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Research Article
Published Online 25 November 2021

Can virtual reality headsets be used safely as a distraction method for paediatric orthopaedic patients? A feasibility study

Publication: The Annals of The Royal College of Surgeons of England
Volume 104, Number 2

Abstract

Introduction

Virtual reality (VR) has been shown to decrease pain and anxiety in clinical areas. The purpose of this study was to assess the feasibility of ‘Rescape DR.VR Junior’ headset as a distraction method for paediatric orthopaedic patients.

Methods

An internal risk assessment by medical engineers to determine its safety deemed the device safe to be used only in the venepuncture and plaster rooms, while further investigation is needed to establish its safety in the operating theatre/anaesthetic room. A total of 32 children (age range: 2–15 years) took the option to use the device while they underwent venepuncture or a cast procedure. Anxiety scores, measured on a Likert scale, were collected pre and postprocedure. Participants were asked if they would use the device again. Subjective feedback was also collated from the supervising clinical staff.

Results

A total of 66% (21) showed a reduction in anxiety scores, 28% (9) had no change in score; all scores being mild, 1–3 on the Likert scale; 6% (2) showed an increase in postprocedure score. All participants stated they would use the device again. One patient declined the device. Health professionals also gave positive subjective feedback and they would all use it again with their paediatric patients. No adverse events were recorded.

Conclusion

The ‘Rescape DR.VR Junior’ headset has been found to be a safe and feasible distraction method for use in children in the venepuncture and plaster room. Further research is required to assess its safety and effectiveness in other clinical areas, including the paediatric orthopaedic operating theatre.

Introduction

Hospitals can be an anxiety-increasing environment for many children, especially those undergoing procedures. Venepuncture and plaster room procedures are two of the most common situations that paediatric orthopaedic patients will encounter. For those children undergoing planned elective surgical procedures, the preoperative time, including the anaesthetic room environment, can be distressing. In specialist children’s hospitals, methods to reduce anxiety are already commonplace. Trained staff, including play specialists, use pictures, books, games, iPads and videos as distraction devices. Parents or guardians may be asked to assist staff while the child undergoes an awake procedure. These methods are well established and distraction with iPads and music have been proven to reduce anxiety while undergoing Plaster Room procedures.1,2
In the last 10 years, there has been an increase in the use of virtual reality (VR) simulator devices used specifically in medical settings. So far, these have been shown to reduce pain and anxiety in patients undergoing procedures such as venepuncture,3 dental procedures,4 treatment of burns and cancer treatments.5,6 Many of these studies have been small, with low patient numbers. A meta-analysis carried out in 2019 supported the results of individual studies in that VR in paediatrics is an effective distraction intervention to reduce pain and anxiety for a wide variety of medical procedures.7 No studies to date have looked specifically at the use of VR in orthopaedic paediatric populations. A literature review conducted in May 2020 using AMED, Embase, Medline and PubMed with the search keywords ‘Virtual Reality’ and ‘Plaster room’ returned no results. Further searches to include keywords ‘VR’, ‘Orthopaedics’ and ‘Paediatrics’ that did not include training simulations yielded two results. Neither of these papers were focused on the paediatric patient but rather used VR for rehabilitation post anterior cruciate ligament surgery or its use for the surgeon in musculoskeletal tumour resection.8,9
The Paediatric Orthopaedic department in a specialist children’s hospital was loaned a VR device, the Rescape DR.VR Junior, for a trial period. This VR device consists of a headset that projects a three-dimensional (3D) image allowing the child to become immersed in a new environment. The headset couples with headphones, a tablet via closed wireless network and an integrated charging unit in the case as seen in Figure 1.
Figure 1 Photograph of Rescape DR.VR Junior kit
Four different landscapes are available for exploration as well as a distraction game and three guided meditation sequences. During this period a feasibility study was carried out trialing the device as a distraction method in the Phlebotomy Room, Plaster Room and preoperatively.
The primary outcome was to determine the safety of using the Rescape DR.VR device in an orthopaedic setting in three different clinical areas. Secondary outcomes were to analyse the difference in patient-recorded anxiety scores pre and postprocedure and to gain health professionals feedback on the practicalities of using the Rescape DR.VR device.

