Background & Aims

The use of extended reality (XR), including virtual reality (VR) and augmented reality (AR), for treating pain has accelerated in the last 10 years. XR is an attractive biobehavioral intervention that may support management of pain intensity itself and/or pain related disability (e.g., anxiety, distress, movement). Several mechanisms of action have been proposed (e.g., cognitive, emotional, physical/behavioural targets) to explain XR effects on pain, but these are not fully understood. Reviews of adult literature report promising results, particularly for acute procedural pain.(1)
This study aimed to (a) summarise the available evidence with respect to feasibility, safety, and effectiveness [pain intensity] of XR for pediatric acute and chronic pain management, (b) summarize assessment tools used to measure study outcomes, and (c) identify gaps in evidence to guide future research efforts in this field.

Methods

This study is a systematic review of the literature (PROSPERO # CRD42022307153). Multiple databases were searched from inception until March 2024: CINAHL, Cochrane Central, Embase, MEDLINE, PsycINFO. Duplicates were removed and citations uploaded into Covidence software.(2) Each title and abstract and a subset of full-text articles were reviewed independently by two team members to determine eligibility for inclusion. Articles were included if: (a) participants were aged 0-18 years; (b) study intervention was VR or AR; (c) study outcomes included safety, feasibility, acceptability, and/or effectiveness on the outcome of pain; and (d) study design was observational or interventional.
For included articles, data were collected on bibliographic information, study characteristics, XR characteristics, outcome domains, and outcome measures, study findings pertaining to safety, feasibility, and effectiveness. The MINORS(3) and RoB-2(4) were used to assess risk of bias of included studies.

Results

A total of 1615 titles/abstracts were screened and 475 full-text articles were reviewed for eligibility, with 90 articles included in the review. All included studies used VR and 93% (n=84) studied VR in the context of acute pain. Seventy-four studies were randomized trials, and 16 studies were observational. Safety was assessed in 23 studies of acute pain, with 13 studies reporting no adverse events and 10 studies reported events of low concern (e.g., mild nausea). Feasibility was assessed in 26 studies of acute pain and 1 study of chronic pain. Of the 84 studies of acute pain, 62% studies reported a positive effect on pain intensity, 21% reported no effect, and 13% reported mixed effects. All 6 studies in chronic pain reported a positive effect on pain intensity. An evidence gap map is used to illuminate gaps in specific research areas stratified by sub-types of pain (e.g., procedural, wound care) and across multiple domains of effectiveness (e.g., pain intensity, fear, physical function). Risk of bias assessment revealed 67 studies had a moderate risk of bias, 17 studies had a high risk, and 5 studies were deemed to be low risk.

Conclusions

The study of XR to treat pediatric acute and chronic pain is accelerating at a fast pace. The current body of literature is focused on acute pain with promising results of safety and effectiveness on pain intensity. The literature pertaining to chronic pain lags behind, limiting our ability to draw conclusions in this population. Study risk of bias is problematic in this field with the inherent challenge of blinding participants and researchers to the intervention. Future research should aim to measure effectiveness beyond pain intensity with a consistent approach to measuring multiple outcome domains and using outcome measures that are validated for use in pediatrics. Current efforts are underway to establish expert consensus on best research practices in this field.

References

1.Mallari B, Spaeth EK, Goh H, Boyd BS. Virtual reality as an analgesic for acute and chronic pain in adults: a systematic review and meta-analysis. J Pain Res. 2019;12:2053-2085. doi:10.2147/JPR.S200498
2.Covidence systematic review software. www.covidence.org
3.Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non?randomized studies ( MINORS ): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712-716. doi:10.1046/j.1445-2197.2003.02748.x
4.Higgins JP, Savovi? J, Page MJ, Elbers RG, Sterne JA. Assessing risk of bias in a randomized trial. In: Higgins JPT, Thomas J, Chandler J, et al., eds. Cochrane Handbook for Systematic Reviews of Interventions. 1st ed. Wiley; 2019:205-228. doi:10.1002/9781119536604.ch8

Presenting Author

Giulia Mesaroli

Poster Authors

Giulia Mesaroli, MScPT

MScPT

SickKids and University of Toronto

Lead Author

Courtney W. Hess

PhD

Stanford University School of Medicine

Lead Author

Brittany Rosenbloom

PhD

Women's College Hospital

Lead Author

Cristal Lopez

PhD

Children's Hospital Los Angeles

Lead Author

Nhat Ngo

BS

Children's Hospital Los Angeles

Lead Author

Estreya Cohen

BA

York University

Lead Author

Jeffrey Gold

PhD

Children's Hospital Los Angeles

Lead Author

Deirdre Logan

PhD

Boston Children's Hospital and Harvard University

Lead Author

Laura Simons

PhD

Stanford University School of Medicine

Lead Author

Jennifer Stinson

PhD

SickKids and University of Toronto

Lead Author

Carley Oulette

RN

McMaster University

Lead Author

Topics

  • Pain in Special Populations: Infants/Children