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. 2020 Oct 22;10(10):CD010686.
doi: 10.1002/14651858.CD010686.pub2.

Virtual reality distraction for acute pain in children

Veronica Lambert  1 , Patrick Boylan  2 , Lorraine Boran  2 , Paula Hicks  3 , Richard Kirubakaran  4 , Declan Devane  5 , Anne Matthews  1
Affiliations

Virtual reality distraction for acute pain in children

Veronica Lambert et al. Cochrane Database Syst Rev. .

Abstract

Background: Virtual reality (VR) computer technology creates a simulated environment, perceived as comparable to the real world, with which users can actively interact. The effectiveness of VR distraction on acute pain intensity in children is uncertain.

Objectives: To assess the effectiveness and adverse effects of virtual reality (VR) distraction interventions for children (0 to 18 years) with acute pain in any healthcare setting.

Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and four trial registries to October 2019. We also searched reference lists of eligible studies, handsearched relevant journals and contacted study authors.

Selection criteria: Randomised controlled trials (RCTs), including cross-over and cluster-RCTs, comparing VR distraction to no distraction, non-VR distraction or other VR distraction.

Data collection and analysis: We used standard Cochrane methodological processes. Two reviewers assessed risk of bias and extracted data independently. The primary outcome was acute pain intensity (during procedure, and up to one hour post-procedure). Secondary outcomes were adverse effects, child satisfaction with VR, pain-related distress, parent anxiety, rescue analgesia and cost. We used GRADE and created 'Summary of findings' tables.

Main results: We included 17 RCTs (1008 participants aged four to 18 years) undergoing various procedures in healthcare settings. We did not pool data because the heterogeneity in population (i.e. diverse ages and developmental stages of children and their different perceptions and reactions to pain) and variations in procedural conditions (e.g. phlebotomy, burn wound dressings, physical therapy sessions), and consequent level of pain experienced, made statistical pooling of data impossible. We narratively describe results. We judged most studies to be at unclear risk of selection bias, high risk of performance and detection bias, and high risk of bias for small sample sizes. Across all comparisons and outcomes, we downgraded the certainty of evidence to low or very low due to serious study limitations and serious or very serious indirectness. We also downgraded some of the evidence for very serious imprecision. 1: VR distraction versus no distraction Acute pain intensity: during procedure Self-report: one study (42 participants) found no beneficial effect of non-immersive VR (very low-certainty evidence). Observer-report: no data. Behavioural measurements (observer-report): two studies, 62 participants; low-certainty evidence. One study (n = 42) found no beneficial effect of non-immersive VR. One study (n = 20) found a beneficial effect favouring immersive VR. Acute pain intensity: post-procedure Self-report: 10 studies, 461 participants; very low-certainty evidence. Four studies (n = 95) found no beneficial effect of immersive and semi-immersive or non-immersive VR. Five studies (n = 357) found a beneficial effect favouring immersive VR. Another study (n = 9) reported less pain in the VR group. Observer-report: two studies (216 participants; low-certainty evidence) found a beneficial effect of immersive VR, as reported by primary caregiver/parents or nurses. One study (n = 80) found a beneficial effect of immersive VR, as reported by researchers. Behavioural measurements (observer-report): one study (42 participants) found no beneficial effect of non-immersive VR (very low-certainty evidence). Adverse effects: five studies, 154 participants; very low-certainty evidence. Three studies (n = 53) reported no adverse effects. Two studies (n = 101) reported mild adverse effects (e.g. nausea) in the VR group. 2: VR distraction versus other non-VR distraction Acute pain intensity: during procedure Self-report, observer-report and behavioural measurements (observer-report): two studies, 106 participants: Self-report: one study (n = 65) found a beneficial effect favouring immersive VR and one (n = 41) found no evidence of a difference in mean pain change scores (very low-certainty evidence). Observer-report: one study (n = 65) found a beneficial effect favouring immersive VR and one (n = 41) found no evidence of a difference in mean pain change scores (low-certainty evidence). Behavioural measurements (observer-report): one study (n = 65) found a beneficial effect favouring immersive VR and one (n = 41) reported a difference in mean pain change scores with fewer pain behaviours in VR group (low-certainty evidence). Acute pain intensity: post-procedure Self-report: eight studies, 575 participants; very low-certainty evidence. Two studies (n = 146) found a beneficial effect favouring immersive VR. Two studies (n = 252) reported a between-group difference favouring immersive VR. One study (n = 59) found no beneficial effect of immersive VR versus television and Child Life non-VR distraction. One study (n = 18) found no beneficial effect of semi-immersive VR. Two studies (n = 100) reported no between-group difference. Observer-report: three studies, 187 participants; low-certainty evidence. One study (n = 81) found a beneficial effect favouring immersive VR for parent, nurse and researcher reports. One study (n = 65) found a beneficial effect favouring immersive VR for caregiver reports. Another study (n = 41) reported no evidence of a difference in mean pain change scores. Behavioural measurements (observer-report): two studies, 106 participants; low-certainty evidence. One study (n = 65) found a beneficial effect favouring immersive VR. Another study (n = 41) reported no evidence of a difference in mean pain change scores. Adverse effects: six studies, 429 participants; very low-certainty evidence. Three studies (n = 229) found no evidence of a difference between groups. Two studies (n = 141) reported no adverse effects in VR group. One study (n = 59) reported no beneficial effect in reducing estimated cyber-sickness before and after VR immersion. 3: VR distraction versus other VR distraction We did not identify any studies for this comparison.

