Virtual Reality for Pain Management: A Guide to Clinical Implementation

August 2020 Issue

  1. Navid Alem, MD Associate Clinical Professor, Department of Anesthesiology and Perioperative Care, Associate Program Director, Residency, University of California, Irvine School of Medicine Co-author
  2. Anthony Machi, MD Assistant Professor; Fellowship Director, University of Texas Southwestern Medical Center Co-author
  3. Shalini Shah, MD Anesthesiologist, UC Irvine Health Co-author


Introduction

Despite efforts to enhance hospital environments, patient experiences inherently remain stressful and unpleasant. Amidst foreign surroundings, combined with apprehension regarding potential investigations and treatments, a fundamental premise of patient satisfaction and improved clinical outcomes may hinge on the ability to get away altogether. By transitioning patients into another virtual world, virtual reality therapy (VRT) provides an opportunity for disruptive innovation[1] in the medical community. Namely, the disrupted is the current multimodal pharmacologic and interventional therapies available for acute and chronic pain management, and VRT is the disruptor. VRT arrives at an auspicious time to help leverage the opioid epidemic that claims more lives than traffic-related injuries nationally.[2] Pain medicine specialists and anesthesiologists must be nimble and amenable to modalities that intend to enhance the repertoire of opioid-sparing strategies available.[2] It should be noted that most devices are currently marketed as wellness devices, without formal Food and Drug Administration (FDA) approval, and with clinical investigations ongoing. This article will discuss clinical application of VRT while outlining the steps pursued for implementation at University of California Irvine (UCI) Health.


Offering an opportunity for environmental change, virtual reality therapy exemplifies a mechanism for hospitalized patients to safely practice mindfulness.


The Science of Virtual Reality

Maani et al[3] illustrated that VRT can be used as an effective adjunctive analgesic for severe burn wound cleaning procedures. When combat soldiers were solely given an intravenous ketamine bolus, they rated the cleansing as “no fun at all”; interestingly, when combining the ketamine bolus with concomitant VRT, the same patients newly rated wound care as “pretty fun” or “extremely fun”.[3] Indeed, VRT relies on computer technology and multisensory input to synthetically create a surrogate 3D atmosphere that a user can escape to.[2] While augmented reality relies on incorporating additional digital components to a real live view, VRT is an absolute immersion experience that is achieved by using hardware (typically a headset) with access to appropriate software (perhaps a peaceful spot in nature or an interactive gaming sequence).[4] Along the lines of precision medicine,[5] content selection and application can be tailored to meet each clinical scenario and patient preference. Technology has made VRT affordable and compact, with mobile point-of-care utilization. Proposed applications of VRT in the realm of pain management are diverse and include acute and chronic clinical conditions (Figure 1).[2-4],[6-8] The use of VRT in pediatric care appears to be promising, for example, in precluding pain with venipuncture.[9] Consistent with the patient-centric visions of enhanced recovery after surgery[10] and the perioperative surgical home,[11] VRT has also been described in the realm of perioperative medicine,[12] such as reduction of preoperative anxiety[13] or postoperative pain[4] after a medical procedure. While consensus on the clinical utility of VRT has yet to be achieved,[4] preliminary results appear favorable in the context of reducing pain and anxiety. Research findings have consistently demonstrated favorable reductions in acute pain, but further investigation is required to determine if there are longitudinal effects in chronic pain.[2-4],[6-8]  Although there are considerations that may prevent universal use (Figure 2), the technology is largely safe,[2-4],[6-8] with patient refusal being the only absolute contraindication.  


Figure 1: Proposed applications of virtual reality in the realm of pain management.

  • Distraction from painful stimulus or anxiety with procedures: IV starts, regional blocks, wound care
  • Chronic pain conditions: sickle cell, lumbago, phantom pain, fibromyalgia, complex regional pain
  • Labor and delivery: distraction, breathing support
  • Perioperative pain and anxiety reduction throughout the surgical continuum: before, during, and after
  • Mental health conditions: anxiety, depression, phobia, PTSD treatment
  • Oncology: application during infusion or chemotherapy treatment
  • Ambulatory clinic setting: nonclinical use when awaiting clinical encounters, biofeedback programs

Figure 2: Relative contraindications to virtual reality utilization.

