Background & Aims

Outpatient pediatric orthopedic procedures induce considerable pain and stress in children.1 Despite their brief duration and the necessity for swift turnover in outpatient clinics, there is a lack of interventions dedicated to alleviating the associated pain, stress, and anxiety.2 Approaches like analgesia and topical anesthetics have proven ineffective in reducing procedural pain in this population.3 Moreover, narcotics and procedural sedation pose challenges, requiring surveillance and elongating clinic visits, resulting in undesirable side effects.4 Thus, it is crucial to explore non-pharmacological pain management methods, as they demand minimal preparation and typically have no side effects. This randomized control trial (RCT) aimed to investigate the impact of Virtual Reality (VR) in comparison to passive distraction in children undergoing percutaneous bone pins or sutures removal in an orthopedic setting. The results presented in this abstract are part of secondary analyses.

Methods

We conducted a prospective RCT at three pediatric centers in Montreal, involving children aged 6-17 undergoing bone pins or sutures removal. The experimental group used VR distraction, while controls used a Tablet video game. The study, aiming for 80% power at a 2.5% significance level, required 188 participants, based on our pilot study.2 We measured primary outcomes of pain intensity using the Numerical Rating Scale, and secondary outcomes of time thinking about pain, pain unpleasantness, worst pain, fun during the session, satisfaction, nausea, and memory of pain using a Graphic Rating Scale. Mid-trial, we added stress level measurements based on pre (T0) – and post (T1) – procedure salivary Alpha-Amylase levels. Statistical analysis involved comparing means between groups and within subgroups stratified by age and gender, using Wilcoxon test, t-test, and ANCOVA.

Results

There was no significant difference (p = 0.90) between groups on the mean score of pain (T0 VR 1.33±2.00; T0 Tablet 1.28±1.93 and T1 VR 3.73±3.12; T1 Tablet 3.71±1.31). VR participants thought less about pain (4.2±3.0 v. 4.4±2.9; p=0.57), had lower pain unpleasantness (4.5±3.0 v. 5.0±3.0), and lower worst pain (4.8±2.9 v. 5.6±3.0), but no significant differences (p=0.22 and p=0.069). VR users had more fun during the sessions (8.0±2.6 v. 7.3±3.1; p=0.098) and more satisfaction with treatment (9.2±1.2 v. 8.6±1.9; p=0.015). Tablet users had slightly more nausea (0.2±1.0 v. 0.1±0.6 for VR; p=0.37). Pain memory did not differ (3.33±3.2 for both; p=0.99). VR (n=36) had a T0 mean amylase level of 127.73 U/L and Tablet (n=35) 158.09 U/L (p=0.54). At T1, VR levels were 134.78 U/L and Tablet were 153.70 U/L (p=0.26). No significant age or gender differences (6-12 years T0 p=0.86 and T1 p=0.23; 13+ years T0 p=0.28 and T1 p=0.94; girls T0 p=0.28 and T1 p=0.94; boys T0 p=0.11 and T1 p=0.12).

Conclusions

This study highlights insights on VR and Tablet use in clinical settings. Alpha-amylase was added mid-trial, resulting in insufficient power to detect a difference between VR and Tablet groups. However, this addition offered valuable insights into the feasibility of implementing this measure in a VR trial. VR group children reported lower pain and higher pleasure scores, with lower nausea levels. These findings suggest VR’s efficacy in enhancing pediatric patient experience, emphasizing its potential in creating a more pleasant clinical environment. Further research is needed to fully explore VR’s benefits in pediatric healthcare, especially in medical procedures.

References

1. Beigom Bigdeli Shamloo M, Zonoori S, Naboureh A, Nasiri M, Bahrami H, Maneiey M, Allahyari Bayatiani F. Effect of Face-to-Face Education on Anxiety and Pain in Children with Minor Extremity Injuries Undergoing Outpatient Suturing in Emergency Department. Indian Pediatrics. 2018 Jan;55:41-4.

2. Le May S, Tsimicalis A, Noel M, Rainville P, Khadra C, Ballard A, Guingo E, Cotes?Turpin C, Addab S, Chougui K, Francoeur M. Immersive virtual reality vs. non?immersive distraction for pain management of children during bone pins and sutures removal: a randomized clinical trial protocol. Journal of advanced nursing. 2021 Jan;77(1):439-47.

3. Lim KB, Tan SS, Abdullah SN, Ong LL, Wong ML, Allen JC. Percutaneous pin removal in the outpatient clinic—do children require analgesia?: a randomized controlled trial. JBJS. 2014 Apr 2;96(7):597-602.

4. Dulai SK, Firth K, Al-Mansoori K, Cave D, Kemp KA, Silveira A, Saraswat MK, Beaupre LA. Does topical anesthetic reduce pain during intraosseous pin removal in children? a randomized controlled trial. Journal of Pediatric Orthopaedics. 2016 Mar 1;36(2):126-31.

Presenting Author

Raissa Passos dos Santos

Poster Authors

Raissa Passos dos Santos

PhD

Université de Montréal

Lead Author

Estelle Guingo

Université du Québec en Abitibi-Témiscamingue

Lead Author

Argerie Tsimicalis

RN

Ingram School of Nursing, McGill University; Shriners Hospitals for Children-Canada

Lead Author

Melanie N. Noel

PhD

Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada

Lead Author

Pierre Rainville

Université de Montréal

Lead Author

Christelle Khadra

PhD

Université de Montréal, CA

Lead Author

Ariane Ballard

PhD

McGill University, CA

Lead Author

Casey Cotes-Turpin

MSc

Université du Québec en Abitibi-Témiscamingue, CA

Lead Author

Sofia Addab

Shriners Hospitals for Children-Canada

Lead Author

Khadidja Chougui

PhD(c)

Université de Montreal, CA

Lead Author

Maxime Francoeur

BScN

Université de Montréal, CA

Lead Author

Nicole Hung

Université de Montréal

Lead Author

Mitchell Bernstein

MD FRCSC

McGill University, CA

Lead Author

Stéphane Bouchard

PhD

UQO Université du Québec en Outaouais, Saint-Jérôme, CA

Lead Author

Stéfan Parent

PhD

Université de Montreal, CA

Lead Author

Mathilde Hupin Debeurme

FRCS(C)

Université de Montréal, CA

Lead Author

Sylvie Le May

Université de Montréal, CA

Lead Author

Pascale OUIMET

RN . BScN

Research Centre, CHU Sainte-Justine, Montreal, QC, Canada

Lead Author

Janick Carmel

BSc Psychology

Université de Montréal, CA

Lead Author

Topics

  • Pain in Special Populations: Infants/Children