Improving Reality Virtually: Advent of the Virtual “Digi-ceutical”?

Management of the psychological state through pharmacological and nonpharmacological treatments has been a focus of health care for millennia. Ancient therapies, such as ingesting devil peppers in ancient India or bowssening (immersing in water) in medieval Europe, relied on distraction rather than alteration of neurobiochemistry to alleviate anxiety. In modern times, pharmacological therapies such as benzodiazepines have replaced such ancient techniques. However, given the concerns of pharmacological interactions, risk of postoperative delirium, and physiological dependence, there has been interest in identifying alternative nonpharmacological solutions that alleviate anxiety, depression, and other psychological disturbances. Surgery is an event that is highly anxiety-provoking and for which clinicians often use pharmacological agents to relieve stress. The focus on alleviating anxiety lies in the association with poor postsurgical outcomes including prolonged induction of anesthesia, poorer postoperative recovery, and increased analgesic requirements.1Pereira L. Figuereido-Braga M. Carvalho I.P. Preoperative anxiety in ambulatory surgery: the imapct of an empathic patient-centered approach on psychological and clinical outcomes.Patient Educ Couns. 2016; 99: 733-738Crossref PubMed Scopus (81) Google Scholar Thus, it is critical to identify ways to manage preoperative anxiety effectively. For many patients, preoperative educational tools or inclusion of known elements into the preoperative environment (family members, friends, etc) can help alleviate anxiety. However, because of the constraints of sterility and optimizing privacy for other patients, use of these approaches has limitations. A number of other psychosocial interventions have also been studied, with the main goal aimed at distraction. These include reading materials, video games, and music therapy. Interactive audiovisual games have been found to be particularly effective in the pediatric population.2Manyande A. Cyna A.M. Yip P. Chooi C. Middleton P. Non-pharmacological interventions for assisting the induction of anaesthesia in children.Cochrane Database Syst Rev. 2015; 7: CD006447Google Scholar These data highlight the potential value of nonpharmacological methods to alleviate acute psychological stress induced by the anticipation of complex medical and surgical interventions. The increasing development and availability of virtual immersive technologies in the past 5 years has raised interest in applications to managing periprocedural and health care–related anxiety, delirium, and depression. There is growing evidence on the use of augmented reality and virtual reality interventions in pain management of adults and children in the hospital, rehabilitation, and preoperative settings.3Eijlers R. Utens E.M.W.J. Staals L.M. et al.Systematic review and meta-analysis of virtual reality in pediatrics: effects on pain and anxiety.Anesth Analg. 2019; 129: 1344-1353Crossref PubMed Scopus (140) Google Scholar, 4Mallari 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.J Pain Res. 2019; 12: 2053-2085Crossref PubMed Scopus (111) Google Scholar, 5Jin W. Choo A. Gromala D. Shaw C. Squire P. A virtual reality game for chronic pain management: a randomized, controlled clinical study.Stud Health Technol Inform. 2016; 220: 154-160PubMed Google Scholar, 6Ryu J.H. Park S.J. Park J.W. et al.Randomized clinical trial of immersive virtual reality tour of the operating theatre in children before anaesthesia.Br J Surg. 2017; 104: 1628-1633Crossref PubMed Scopus (66) Google Scholar, 7Bekelis K. Calnan D. Simmons N. MacKenzie T.A. Kakoulides G. Effect of an immersive preoperative virtual reality experience on patient reported outcomes: a randomized controlled trial.Ann Surg. 2017; 265: 1068-1073Crossref PubMed Scopus (71) Google Scholar The theory behind the use of virtual reality is rationally based. First, distracters that subsume multiple senses (visual, auditory) or allow for mental engagement are known to improve psychological state, reduce pain, and diminish anxiety regarding procedures.2Manyande A. Cyna A.M. Yip P. Chooi C. Middleton P. Non-pharmacological interventions for assisting the induction of anaesthesia in children.Cochrane Database Syst Rev. 2015; 7: CD006447Google Scholar Second, most traditional distraction techniques (eg, use of tablet-based games or engagement of family members) still involve the distracter being only one small element of a much larger, dynamic, and often noisy environment. Finally, virtual reality tools are now more accessible and the technology is less expensive. Thus, it is reasonable to hypothesize that virtual reality technologies may effectively and efficiently alleviate patient anxiety in stressful health care environments because of their ability to “remove” the patient from the environment via comprehensive engagement of multiple senses. The main limitation of assessing the value of virtual reality to alleviate psychological stress is the lack of rigorously obtained prospective data and standardization of procedures. Additionally, most studies have evaluated use in pediatric populations, though recent studies are increasingly focused on adult populations as well.4Mallari 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.J Pain Res. 2019; 12: 2053-2085Crossref PubMed Scopus (111) Google Scholar,7Bekelis K. Calnan D. Simmons N. MacKenzie T.A. Kakoulides G. Effect of an immersive preoperative virtual reality experience on patient reported outcomes: a randomized controlled trial.Ann Surg. 2017; 265: 1068-1073Crossref PubMed Scopus (71) Google Scholar Finally, data are still limited to small cohorts with often observational study designs. Thus, the use of virtual reality broadly in health care has been hindered by lack of clear evidence to support broad applicability and efficacy. Given these limitations, the article by Hendricks et al8Hendricks T. Gutierrez C. Stulak J. Dearani J. Miller J. The use of virtual reality to reduce preoperative anxiety in first time sternotomy patients: a randomized-controlled pilot trial.Mayo Clinic Proc. 2020; 95: 1148-1157Abstract Full Text Full Text PDF Scopus (9) Google Scholar in this issue of Mayo Clinic Proceedings should be applauded for assessing the use of virtual reality in alleviating anxiety in a medically complex population with randomization, a clear control group, and blinding on the part of the study operators. They reported that multiple subjective assessors of anxiety improved with the use of a virtual reality program. These findings are supportive of the premise that virtual reality–based interfaces may alleviate preoperative anxiety better than systems that do not offer the same level of immersion. One of the key findings was that there was minimal disruption of workflows in the preoperative setting, which is often a major concern when introducing new technology into complex health care environments. The study by Hendricks et al should be seen as a relevant advance and building block in establishing how useful virtual reality may be as a therapeutic tool. However, it still should not be seen as foundational proof either. There are several limitations including the size of the study (20 patients), the subjective nature of anxiety assessment, lack of correlation with improvement in outcomes to justify differences in cost, and the finding that those who were randomized to the use of virtual reality experienced more imbalance. Ideally, objective evidence of reduction in stress as assessed by biological variables (heart rate variability, skin sympathetic nerve activity, etc) will be important to address value. Furthermore, it is possible that the subjective response may be due to the newness of the virtual reality solution among its users. Finally, although the cost of virtual technology continues to decrease, it will be important to find that the health benefits attained through its use justify the cost of its adoption. Despite these limitations, Hendricks et al should be congratulated on a sound trial design and clear methodology. With the continuing development of digital technologies that may work in concert with patients and physicians to improve the patient experience and patient outcomes, such “digi-ceuticals” require appropriate attention from the medical research community and rigorous evaluation. Hopefully, future studies will build on this scientific foundation in establishing how virtual tools may improve our current health care realities. The Use of Virtual Reality to Reduce Preoperative Anxiety in First-Time Sternotomy Patients: A Randomized Controlled Pilot TrialMayo Clinic ProceedingsVol. 95Issue 6PreviewTo report the first randomized controlled trial to investigate if immersive virtual reality (VR) treatment can reduce patient perceptions of anxiety compared with a tablet-based control treatment in adults undergoing a first-time sternotomy. Full-Text PDF