Methods

This pragmatic feasibility study was designed with three arms, one for each clinical area; the paediatric venepuncture room, plaster room and the preoperative environment. The Rescape DR.VR Junior device was available for trial use for 1 month starting in January 2020.
Primarily before trialling the VR device an internal risk assessment by medical engineers was carried out in December 2019 to determine the safety of the Rescape DR.VR headset in the three clinical areas. The device is CE Marked and specifically designed to be used in the healthcare setting. From an infection control standpoint the VR headset is designed to be cleaned with Clinell wipes between uses. This has been proved to remove 99% of surface contaminants from the headset.10 On the internal risk assessment the Rescape DR.VR headset was deemed safe to be used only in the venepuncture and plaster rooms, while further investigation is needed to establish its safety in the operating theatre/anaesthetic room. This was due to the risk of potential harm if the electromagnetic field interfered with medical equipment in level 2 and 3 areas. Such areas would include critical care or the theatre and anaesthetic environment. Specifically, the Rescape DR.VR device was found to be low risk when used alongside simple mechanical equipment such as cast saws.
The feasibility study was carried out in one specialist Children’s Hospital. Arm one in the Phlebotomy Room. Arm two in the fracture clinic Plaster Room. Arm three in the preoperative ward and the anaesthetic rooms was not carried out based on the risk assessment. Healthcare professionals involved, including those giving feedback on the usability of the device, were phlebotomists and plaster technicians. Data collection was carried out by medical students (YS, OK) and an orthopaedic specialist registrar (KS) who oversaw the use of the device inline with the risk assessment.
A total of 33 children (age range: 2–15 years) were given the option to use the Rescape DR.VR-headset while they underwent venepuncture or a cast procedure. Once the participant, with their parent or guardian, had agreed to trial the device, they underwent their procedure as planned with the VR head device fitted and a choice of age appropriate immersive VR simulations were offered using the Rescape compatible tablet. Once the child had made their selection the immersive simulation began. This simulation continued throughout the procedure. Anxiety scores, measured on a Likert scale, were collected pre and postprocedure Figure 2.
Figure 2 Likert scale on a tablet
Participants, including the parent or guardian, were asked if they would use the device again. Subjective feedback was also collated from the supervising clinical staff.
Data analysis was conducted using a paired t test to determine if there was a significant change in the pre and postprocedure anxiety scores.

Results

A total of 66% (21) of patients showed a reduction in anxiety scores, 28% (9) had no change in score; all scores being mild, 1–3 on the Likert scale; 6% (2) showed an increase in postprocedure score. One child declined the head set from the offset and therefore no scores were recorded (Table 1).
Table 1 Summary of results
 Venepuncture roomPlaster roomTotals (%)
Number of participants211132
Age range (years)2–152–13
Anxiety score increased022 (6%)
Anxiety score static459 (28%)
Anxiety score decreased17421 (66%)
Would use the device again (%)211132 (100%)
Analysis of the pre and postprocedure anxiety scores was carried out using a paired t test giving t =−4.78 with p=0.00004. The result is significant at p<0.05. All participants stated they would use the device again. One patient declined the headset and therefore was not included in the trial. Health professionals gave positive subjective feedback and they would all use it again with their paediatric patients. No adverse events were recorded during this study; however, practical comments were offered by participants and observers as to how the usability of the device could be improved. One observation from the Plaster Room was that, when completing an upper limb procedure, it is best not to use the ‘distraction game’ as this encourages head and upper body movements. Two comments were noted regarding having to restart the device before the procedure started as the wireless connection was interrupted between the tablet and the headset.

Discussion

It is known that preprocedural anxiety can affect the severity of pain experienced during a medical procedure.11,12 Although venepuncture and plaster room procedures are low risk in the majority of cases, reports have been made of extreme reactions.13 The Rescape DR.VR Junior combines techniques of sound and visual distraction as well as blocking the noise from the cast saw that are already known to reduce anxiety.1,2,14 The VR headset technology adds in a further immersive element, which is thought to increase the level of distraction and therefore further reduce anxiety levels during awake procedures. This feasibility study aimed to test the practicality of using a VR device in orthopaedic practice. The internal risk assessment deemed the Rescape DR.VR Junior headset a safe device to use in the phlebotomy and plaster rooms. This study showed the device is useable and patient- and staff-friendly. The intuitive nature of the VR headset importantly makes it suitable for the paediatric population and this is supported by the study results of no adverse events. This is also in line with published research on VR use during medical paediatric procedures.7 No delays were reported throughout the trial period in either setting, and no part of the usual practice was altered, suggesting the headset does not interfere with these practical procedures. The study was limited by the number of headsets available and the time frame. Both limited the number of patients the VR device was trialled on.
Even with the limitations of the feasibility study and the low patient numbers, the reduction in anxiety score was significant with p<0.05. Pragmatic feedback from the plaster room suggested that using the distraction game can make upper limb casting more challenging is useful in developing a local protocol for using the device.
With no published trials to date on using VR headsets in a specialist paediatric orthopaedic setting, this feasibility study provides a valuable insight into the practicalities and benefits of using such a device.