Authors' conclusions: We found low-certainty and very low-certainty evidence of the effectiveness of VR distraction compared to no distraction or other non-VR distraction in reducing acute pain intensity in children in any healthcare setting. This level of uncertainty makes it difficult to interpret the benefits or lack of benefits of VR distraction for acute pain in children. Most of the review primary outcomes were assessed by only two or three small studies. We found limited data for adverse effects and other secondary outcomes. Future well-designed, large, high-quality trials may have an important impact on our confidence in the results.

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Conflict of interest statement

VL: None known.

PB: None known.

LB: None known.

PH: None known.

RK: None known.

DD: None known.

AM: None known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
See this image and copyright information in PMC

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    1. Zelmar A. Augmented reality to reduce pain during botulinum toxin injections in cerebral-palsied children (MINIDOCS). ClinicalTrials.gov (http://clinicaltrials.gov/) [accessed 7 September 2018] 2015.

References to studies awaiting assessment

Festini 2016 {unpublished data only}
    1. Festini F. Virtual reality for the reduction of pain during venipuncture in children with CF (VRAP). ClinicalTrials.gov (http://clinicaltrials.gov/) [accessed 7 September 2018] 2016.
Meyer 2014 {unpublished data only}
    1. Meyer W. Virtual reality analgesia for pediatric burn survivors. ClinicalTrials.gov (http://clinicaltrials.gov/) [accessed 7 September 2018] 2014.
NCH 2016 {unpublished data only}
    1. Dunn AL, Patterson J, Biega C. A feasibility and usability study of a nursing orchestrated, customized 3 dimensional virtual reality environment in children with hemophilia undergoing routine intravenous procedures. In: Blood. Vol. 130. 2017:3691.
    1. Nationwide Children’s Hospital. Virtual reality for hemophilia. ClinicalTrials.gov (http://clinicaltrials.gov/) [accessed 7 September 2018] 2016.
Patterson 2009 {unpublished data only}
    1. Patterson DR. Virtual reality analgesia during pediatric physical therapy (VRD/Peds). ClinicalTrials.gov (http://clinicaltrials.gov/) [accessed 7 September 2018] 2009.

