Decreasing REcurrent Pain and Anxiety in Medical Procedures With a Pediatric Population: a Pilot Study
Condition: Pain; Anxiety; Burns; Child; Injuries
MeSH terms: Anxiety Disorders
Study type: Interventional

Summary: 
      Children with injuries, including burns, experience severe pain intensity during medical
      procedures despite the increasing doses of analgesics. Current guidelines on pediatric
      procedural pain management recommend the combination of non-pharmacological and
      pharmacological interventions to enhance pain management and decrease the numerous side
      effects of analgesics. Virtual reality (VR) has gained growing consideration as a
      non-pharmacological method as it engages multiple senses and allows interactions with a
      virtual world. Oculus Rift ® (OR) is a new technology in VR that provides more immersiveness,
      at a relatively low cost, and could probably improve the management of pain and anxiety in
      wound care.

      Overall hypothesis: Distraction by VR via the OR, in combination with the standard
      pharmacological treatment, is a feasible, acceptable and satisfactory method for the
      management of pain and anxiety during wound-related treatments in children with injuries.

      Note that this pilot study will precede a larger trial aimed at assessing the effect of
      virtual reality distraction via the Oculus Rift ® (DREAM-T: NCT02947243)
    

Detailed description: 
      BACKGROUND:

      Injuries, including burns, are the leading cause of morbidity and mortality in children. They
      are associated with a lot of pain that is difficult to treat and can impede recovery, cause
      high levels of anxiety and alter future pain behaviors, resulting, at times, in chronic pain,
      paresthesia, or depression. Pain can also decrease participation in treatments such as
      physiotherapy resulting in poor health outcomes. Beyond the immediate pain experience,
      children may also develop pain memory circuits. Procedural pain is still largely managed
      pharmacologically mostly through the use of opioids, benzodiazepines, and other
      pharmacological agents which cause a lot of side effects and do not always provide sufficient
      pain reduction. In recent years, the effectiveness of multimodal approaches combining
      medication with non-pharmacological interventions for procedural pain relief has been
      highlighte. Distraction techniques engaging multiple senses may grab the child's attention
      more than the techniques that only engage one sense (e.g, music), hence, the increasing
      interest in more immersive and interactive methods of distraction such as Virtual Reality
      (VR).

      VR is an active distraction method that allows the user to interact with an immersive
      environment generated by a computer stimulating different senses. A review of studies on VR,
      mostly conducted with adult burn patients, showed a 35 to 50% reduction in procedural pain
      while using VR. However, despite promising results, the use of VR in healthcare settings has
      been limited, mainly due to its high cost. Reviews have highlighted the need for more
      research but mostly for the development of more portable, less expensive and more developed
      VR systems that would promote pain reduction during burn procedures especially for children
      with burn injuries who are considered one of the most challenging burn populations. However,
      there has been a breakthrough in technology since 2014 when big scale companies started
      investing in VR development for commercial gaming. Facebook purchased the Oculus Rift (OR)
      for mass production allowing access to the latest technology in VR at a relatively low cost.
      OR is a VR tool that provides a wide field of view (FOV), high-resolution display, integrated
      3D audio and motion detection. In addition, it's highly immersive properties could help
      achieve more analgesia compared to other VR techniques as a review has shown that the sense
      of presence influences the effectiveness of VR-based analgesia. The sense of presence is a
      subjective psychological state of consciousness of being in the virtual world whereas
      immersiveness refers to the physical environment that could be quantified by measuring the
      field of view or the peripheral vision in the VR goggles. The availability of inexpensive yet
      highly immersive VR goggles such as OR could increase the use of VR in pain management and
      burn settings while significantly improving its cost-effectiveness. A single case study
      assessed the feasibility of a VR intervention via OR in one child of 11 years old with burn
      injuries during occupational therapy. The study showed a reduction in pain intensity and pain
      unpleasantness experienced by the patient, without any side effects. To our knowledge, no
      other studies have tested the feasibility of OR for procedural pain management in children
      with injuries undergoing painful physiotherapy treatments or wound care.

      AIM: The aim of this pilot clinical trial is to assess the acceptability and feasibility of
      VR distraction using the OR in children with injuries undergoing wound-related treatments
      (physiotherapy or dressing change). We also plan to evaluate the feasibility of the design
      and to predict appropriate sample size for a larger-scale clinical trial.

      METHODS:

      Design: Within-subject/crossover study design. Each child will serve as his own control and
      will receive both standard and experimental treatment during the same treatment session
      through a randomized order.

      Sample and Setting: Convenience sampling on the surgical-trauma unit at CHU Ste-Justine, of
      children presenting with an injury.

      Interventions. A) Standard pharmacological treatment as per the unit's protocol. B) VR
      distraction through the use of OR.The video games were developed by our team with a
      personalized care content tailored to the children's developmental stage and to maximize the
      feeling of immersion and minimize cybersickness, and approved by a team of healthcare
      professionals in pediatric care.

      Study proceedings: Physiotherapy sessions and dressing changes typically last between 20 to
      30 minutes. The duration will be divided into two sequences of the same duration (10 to 15
      minutes) where the participant receives the same care by the same healthcare professional.
      For one sequence, only the standard treatment will be administered and for the other
      sequence, patients will receive the standard treatment in addition to VR via OR in a
      randomized order.

      Measures: Pain and anxiety measures will be taken before the treatment session at (T1), after
      the first sequence of the session (T2) and after the second sequence of the session (T3)
      followed by a measure of nurses' satisfaction level via a questionnaire developed and
      pretested by the team. We will collect data on the average doses of analgesics administered
      before and during the session, and the side effects experienced in addition to the design's
      feasibility outcomes: participants recruited each month, adherence to study protocol.

      Data analysis: Quantitative analysis. Mean differences in pain scores between sequences will
      be compared using Wilcoxon test.
    

Intervention name(s): VR distraction via Oculus Rift; Standard pharmacological treatment
Intervention type(s): Device; Other
Intervention description(s): In addition to standard pharmacological treatment, Virtual reality distraction through the use of Oculus Rift® will be used as the experimental intervention. The Oculus Rift (Consumer version) is made of two Oled panels with a resolution of 1200p running at 90Hz. It has very effective 360 degree positional tracking and integrated 3D audio. These combine to produce a high level of immersion, with high photorealism while maintaining the low latency necessary to induce presence and prevent cybersickness. The child, depending on the site of the injury, will have the opportunity to interact with the game. Video games, approved by healthcare professionals with extensive experience in pediatrics, were adapted for children and tailored to minimize cyber sickness.; according to the unit's protocol and adjusted to each participant's age, weight and condition by the anesthetist and pain clinic nurse.
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Virtual reality; Immersive distraction; Oculus rift; Virtual world; Virtual environment; Procedural pain; Procedural anxiety; Acute pain; Pain management; Anxiety; Children, Child; Kid, Kids; Pediatric, Pediatrics; Young children; Burns; Burn injuries; Burn unit; Physiotherapy; Physical therapy; Burn dressing; Dressing change; Non-pharmacological, nonpharmacological; Clinical Research; Nursing Practice; Trauma