Conclusion

The ‘Rescape DR:VR’ headset has been found to be safe and a feasible distraction method for use in the venepuncture and plaster room. Further research is required to assess its use safety and effectiveness in other clinical areas, including the paediatric orthopaedic anaesthetic rooms and theatre environment.

Acknowledgements

We would like to acknowledge the Rescape Innovation Ltd company for the use of their DR.VR Junior headset device during this trial period.

References

1.
Liu RW, Mehta P, Fortuna S et al. A randomized prospective study of music therapy for reducing anxiety during cast room procedures. J Pediatr Orthop 2007; 27: 831–833.
2.
Ko JS, Whiting Z, Nguyen C et al. A randomized prospective study of the use of Ipads in reducing anxiety during cast room procedures. Iowa Orthop J 2016; 36: 128–132.
3.
Ovid. Effects of virtual reality and external cold and vibration on pain in 7- to 12-year-old children during phlebotomy: a randomized controlled trial. https://oce.ovid.com/article/00062704-201812000-00022 (cited August 2020).
4.
Aminabadi N A, Erfanparast L, Sohrabi A et al. The impact of virtual reality distraction on pain and anxiety during dental treatment in 4-6 year-old children: a randomized controlled clinical trial. J Dent Res Dent Clin Dent Prospects 2012; 6: 117–124.
5.
Jeffs D, Dorman D, Brown S et al. Effect of virtual reality on adolescent pain during burn wound care. J Burn Care Res Off Publ Am Burn Assoc 2014 Oct; 35: 395–408.
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Schneider SM, Workman ML. Effects of virtual reality on symptom distress in children receiving chemotherapy. Cyberpsychol Behav 1999; 2: 125–134.
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Eijlers R, Utens EMWJ, Staals LM et al. Systematic review and meta-analysis of virtual reality in pediatrics: effects on pain and anxiety. Anesth Analg 2019; 129: 1344–1353.
8.
Shahid R, Benedict C, Mishra S et al. Using iPads for distraction to reduce pain during immunizations. Clin Pediatr (Phila) 2015; 54: 145–148.
9.
Hao Y, Yang C, He J. The accurate surgical margin before surgery for malignant musculoskeletal tumors: a retrospective study. Am J Transl Res 2018; 10: 2324–2334.
10.
GAMA Healthcare. Clinell | Universal Range. https://gamahealthcare.com/products/universal-wipes-200 (cited August 2020)
11.
Eijlers R, Dierckx B, Staals LM et al. Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial. Eur J Anaesthesiol EJA 2019; 36: 728–737.
12.
Blount RL, Piira T, Cohen LL, Cheng PS. Pediatric procedural pain. Behav Modif 2006; 30: 24–49.
13.
Katz K, Fogelman R, Attias J et al. Anxiety reaction in children during removal of their plaster cast with a saw. J Bone Joint Surg Br 2001; 83: 388–390.
14.
Carmichael KD, Westmoreland J. Effectiveness of ear protection in reducing anxiety during cast removal in children. Am J Orthop Belle Mead NJ 2005; 34: 43–46.

Information & Authors

Information

Published In

cover image The Annals of The Royal College of Surgeons of England
The Annals of The Royal College of Surgeons of England
Volume 104Number 2February 2022
Pages: 144 - 147
PubMed: 34821519

History

Accepted: 1 April 2021
Published online: 25 November 2021
Published in print: February 2022

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Keywords

  1. Virtual reality
  2. Orthopaedics
  3. Paediatrics
  4. Plaster room
  5. Venepuncture
  6. Anxiety

Authors

Affiliations

Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Trust, UK
Y Shanmugharaj
O Kattan
M Kokkinakis
Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Trust, UK

Notes

CORRESPONDENCE TO Karen Shepherd, E: [email protected]

Conflict of Interest

Rescape Innovations Ltd company provided the Rescape DR.VR Junior headset for a trial period at zero cost. Following this trial period the headset was returned.

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