians are working on the integration of VR in the United States pain management clinical sittings (Clinical trials.gov, 2023; Stanford Medicine Children's Health 2023Stanford Medicine Children's Health, (2023). Virtual reality: Alleviating patients’ pain and anxiety with VR and AR technology. Retrieved January 21, 2023, from https://www.stanfordchildrens.org/en/innovation/virtual-realityGoogle Scholar), and in an ongoing project to use VR in the quality of life at the end of life (Quality of Life at the End of Life 2023Quality of Life at the End of Life, (2023) Changing the narrative of the end of life care: International research project. Retrieved January 21, 2023, from https://qeol.weplus.care/quality-of-life-at-the-end-of-lifeGoogle Scholar). Despite the broad range of uses of VR and its growing evidence base, the possibility of negative effects on health and safety must be considered. As with many innovations, the majority of studies investigating VR are conducted on healthy users. Yet, side effects have been noted, such as motion sickness, eyestrain, neck strain, isolation, and triggering seizures in vulnerable people (Garrett et al., 2018Garrett B. Taverner T. Gromala D. Tao G. Cordingley E. Sun C. Virtual reality clinical research: Promises and challenges.JMIR Serious Games. 2018; 6 (2018;6(4):E10839 Https://Games.Jmir.Org/2018/4/E10839): e10839https://doi.org/10.2196/10839Crossref PubMed Scopus (89) Google Scholar; Korolov, 2014Korolov M. The real risks of virtual reality. Risk Management.Gale Academic OneFile. 2014; 61: 20-24https://go.gale.com/ps/i.do?id=GALE%7CA386338813&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=00355593&p=AONE&sw=wGoogle Scholar; Subrahmanyam et al., 2000Subrahmanyam K. Kraut R.E. Greenfield P.M. Gross E.F. The impact of home computer use on children's activities and development.The Future of Children. 2000; : 123-144https://www.jstor.org/stable/1602692Crossref PubMed Scopus (282) Google Scholar). Motion sickness (cybersickness) includes dizziness, nausea, disorientation, sweating, pallor, loss of balance, and headache due to the brain's confusion between two different worlds (Garrett et al., 2018Garrett B. Taverner T. Gromala D. Tao G. Cordingley E. Sun C. Virtual reality clinical research: Promises and challenges.JMIR Serious Games. 2018; 6 (2018;6(4):E10839 Https://Games.Jmir.Org/2018/4/E10839): e10839https://doi.org/10.2196/10839Crossref PubMed Scopus (89) Google Scholar; Korolov, 2014Korolov M. The real risks of virtual reality. Risk Management.Gale Academic OneFile. 2014; 61: 20-24https://go.gale.com/ps/i.do?id=GALE%7CA386338813&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=00355593&p=AONE&sw=wGoogle Scholar; Regan & Price, 1994). Adverse effects are variable and may appear within the first few minutes of VR use in some people. Symptoms depend on the duration, frequency, sound volume, and applications' age-appropriateness (Subrahmanyam et al., 2000Subrahmanyam K. Kraut R.E. Greenfield P.M. Gross E.F. The impact of home computer use on children's activities and development.The Future of Children. 2000; : 123-144https://www.jstor.org/stable/1602692Crossref PubMed Scopus (282) Google Scholar). Albani et al., 2015Albani G. Pedroli E. Cipresso P. D B.-P. Visual hallucinations as incidental negative effects of virtual reality on Parkinson's disease patients: a link with neurodegeneration?.Parkinson's Disease. 2015; https://doi.org/10.1155/2015/194629Crossref PubMed Scopus (9) Google Scholar found that 25% of Parkinson's disease (PD) patients who had performed a VR protocol reported visual hallucinations in the following years after the VR protocol. The researchers concluded that VR might cause side effects in cognitive impairment-predisposed PD patients. Certainly, for persons with pain, additional symptoms cannot be taken lightly. Benefits must be weighed against possible risks. For cybersickness, manufacturers recommend stopping the VR session and taking a rest (ANSES, 2021). Yet, in the case of pediatric or cognitively-impaired populations, there may be difficulty communicating feelings of sickness or discomfort. Moreover, is it possible that cybersickness could trigger worsening symptoms and distress for adults with persistent pain-associated mood disorders. And, as long as the VR analgesic effect seems to be transient, how it can be safely used for persistent pain remains uncertain. Unfortunately, research cannot exhaust every possible scenario; therefore, it is up to nurses to be vigilant as they would be with any new drug or device once VR enters the clinical setting. Future controlled randomized trials will be required not only to calibrate the dosage, and frequency of VR in persistent pain for adults and children, but also to explore its short and long-term side effects. Such studies can generate evidence-based clinical practice guidelines to guarantee that VR-pain management interventions' pros outweigh their cons. We can look to other examples of pain innovations to see opportunities to improve on how to roll out and integrate new treatment options. In the case of opioids, it was believed at one time that the risk of addiction was low if opioids were used for pain management (Collier, 2018Collier R. A short history of pain management.CMAJ. 2018; 190 (PMID: 29311105; PMCID: PMC5760261): E26-E27https://doi.org/10.1503/cmaj.109-5523Crossref PubMed Scopus (10) Google Scholar). Now it is widely agreed upon, that is simply not true. Substance use disorders can develop in anyone who is at risk, even if opioids are being appropriately used for pain (Webster, 2017Webster L.R. Risk factors for opioid-use disorder and overdose.Anesthesia and Analgesia. 