SGEM#363: View Master – Virtual Reality Immersion Tool to Reduce Pediatric Anxiety

Background: Pediatric emergency department (ED) visits and related procedures can invoke pain and anxiety among children. Patients who experience adequate pain relief during their ED stay have significant reductions in distress, improved rapport with their physician, improved intent to comply with discharge instructions and higher levels of personal and caregiver satisfaction.

Children represent one group of patients that are less likely to receive adequate analgesia (Brown et al, Selbst and Clark). This phenomenon is known as oligoanalgesia or poor pain management through the underuse of analgesia.

Dr. Anthony Crocco

We have covered pediatric pain with PEM super hero Dr. Anthony Crocco on SGEM#78 who did a RANThony on this issue. Dr. Samina Ali is a PEM super (s)hero who was on SGEM#242 looking at intranasal (IN) ketamine vs fentanyl on pain reduction for extremity injuries in children. The bottom line from that trial was IN ketamine appears to be non-inferior to IN fentanyl for efficacy, but with more adverse events.

Many clinicians utilize distraction techniques to reduce pain and anxiety in children during their ED visits [4]. However, there are no prospective randomized trials using virtual reality (VR) as a distraction technique while awaiting physician evaluation.

Clinical Question: Does a 5-minute virtual reality program reduce situational anxiety in the pediatric ED?

Reference: Butt et al. Take-Pause: Efficacy of mindfulness-based virtual reality as an intervention in the pediatric emergency department. AEM March 2022

• Population: Patients ages 13-17 years who presented to the pediatric ED with mild to moderate acute pain (pain score 2-6 on FACES pain scale)
  • Exclusions: Patients with developmental delays, inability to speak English, prone to motion sickness, significant visual/hearing impairment, pregnancy, parental refusal, received analgesic ≤4 hours prior to ED arrival, or inability to use the pain scale.
• Intervention: Virtual reality “Take Pause” program for 5 minutes
• Comparison: Passive distraction technique with hospital-owned iPad with pre-downloaded age-appropriate games for 5 minutes
• Outcome:
  • Primary Outcome: Difference in the change in situational anxiety level between groups 15 minutes after intervention using the Spielberger State – Trait Anxiety Inventory (STAI: Y-6 item)
  • Secondary Outcomes: Mean difference in pain score on the FACES scale, heart rate, respiration rate from baseline to 15 minutes after intervention
• Trial: Prospective, randomized, single-blind trial

Mahlaqa Butt

This is an SGEMHOP episode which means we have the lead author on the show. Mahlaqa Butt, MPH is a third-year medical student at New York Institute of Technology-College of Osteopathic Medicine and a clinical research associate at the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn NY. She has co-authored 11 peer-reviewed emergency medicine research publications primarily focused on opioid-free pain management in the ED. She will be pursuing a residency in emergency medicine this fall.

Authors’ Conclusions: “Take-Pause, offering an active and immersive distraction technique, is more effective than a passive distraction approach to lower anxiety levels in adolescent ED patients.”

Quality Checklist for Randomized Clinical Trials:

1. The study population included or focused on those in the emergency department. Yes
2. The patients were adequately randomized. Yes
3. The randomization process was concealed. Yes
4. The patients were analyzed in the groups to which they were randomized. Yes
5. The study patients were recruited consecutively (i.e. no selection bias). No
6. The patients in both groups were similar with respect to prognostic factors. Unsure
7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
8. All groups were treated equally except for the intervention. Yes
9. Follow-up was complete (i.e. at least 80% for both groups). Yes
10. All patient-important outcomes were considered. No
11. The treatment effect was large enough and precise enough to be clinically significant. Unsure
12. Financial conflicts of interest. The authors stated they had no potential conflicts to disclose.

Results: They enrolled 110 teenagers into the trial with 55 participants in each group. The mean age was 15 years, 60% were male and the mean pain score was 4.1/10.

Key Result: Anxiety levels were reported lower in the intervention group compared to the comparison group.

