Virtual Reality Compared to Passive Distraction for Pain Management During Orthopedic Procedures in Children: A Randomized Controlled Trial.

BACKGROUND

In children, many fractures treated surgically will be stabilized percutaneously with Kirschner wires and some will require sutures to help the surgical wound to heal. When the fracture is adequately healed, the percutaneous wires and/or the sutures are generally removed in the outpatient clinic. These procedures represent a potential source of pain, stress and anxiety for the patient, as well as for the parents and the caregivers.

A study looked at different types of analgesia during percutaneous pin removal comparing Acetaminophen, Ibuprofen and placebo but no clinically nor statistically significant difference was found among the three groups. Another study compared topical liposomal lidocaine to a placebo but found no statistically significant difference in postprocedure pain scores between groups. On the other hand, administration of narcotics or procedural sedation for pin removal procedure probably exceeds the real needs for the majority of patients. Adding the fact that the administration of narcotics or procedural sedation requires monitoring post administration, those options lengthen visit time, reduce significantly the efficiency in an outpatient clinic setting and are not recommended for routine administration.

In contrast, there seems to be some emerging evidence about distraction methods such as distraction techniques facilitated by a hospital play specialist for pin removal procedures. Distraction use for children in orthopedic outpatient clinics has been reported anecdotally in some literature but, to our knowledge, has never been formally assessed in a randomised controlled trial. Exploring non-pharmacological interventions, including distraction, could be a promising venue for pain management in this population as they are simple, practical, easily implementable and usually without side effects.

Virtual Reality (VR) is a distraction method that allows the user to interact with an immersive environment generated by a computer stimulating different senses. A review of studies on VR, mostly conducted with adult burn patients, showed a 35 to 50% reduction in procedural pain while using VR. Its positive effect has also been reported on anxiety and general distress during painful medical procedures in children and in adults such as venipuncture, wound care, chemotherapy, dental procedures, etc. A recent randomized-controlled trial comparing VR and standard distraction in children undergoing blood drawn procedures, demonstrated a significant positive effect of VR on pain and anxiety reduction as well as patients', caregivers' and phlebotomist's satisfaction. The authors also concluded that VR was more effective for children with higher anxiety sensitivity, adding another plus value to this new technology in children's care.