  • Motion sickness or active nausea/vomit
  • Neurologic issues: recent stroke, uncontrolled seizure, severe dementia, vestibulo-ocular problems
  • Isolation status for infection control
  • Claustrophobia

Diverse hypotheses have been proposed to elucidate how VRT may regulate the experience of pain. These theories include elements derived from the Gate Control Theory, the Multiple Resources Theory (which proposes that sensory systems function autonomously and sensory distraction is key), and, more recently, postulation that specific pain modulation pathways are altered as evidenced by functional MRI studies.[7] What appears uniform in the proposed theories is an inclination to explain VRT via the concept of mindfulness, which is defined as “moment-by-moment awareness…a state of psychological freedom that occurs when attention remains quiet and limber, without attachment to any particular point of view.”[14] Offering an opportunity for environmental change, VRT exemplifies a mechanism for hospitalized patients to safely practice mindfulness.

Clinical Implementation of Virtual Reality at UC Irvine Health

With the general popularity of VRT and applications in healthcare growing, there was interest at UCI Health to further investigate implementation at our institution. Leadership selected a physician champion to help navigate the evaluation and assessment process. A strategic team including physician and nursing leadership, information and technology experts, and research support was constructed. The team then elected to conduct a needs assessment survey to tailor and vet optimal implementation strategies. A Likert scale, 26-question Qualtrics® survey was distributed to all UCI Health attending physicians.[15] A total of 105 voluntary responses were received with 8 excluded due to incompletion, leaving a total of 97 responses for interpretation. Respondents came from a variety of specialties including both medical and surgical subspecialties, with anesthesiologists being the most represented at 27%. Greater than 66% of respondents welcomed VRT as a new modality for pain management. Physicians highlighted cost, user training, and equipment availability as factors most likely to impede clinical growth. Three divisions emerged as the most motivated to pursue clinical application: 1) Pain Medicine, 2) Burn Surgery/Critical Care, 3) Hematology/Oncology (Infusion Therapy).

The next step in the process was determining a specific hardware and software pairing that met UCI’s clinical needs. The initial investigation focused on an “over-the-counter” device, similar to one available for purchase and use by the general population. From a cost perspective, this was the most pragmatic approach, with typical units starting at around $399 and devoid of any subsequent licensure subscription fees. While ideal in certain proposed applications, several shortcomings manifested during our research that directed us towards other approaches. Most notably, simply buying a VRT headset targeted for broad use in the general population failed to provide software (content) specifically curated and studied for use in the medical field. Additional shortcomings included an absence of infection control protocols, an absolute need to utilize Wi-Fi for streaming, a scarcity of customer support, and a lack of gaze-based control. Gaze-based control was a desirable feature because it ensured proper use of the device in a tilted position, such as when a patient was placed in the Trendelenburg position for a procedure and would otherwise not have been able to navigate an avatar beyond a narrow scope of view. 

Using a vendor specific to the realm of medicine and specifically pain management was deemed most likely to meet UCI’s clinical needs. A healthcare-specific vendor allowed for access to hardware and licensed content aimed for medical use, proprietary infection control and cleaning protocols, and ongoing training and technical support.[16] However, as VRT remains to be reimbursed by insurers, cost had to be considered alongside the potential to yield additional value[17] in clinical outcomes. With these vendors, each unit costs around $500-$1,000 and annual subscription fees can hover near $3,500 per unit, with negotiation considerations for bulk orders.[16] Delshad et al[16] analyzed the “return on investment” for inpatient VRT to provide a guide for cost and effectiveness thresholds. Analyzing key hospital metrics including opioid use, hospital length of stay, and reimbursement from enhanced patient satisfaction scores, the authors were able to demonstrate a net cost-savings of $5.39 per patient primarily via a reduction in length of stay with VRT.[16] We propose that access to VRT also may be a prudent marketing strategy, as prospective patients may view participating hospitals as more “cutting-edge.” Moreover, an inpatient pain service that is a key stakeholder and well versed in clinical application of VRT may receive supplementary consultations, further contributing to profit margins. With these insights, it can be argued that supporting access to VRT for patients who are most likely to benefit is a principled fiscal approach.