References to ongoing studies

ACTRN12617000285358 {unpublished data only}
    1. ACTRN12617000285358. Investigating the management of paediatric procedural pain relief obtained through virtual reality (IMPROVR) [To investigate the effect of using Virtual reality distraction (using a computer simulation of an environment) on pain and distress in children aged 4 – 11 year olds during needle based procedures compared to standard care]. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372399 (first received 23 Feburary 2017).
ACTRN12618001363279 {unpublished data only}
    1. ACTRN12618001363279. The use of a virtual reality headset for 4 year old immunisations to reduce pain and distress [Virtual reality for immunisation pain: a randomised controlled clinical trial in general practice]. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375746 (first received 6 August 2018).
LeMay 2016b {unpublished data only}
    1. LeMay S, Paquin D, Bouchard S, Fortin J-S, Khadra C. DREAM Project: Decreasing recurrent pain and anxiety in medical procedures on a pediatric population. International Journal of Virtual Reality 2016;16(1):49-57.
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NCT02646787 {unpublished data only}
    1. NCT02646787. Virtual reality water friendly wound care (H2OWC) [Water friendly virtual reality for burns]. clinicaltrials.gov/ct2/show/NCT02646787 (first received 6 Janurary 2016).
NCT02929771 {unpublished data only}
    1. NCT02929771. Using virtual reality to reduce procedural pain in children with cancer [Using virtual reality to reduce procedural pain in children with cancer: a pilot randomized controlled trial]. clinicaltrials.gov/ct2/show/NCT02929771 (first received 11 October 2016).
NCT02986464 {unpublished data only}
    1. NCT02986464. Virtual reality distraction for procedural pain management in children with burn injuries: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT02986464 (first received 8 December 2016).
NCT03155607 {unpublished data only}
    1. NCT03155607. Novel virtual reality for burn wound care pain in adolescents. clinicaltrials.gov/ct2/show/study/NCT03155607 (first received 16 May 2017).
NCT03239743 {unpublished data only}
    1. NCT03239743. Effects of virtual reality on pre-operative anxiety and induction of anesthesia in children and adolescents [A pilot study to evaluate the efficacy of virtual reality on pre-operative anxiety and Induction of anesthesia in a children's hospital]. clinicaltrials.gov/ct2/show/NCT03239743 (first received 4 August 2017).
NCT03304769 {unpublished data only}
    1. NCT03304769. Virtual reality distraction during pediatric intravenous line placement [Virtual reality distraction during pediatric intravenous line placement: a prospective randomized comparison study]. clinicaltrials.gov/ct2/show/NCT03304769 (first received 9 October 2017).
NCT03353584 {unpublished data only}
    1. NCT03353584. Effect of virtual reality technology for pain management of vaso-occlusive crisis in patients with sickle cell disease [Pain management of vaso-occlusive crisis in children and young adults with sickle cell disease-effect of virtual reality technology]. clinicaltrials.gov/ct2/show/NCT03353584 (first received 27 November 2017).
NCT03435367 {unpublished data only}
    1. NCT03435367. Immersive virtual reality to reduce procedural pain during IV insertion in children in the emergency department [Immersive virtual reality to reduce procedural pain during IV insertion in children in the emergency department: a feasibility pilot study]. clinicaltrials.gov/ct2/show/NCT03435367 (first received 19 February 2018).
NCT03464955 {unpublished data only}
    1. NCT03464955. VR usage in non-invasive surgical sub-specialty procedures [Virtual reality usage in non-invasive surgical sub-specialty procedures]. clinicaltrials.gov/ct2/show/NCT03464955 (first received 14 March 2018).
NCT03480724 {unpublished data only}
    1. NCT03480724. Assessing the efficacy of virtual reality analgesia (VRA) in pediatric patients for pain control (PEDSPAINVR) [Assessing the efficacy of virtual reality analgesia (VRA) in pediatric patients for pain control during botox injections for spasticity management: a randomized control trial]. clinicaltrials.gov/ct2/show/NCT03480724 (first received 29 March 2018).
NCT03518346 {unpublished data only}
    1. NCT03518346. Use of virtual reality game playing during venipuncture. clinicaltrials.gov/ct2/show/NCT03518346 (first received 8 May 2018).
NCT03521076 {unpublished data only}
    1. NCT03521076. Randomized controlled trial of virtual reality [Randomized controlled trial of virtual reality for pain management in a specialty rehabilitation context]. clinicaltrials.gov/ct2/show/NCT03521076 (first received 11 May 2018).
NCT03584776 {unpublished data only}
    1. NCT03584776. Virtual reality for post-operative pain management [A randomized controlled trial of virtual reality for pain management in the post-operative period following orthopedic surgery]. clinicaltrials.gov/ct2/show/NCT03584776 (first received 12 July 2018).
