From the Editor
New technology is changing the way we think about the delivery of psychiatric services. But new isn’t necessarily better. Can care really be transformed? What does the literature say?
In a two-part Reading of the Week series, we look at technology and psychiatry.
This week, Virtual Reality.
Next week, e-therapies.
This week, we consider a new paper that looks at virtual reality to treat pain in hospitalized patients. The authors find that people utilizing VR have less pain as compared to controls. This finding leads us to another recent paper on VR; in this second study, patients with social anxiety are treated with a VR intervention.
Pain and Technology
“Virtual Reality for Management of Pain in Hospitalized Patients: Results of a Controlled Trial”
Vartan C. Tashjian, Sasan Mosadeghi, Amber R. Howard, Mayra Lopez, Taylor Dupuy, Mark Reid, Bibiana Martinez, Shahzad Ahmed, Francis Dailey, Karen Robbins, Bradley Rosen, Garth Fuller, Itai Danovitch, Waguih IsHak, Brennan Spiegel
JMIR MENTAL HEALTH, 29 March 2017 Online First
Hospitalized patients frequently experience physical, emotional, and social distress that is exacerbated by a radical change in living environment, loss of customary rights and privileges, and a high prevalence of pain. Nearly half of hospitalized patients experience pain, of which a quarter is considered ‘unbearable’. In order to care for the whole patient, hospital clinicians must consider not only the physical impact of illness, but also the psychosocial impact. However, the dynamic nature of hospital medicine, coupled with limited time to spend with individual patients, poses challenges to offering holistic inpatient care.
Treatment of pain in the acute care setting is often focused on pharmacological management, which can yield inconsistent and suboptimal pain control. However, extensive data reveal that adjunctive nonpharmacological techniques, such as cognitive behavioral therapy and relaxation techniques, can modify cognitions and behaviors that influence the perception of pain.
Virtual reality (VR) technology provides an immersive, multisensory, and three-dimensional (3D) environment that enables users to have modified experiences of reality by creating a sense of ‘presence’. To date, VR has been used in numerous clinical settings to help treat anxiety disorders, control pain, support physical rehabilitation, and distract patients during wound care. For example, VR coupled with medication is effective in decreasing pain during bandage changes for severe burns. Similarly, VR reduces pain and provides positive distraction during routine procedures such as intravenous line placements and dental procedures. Other studies reveal that VR helps manage chronic pain conditions such as complex regional pain syndrome and chronic neck pain. By stimulating the visual, auditory, and proprioception senses, VR acts as a distraction to limit the user’s processing of nociceptive stimuli.
So begins a paper by Tashjian et al.
Here’s what they did:
- The authors recruited people into a nonrandomized, comparative cohort study over a six-month period comparing 3D VR pain distraction with a 2D high-definition nature video.
- Adults were recruited from the Inpatient Specialty Program at Cedars-Sinai Medical Center.
- Exclusion criteria included: a history of seizure disorder and vertigo, and bandages that made wearing the VR headset difficult.
- “Patients rated their current pain using a standard 11-point numeric rating scale (NRS), ranging from 0 (no pain) to 10 (‘the worst pain of your life’). The NRS is a validated measure of pain widely employed in clinical practice based on its ease of use, high compliance rates, and responsiveness to detect meaningful changes in pain.” This scale was done before and after the intervention. Patients had a pain score of at least 3 (out of 10) in the 24 hours before participation.
- The VR intervention: “Patients watched a 15-minute VR experience called Pain RelieVR, specifically designed to treat pain in patients… Pain RelieVR is an immersive, 360-degree, game experience that takes place in a fantasy world where the user attempts to shoot balls at a wide range of moving objects by maneuvering his or her head toward the targets.” See the screen shot below.
- The non-VR intervention: “We administered a 2D high-definition (1080p) video depicting relaxing nature scenes, including mountain lakes and running streams from Patagonian vistas presented with an audio track featuring Native American Shaman music.”
- Different statistical analyses were done.
Here’s what they found:
- There were 50 people in each group.