2017; 125: 1741-1748https://doi.org/10.1213/ANE.0000000000002496Crossref PubMed Scopus (226) Google Scholar). In another example, transcutaneous electrical nerve stimulation (TENS) units have been available for decades, with robust evidence showing they are helpful and safe (Tiktinsky et al., 2010Tiktinsky, R., Chen, L., Haemophilia, P. N.-, & 2010, undefined. (2010). Electrotherapy: yesterday, today and tomorrow. Wiley Online Library, 16(SUPPL. 5), 126–131. https://doi.org/10.1111/j.1365-2516.2010.02310.xGoogle Scholar). However, TENS-offering clinical settings and TENS-trained nurses to teach patients their use are still limited (Bazinski et al., 2022Bazinski M.A. Riley P. Ellis J. Darmody J. A quality initiative incorporating tablet technology to facilitate nonpharmacologic pain intervention use in the hospital.Pain Management Nursing. 2022; 23: 655-662https://doi.org/10.1016/J.PMN.2022.02.067Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). Additionally, there are many helpful pain self-management strategies that remain out of reach for patients due to cost and variation in health plan coverage (Gordon et al., 2017Gordon K. Rice H. Allcock N. Bell P. Dunbar M. Gilbert S. Wallace H. Barriers to self-management of chronic pain in primary care: a qualitative focus group study.British Journal of General Practice. 2017; 67: e209-e217https://doi.org/10.3399/BJGP17X688825Crossref PubMed Google Scholar). An opportunity exists with VR to do better with both the speed at which the innovation gets to people who may benefit and to avoid minimizing potential unwanted harms. Nurses can play a key role by keeping up with the recent research and evidence-based practice regarding integrating VR technology in clinical practice, including pain management nursing practice (Addab et al., 2022Addab S. Hamdy R. Thorstad K. Le May S. Tsimicalis A. Use of virtual reality in managing paediatric procedural pain and anxiety: An integrative literature review.Journal of Clinical Nursing. 2022; https://doi.org/10.1111/jocn.16217Crossref PubMed Scopus (6) Google Scholar; Furness et al., 2019Furness P.J. Phelan I. Babiker N.T. Fehily O. Lindley S.A. Thompson A.R. Reducing pain during wound dressings in burn care using virtual reality: A study of perceived impact and usability with patients and nurses.Journal of Burn Care & Research. 2019; 40: 878-885https://doi.org/10.1093/JBCR/IRZ106Crossref PubMed Google Scholar). Healthcare facilities have a role as well in updating their nursing staff for the appropriate application of VR in all clinical settings (Desselle et al., 2022Desselle M.R. Holland L.R. McKittrick A. Kennedy G. Yates P. Brown J. “A Wanderer's Tale”: The development of a virtual reality application for pain and quality of life in Australian burns and oncology patients.Palliative & Supportive Care. 2022; : 1-7https://doi.org/10.1017/S1478951522000530Crossref Google Scholar; Ferguson et al., 2016Ferguson, C., Davidson, P. M., Scott, P. J., Jackson, D., & Hickman, L. D. (2016). Augmented reality, virtual reality and gaming: an integral part of nursing. Https://Doi.Org/10.1080/10376178.2015.1130360, 51(1), 1–4. https://doi.org/10.1080/10376178.2015.1130360Google Scholar; Son et al., 2022Son H. Ross A. Mendoza-Tirado E. Lee L.J. Virtual reality in clinical practice and research: Viewpoint on novel applications for nursing.JMIR Nursing. 2022; 5 (2022;5(1): E34036 Https://Nursing.Jmir.Org/2022/1/E34036): e34036https://doi.org/10.2196/34036Crossref PubMed Google Scholar). Research and quality improvement projects can continue to explore preferred duration and kinds of VR content utilized along with optimizing infection control practices and training for VR use (Dreesmann et al., 2022Dreesmann N.J. Su H. Thompson H.J. A systematic review of virtual reality therapeutics for acute pain management.Pain Management Nursing. 2022; 23 (Epub 2022 Jul 19): 672-681https://doi.org/10.1016/j.pmn.2022.05.004Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). The time has arrived to provide nurses with sufficient knowledge and skills to understand VR and to safely apply it in their clinical practice for better enhancement of pain nursing care. Healthcare strategies are needed that utilize technology-based modalities with appropriate caution, checks, and balances. However, this won't be achieved unless healthcare systems are nimble and prioritize judicious adoption of innovations, thus providing patients the option to benefit from research outcomes. VR offers an opportunity to create systems that can test new products efficiently, while considering the probability of a small sub-population not tolerating the VR experiences. This month's Pain Management Nursing journal features a study by researchers from Mashhad, Iran who found VR could be used effectively for patient education while reducing anxiety and pain in a surgical setting. These and other creative ideas from researchers demonstrate the countless ways VR can make meaningful improvements. The ideal practice settings will stand ready and able to launch VR as a novel solution and modify as necessary to achieve the best possible outcomes for people with pain.