• Primary Outcome: Mean anxiety score on the Spielberger State – Trait Anxiety Inventory (STAI: Y-6 item)
  • VR group improved by 10 points vs. 6 points in the iPad group (95% CI: 0.44 to 7.6) p < 0.001
• Secondary Outcomes: At 15 minutes, there was no difference in mean pain scores (3.6 vs 3.6), heart rate (intervention 81 bpm vs control 83 bpm), or respiratory rate (intervention 18 vs control 20)

Listen to the SGEM podcast to hear Mahlaqa answer our five nerdy questions.

1. Patient Characteristics – Very little information is given regarding patient characteristics. For example, we have no information on traumatic vs nontraumatic pain, location of pain, race/ethnicity, or other potentially important variables. Although randomization should theoretically balance out any differences, it is helpful to have patient characteristics reported so we can gauge – are these patients like my patients?

2. Virtual Reality (VR) for Mindfulness – We have looked at mindfulness to help relieve the stress of interns on their EM rotation on SGEM#178. In this other small study, it seemed to be effective. However, that study had 10 weeks of mindfulness training sessions as the intervention. Can you describe this Take Pause VR immersion tool in more detail?

3. Effect Size – Effect size is a quantitative measurement of the magnitude of the difference between groups. In this study, the authors set out to find a difference of ≥3 on the STAI Y-6 from baseline to post-intervention. They felt this would be statistically significant as a 1999 study that looked at music before bronchoscopy had a 3.6 reduction on the anxiety score (but did not meet the arbitrary 5 points set out by those authors). It often takes more participants to detect a smaller effect size.

4. Comparison Group – You compared the VR Take Pause immersion tool to standard distraction techniques using an iPad. This could have introduced a bias towards lower anxiety because some teenagers desire to use some cool new technology. Why not use another VR headset intervention?

Patients knew they were going to be randomized into the VR or iPad group. You mentioned in your publication this could have led to optimism bias. Could you explain that type of bias further?

Did you consider other techniques not involving technology like animal therapy? On SGEM#289 we looked at having a dog to play with to relieve stress on the staff. The intervention looked promising, and I wonder how it would have compared to using a VR device.

5. Statistical Significance vs Clinical Significance – The mean baseline anxiety score (STAI Y-6 score) placed nearly the same proportion of patients in the mild anxiety group (score 20-40) ~82-94% and in the moderate anxiety group (score 41-60) – 16% of patients in both groups. The virtual reality arm had a 10-point reduction from baseline while the iPad group had a 6-point reduction. However, the post-intervention score was only 2.9 points different between groups. Overall, it’s not clear that the statistically significant difference between groups is clinically significant.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We disagree with the authors conclusion and believe that this trial shows both Take-Pause and passive distraction with an iPad reduce self-reported anxiety levels in adolescent ED patients.

SGEM Bottom Line: The virtual reality “Take Pause” immersion tool is another possible non-pharmaceutical intervention to reduce anxiety of paediatric patients in the ED.

Case Resolution: The patient is offered either a mindfulness-based virtual reality program or an iPad with preprogrammed games while awaiting clinician evaluation.

Dr. Lauren Westafer

Clinical Application: Reducing anxiety is important in the emergency department. There are several non-pharmacologic techniques that can be used. This small study suggests the VR Take Pause immersion tool can be one of those techniques.

What Do I Tell My Patient?  There are several ways to reduce anxiety in the pediatric emergency department. Both a mindfulness based virtual reality program and playing games on an iPad may help reduce your anxiety.

Keener Kontest: Last weeks’ winner was Danny Driskill from the Kentucky College of Osteopathic Medicine. He knew IBM Simon Personal Communicator was the first “smart phone”.  It was released August 16, 1994.

Listen to the SGEM podcast for this weeks’ question.  If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on the Take Pause VR tool to reduce anxiety in the ED? Tweet your comments using #SGEMHOP.  What questions do you have Mahlaqa? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Ken’s virtual reality device as a kid