Decreasing REcurrent Pain and Anxiety in Medical Procedures With a Pediatric Population: Trial

1. BACKGROUND:

Burn injuries are the leading cause of morbidity and mortality in children. They are associated with a lot of pain that is difficult to treat and can impede recovery, cause high levels of anxiety and alter future pain behaviors, resulting at times in chronic pain, paresthesia, or depression. Pain can also decrease participation in treatments such as physiotherapy resulting in poor health outcomes. Beyond the immediate pain experience, children may develop memories that are accurate, positively or negatively estimated (i.e., remembering more or less pain, respectively, as compared to initial pain reports). The way that children's memories are framed is important for future pain coping and distress at subsequent painful experiences. Moreover, it has been shown that pharmacological and non-pharmacological pain management strategies may buffer children from developing such biases in pain memories. Procedural pain is still largely managed pharmacologically mostly through the use of opioids, benzodiazepines and other pharmacological agents which cause a lot of side effects and do not always provide sufficient pain reduction. In recent years, the effectiveness of multimodal approaches combining medication with non-pharmacological interventions for procedural pain relief has been highlighted. Distraction techniques engaging multiple senses may grab the child's attention more than the techniques that only engage one sense (e.g, music), hence, the increasing interest in more immersive and interactive methods of distraction such as VR.

VR is an active 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. However, despite promising results, the use of VR in healthcare settings has been limited, mainly due to its high cost. Reviews have highlighted the need for more research but mostly for the development of more portable, less expensive and more developed VR systems that would promote pain reduction during burn procedures especially for children with burn injuries who are considered one of the most challenging burn populations. However, there has been a breakthrough in technology since 2014 when big scale companies started investing in VR development for commercial gaming. Facebook purchased the Oculus Rift® for mass production allowing access to the latest technology in VR at a relatively low cost. Oculus Rift® is a VR tool that provides a wide field of view, high resolution display, integrated 3D audio and motion detection. In addition, its highly immersive properties could help achieve more analgesia compared to other VR techniques as a review has shown that the sense of presence influences the effectiveness of VR-based analgesia. The sense of presence is a subjective psychological state of consciousness of being in the virtual world whereas immersiveness refers to the physical environment that could be quantified by measuring the field of view or the peripheral vision in the VR goggles. The availability of inexpensive yet highly immersive VR googles such as Oculus Rift® could increase the use of VR in pain management and burn settings while significantly improving its cost effectiveness. A single case study assessed the feasibility of a VR intervention via Oculus Rift® in one child of 11 years old with burn injuries during occupational therapy. The study showed a reduction in pain intensity and pain unpleasantness experienced by the patient, without any side effects. To the knowledge of the investigators, no other studies have tested the distraction via Oculus Rift® for procedural pain management in children with burn injuries undergoing painful physiotherapy treatments. 2. AIM:

The aim of this study is to assess the effect of distraction by VR via Oculus Rift® for the relief of procedural pain, anxiety and decrease memory of pain in children with burn injuries.

Primary Research Question: In children aged 7 to 18 years, who have suffered burn injuries, does VR distraction via Oculus Rift® combined with analgesics provide better pain relief during painful procedures including dressing changes and physiotherapy than standard pharmacological treatment alone?