- Basic demographics: “There were no significant differences between groups for age, sex, race, or ethnicity.” Patients tended to be in their late 40s or early 50s, and were in hospital for internal medicine reasons (GI, cardiac, infectious disease).
- “When focusing on within-subject changes in pain, there was a significant drop in pain in both the patients in the VR group (percent reduction=24%) and the control patients (percent reduction=13.2%), with a larger drop in the VR group than controls…”
- “Using a binary responder definition of a ≥0.5 standard deviation drop in pain,there was a higher proportion of responders in the VR group (65%) versus the control group (NNT=4)…”
- Using multilevel logistic regression analysis adjusting for age, race, ethnicity, and gender: “VR remained a significant predictor of pain reduction… There were no differences in the effect of VR by age, race, ethnicity, sex, or reason for hospitalization.”
- No adverse events were reported with VR participants.
In this study, we found that use of a 15-minute VR intervention in a diverse group of hospitalized patients resulted in statistically significant and clinically relevant (NNT=4) improvements in pain versus a control distraction video without triggering adverse events or altering vital signs.
The authors conclude:
Although VR has been studied in a variety of conditions including wound care, rehabilitation, and anxiety, its effectiveness for managing pain in hospitalized patients has not been fully examined. In this study, we found that use of a 15-minute VR intervention in a diverse group of hospitalized patients resulted in statistically significant and clinically relevant (NNT=4) improvements in pain versus a control distraction video without triggering adverse events or altering vital signs. These results indicate that VR may be an effective adjunctive therapy to complement traditional pain management protocols in hospitalized patients.
A few thoughts…
- This is an interesting study – a new approach to the old problem of pain management. Needless to say, the paper gathered some media attention.
- It’s great to see non-pharmacologic approaches to pain management being discussed. In light of our opioid epidemic, this paper is particularly refreshing.
- It’s difficult not to marvel at how “modern” this selection is. The paper is on VR, and published in a journal that appears only online and is open-access.
- The topic of VR is hot right now, and others are doing research in this area. The April issue of The British Journal of Psychiatry has a paper and an editorial on VR for social anxiety. (The editorial has the snappy title: “The virtues of virtual reality in exposure therapy”). The Tashjian et al. paper is published in one of the newest psychiatry journals, the Bouchard et al. paper is published in one of the oldest.
You can find the Bouchard et al. paper here:
- The Bouchard et al. paper is thoughtful (and, as an aside, very “local” with all co-authors hailing from Quebec).
Participants with social anxiety disorder were randomly assigned to one of three groups: VR exposure (17 people), in vivo exposure (22 people) or waiting list (20 people). The VR and in vivo exposure groups received CBT. Improvements were found on the Liebowitz Social Anxiety Scale (the primary measure) and all five secondary outcome measures in the treatment groups (over the waitlist group). The VR participants did better on the Liebowitz Social Anxiety scale on follow up.
They conclude: “These results support what has been found with other anxiety disorders and show that CBT combined with exposure in VR is an effective and efficient alternative to classical individual CBT, acutely and in the long term.”
It’s a cool study – though I note that the number of active participants wasn’t particularly high.
The accompanying editorial notes the potential of VR:
The whole point of using virtual reality is to harness its full potential and go beyond what we can do in real life. For example, virtual reality can facilitate multicontext, tailored, mass practice of extreme exposure scenarios in a short period of time; matching it to real life would mean that patients only experience the quantity and nature of scenarios that are possible in vivo and nothing more. With the proviso that patients follow-up on what they learn in the virtual world by applying it to real life, the optimal way of using in virtuo exposure is not to match it to in vivo, but to make full use of the virtual reality features that can have added therapeutic value over and above real life.
- It should be emphasized that both these studies have significant limitations. The Tashjian et al. paper used a nonrandomized control approach – it’s not indefensible, but it’s hardly ideal. The Bouchard et al. paper had just 17 people in the VR group. Same comment: it’s not indefensible, but it’s hardly ideal. We are in the early days of research in this area.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.