At UCI Health, units and subscriptions were purchased to support our three identified divisions that expressed the most interest to pilot clinical application as well as a means for funding. We deemed that this would permit an opportunity to research and ascertain if the units are appropriately being used while demonstrating a value-add[17] to patient care. Supporting technology advancement is important since it is dynamically evolving, with newer devices continually being marketed. Ultimately, we believe the value proposition of VRT is that it exemplifies the Institute for Healthcare’s triple aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.[18]

References

  1. Hwang J, Christensen C. Disruptive innovation in health care delivery: a framework for business-model innovation. Health Aff. 2008;27(5):1329-35. https://doi.org./10.1377/hlthaff.27.5.1329
  2. Pourmand A, Davis S, Marchak A, Whiteside T, Sikka N. Virtual reality as a clinical tool for pain management. Curr Pain Headache Rep. 2018;22(53):1-6. https://doi.org/10.1007/s11916-018-0708-2
  3. Maani C, Hoffman H, Fowler M, Maiers A, Gaylord K, Desocia P. Combining ketamine and virtual reality pain control during severe burn wound care: one military and one civilian patient. Pain Med. 2011;12(4):673-8. https://doi.org/10.1111/j.1526-4637.2011.01091.x
  4. Freitas D, Spadoni V. Is virtual reality useful for pain management in patients who undergo medical procedures? Einstein (Sao Paulo). 2019;17(2):eMD4837. https://doi.org/10.31744/einstein_journal/2019MD4837
  5. Chan S, Erikainen S. What’s in a name? The politics of ‘precision medicine’. Am J Bioeth. 2018;18(4):50-2. https://doi.org/10.1080/15265161.2018.1431324
  6. Mallari B, Spaeth E, Goh H, Boyd B. Virtual reality as an analgesic for acute and chronic pain in adults: a systemic review and meta-analysis. J Pain Res. 2019;12:2053-85. https://doi.org/10.2147/JPR.S200498 
  7. Mahrer N, Gold J. The use of virtual reality for pain control: a review. Curr Pain Headache Rep. 2009;13(2):100-9. https://doi.org/10.1007/s11916-009-0019-8
  8. Spiegel B, Fuller G, Lopez M, et al. Virtual reality for management of pain in hospitalized patients: a randomized comparative effectiveness trial. PLoS One. 2019:14(8)e0219115. https://doi.org/10.1371/journal.pone.0219115
  9. Chan E, Hovenden M, Ramage E, et al. Virtual reality for pediatric needle procedural pain: two randomized clinical trials. J Pediatr. 2019;209:160-7. https://doi.org/10.1016/j.jpeds.2019.02.034
  10. Fawcett WJ, Mythen MG, Scott MJP. Enhanced recovery: more than just reducing length of stay? Br J Anaesth. 2012;109(5):671-4. https://doi.org/10.1093/bja/aes358
  11. Kash BA, Zhang Y, Cline KM, Menser T, Miller, TR. The perioperative surgical home (PSH): a comprehensive review of US and non-US studies shows predominantly positive quality and cost outcomes. Milbank Q. 2014;92(4):796-821. https://doi.org/10.1111/1468-0009.12093
  12. Grocott MP, Mythen MG. Perioperative medicine: the value proposition for anesthesia?: a UK perspective on delivering value from anesthesiology. Anesthesiol Clin. 2015;33(4):617-28. https://doi.org/10.1016/j.anclin.2015.07.003
  13. Dehghan F, Jalali R, Bashiri H. The effect of virtual reality technology on preoperative anxiety in children: a Solomon four-group randomized trial. Perioper Med (Lond). 2019;8:5. https://doi.org/10.1186/s13741-019-0116-0
  14. Davis DM, Hayes JA. What are the benefits of mindfulness? A practical review of psychotherapy-related research. Psychotherapy (Chic). 2011;48(2):198-208. https://doi.org/10.1037/a0022062
  15. Koohian B, Lin WC, Alem N, Shah S. Virtual reality in pain management: where’s the applicability in a hospital setting? Poster presented at: 2019 ASRA Pain Medicine Meeting; November, 2019; New Orleans, LA.
  16. Delshad SD, Almario CV, Fuller G, Luong D, Spiegel BMR. Economic analysis of implementing virtual reality therapy for pain among hospitalized patients. NPJ Digit Med. 2018;1(22). https://doi.org/10.1038/s41746-018-0026-4
  17. Atkins JH, Fleischer LA. Value from the patients’ and payers’ perspectives. Anesthesiol Clin. 2015;33(4):651-8. https://doi.org/10.1016/j.anclin.2015.07.001
  18. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27(3):759-69. https://doi.org/10.1377/hlthaff.27.3.759

Tags: virtual reality, pain management

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