NCT03645213 {published data only}
    1. NCT03645213. Two different distraction methods on pain and fear duingvenipuncture in children [Comparision of two different distraction methods on pain and fear during venipuncture in school-age children: a randomized controlled trial]. clinicaltrials.gov/ct2/show/NCT03645213 (first retrieved 24 August 2018).
NCT03680625 {unpublished data only}
    1. NCT03680625. Virtual reality vs passive distraction for pain management [Virtual reality compared to passive distraction for pain management during orthopedic procedures in children: a randomized controlled trial.]. clinicaltrials.gov/ct2/show/NCT03680625 (first received 21 September 2018).
NCT03681717 {unpublished data only}
    1. NCT03681717. Virtual reality vs. standard-of-care for comfort during laceration repair [A pragmatic randomized controlled trial of virtual reality vs. standard-of-care for comfort during laceration repair]. clinicaltrials.gov/ct2/show/NCT03681717 (first received 24 September 2018).
NCT03681730 {unpublished data only}
    1. NCT03681730. Virtual reality vs. standard-of-care for comfort during intravenous catherterization [A pragmatic randomized controlled trial of virtual reality vs standard-of-care for comfort during intravenous catheterization]. clinicaltrials.gov/ct2/show/NCT03681730 (first received 24 September 2018).
NCT03681743 {unpublished data only}
    1. NCT03681743. Virtual reality vs. standard-of-care for comfort during minor plastic surgery procedures in children [A pragmatic randomized controlled trial of virtual reality vs. standard-of-care for comfort during minor plastic surgery procedures in children]. clinicaltrials.gov/ct2/show/NCT03681743 (first received 24 September 2018).
NCT03693469 {published data only}
    1. NCT03693469. Virtual reality vs. standard-of-care for comfort during immunizations in children [A pragmatic randomized controlled trial of virtual reality vs. standard-of-care for comfort during immunizations in children]. clinicaltrials.gov/ct2/show/NCT03693469 (first received 3 October 2018).
NCT03750578 {published data only}
    1. NCT03750578. Virtual reality for needle procedures in pediatric emergency department [Distraction in the emergency using virtual reality for intravenous needs in children to improve comfort (DEVINCI): a pilot randomized controlled trial]. clinicaltrials.gov/ct2/show/NCT03750578 (first received 23 November 2018).
NCT03784352 {published data only}
    1. NCT03784352. Virtual reality pediatric orthopaedic outpatient procedures [Virtual reality in reducing pain and anxiety in pediatric orthopaedics, a pilot randomized controlled trial]. clinicaltrials.gov/ct2/show/NCT03784352 (first received 21 December 2018).
NCT03888690 {unpublished data only}
    1. NCT03888690. Effect of virtual reality distraction on procedural pain for children and adolescents in onco-haematology unit [Randomized controlled trial evaluating the effectiveness of the virtual reality distraction compared to current practice on reducing procedural pain in children and adolescents supported in pediatric onco-hematology unit]. clinicaltrials.gov/ct2/show/NCT03888690 (first received 25 March 2019).
NCT03903510 {published data only}
    1. NCT03903510. Virtual reality during paediatric cast removal [A randomized control trial of virtual reality to reduce anxiety during pediatric cast removal]. clinicaltrials.gov/ct2/show/NCT03903510 (first received 4 April 2019).
NCT03913897 {published data only}
    1. NCT03913897. The effect of virtual reality and kaleidoscope on pain and anxiety levels during venepuncture in children. clinicaltrials.gov/ct2/show/NCT03913897 (first received 12 April 2019).
NCT03985930 {unpublished data only}
    1. NCT03985930. Non-immersive virtual reality for paediatric pain management. clinicaltrials.gov/ct2/show/NCT03985930 (first received 14 June 2019).
NCT04040036 {published data only}
    1. NCT04040036. Effects of virtual reality on pain, fear and anxiety during blood draw in children aged 5-12 years old [Effects of virtual reality on pain, fear and anxiety during blood draw in children aged 5-12 years old: a randomized controlled study]. clinicaltrials.gov/ct2/show/NCT04040036 (first received 31 July 2019).
Wong 2019 {unpublished data only}
    1. ChiCTR1800016589. Effects of immersive virtual reality intervention on pain and anxiety among paediatric patients undergoing venipuncture: a randomized controlled trial. chictr.org.cn/showprojen.aspx?proj=28246 (first received 11 June 2018).
    1. Wong CL, Wa Lui MM, Choi KC. Effects of immersive virtual reality intervention on pain and anxiety among pediatric patients undergoing venipuncture: a study protocol for a randomized controlled trial. Trials 2019;20(369):doi.org/10.1186/s13063-019-3443-z. - PMC - PubMed

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References to other published versions of this review

Lambert 2013
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