table A and B

Citation

Question or Hypothesis

Theoretical Foundation

Research Design (include tools) and Sample Size

Key Findings

Recommendations/

Implications

Level of Evidence

Chirico, A., Lucidi, F., De Laurentiis, M., Milanese, C., Napoli, A., & Giordano, A. (2016). Virtual reality in health system: beyond entertainment. a mini‐review on the efficacy of VR during cancer treatment. Journal of cellular physiology.

(1) Is VR an intervention that could support patients during cancer-related treatment?

(2) Is there a type of treatment/condition for which the VR has the best efficacy?

(3) What are the main variables on which VR operates?

Theory not mentioned in the article

This study was systematic reviews. 19 studies were selected. They explored various relevant variables including different types of settings (i.e., during chemotherapy, during pain procedures, during hospitalization).

These studies found that VR improved patients’ emotional well-being, and diminished cancer-related psychological symptoms. They explored various relevant variables including different types of settings (i.e., during chemotherapy, during pain procedures, during hospitalization).

patients reducing their distress; more over the patients do not need any kind of training to use VR, which is without risk for the patient and very inexpensive for the Health Institution. During studies of painful procedures, results showed a reduction of pain; however, these studies did not use-self reported measure.

Level V

Czub, M., & Piskorz, J. (2018). Body Movement Reduces Pain Intensity in Virtual Reality–Based Analgesia. International Journal of Human–Computer Interaction.

Is the amount of movement a differentiating factor with respect to the participants’ tolerance to pain?

What is the amount of time (in seconds) participants kept their hand in the cold water?

Theory not mentioned in the article

Experimental design was used in this study.

Forty-six volunteers, students of Wroclaw universities participated in the study. There were 31 females and 15 males they were recruited through University’s social media pages

VR was found to be effective in increasing pain tolerance and decreasing pain intensity.

the results did not confirm our initial assumptions: the amount of movement was not a differentiating factor with respect to the participants’ tolerance to pain. Participants kept their hands in the cold water for a similar time in small movement VR and in large movement

Only one aspect of movement was investigated in this study, but one can speculate that other movement parameters apart from its scope may be important in decreasing the intensity of pain, or increasing tolerance to pain. Such parameters could be the dynamics, complexity of movement

Level IV

Frieden, T. R., & Houry, D. (2016). Reducing the risks of relief—the CDC opioid-prescribing guideline. New England Journal of Medicine.

Is the rates of opioid prescribing, a tightly correlated epidemic of addiction, overdose, and death from prescription opioids?

Is the use of opioids evolving to increasing use and overdoses of heroin and illicitly produced fentanyl?

Theory not mentioned in the article

Systematic literature Review of the scientific evidence and input from hundreds of leading experts and practitioners, other federal agencies, more than 150 professional and advocacy organizations, a wide range of key patient and provider groups, a federal advisory committee, peer reviewers, and more than 4000 public comments.

Several studies have showed that use of opioids for chronic pain may actually worsen pain and functioning, possibly by potentiating pain perception. After surgery, patients who had received long-term opioid therapy reported higher pain intensity (a rating of 7.6 vs. 5.5 out of 10). Nonpharmacologic therapies can ameliorate chronic pain with less risk to patients. In some instances, other therapies result in better outcomes than opioids. These therapies include exercise therapy, weight loss, psychological therapies..

The evidence review revealed that exercise therapy helped improve, and sustain improvements in, pain and function in patients with osteoarthritis

Management of chronic pain is an art and a science. The science of opioids for chronic pain is clear: for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits.

It is recommended to follow up the CDC opioid-prescribing guideline.

Level VII:

Garrett, B., Taverner, T., & McDade, P. (2017). Virtual reality as an adjunct home therapy in chronic pain management: an exploratory study. JMIR medical informatics.

 Is any changes from baseline pain scores and in reported pain experiences using VR?

Can be VR practically and safely used at home?

Is any weekly pain score changes, any adverse effects, effects on function, and any preferences in type of VR experience?

Theory not mentioned in the article

A mixed-methods pilot case-series approach was used. Instruments: Quantitative Tools, Pre- and Postexposure NRS Scores, Weekly Pain Trends: The Brief Pain Inventory (BPI) and Short Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), Cybersickness Reporting Form.

Qualitative Tools

Initial Individual Interviews, Terminal Individual Interviews.

The majority of these study participants reported a reduction in pain while using the VR but with highly individualized responses. One patient also reported some short-term improved mobility following VR use. Some evidence was found for the short-term efficacy of VR in chronic pain but no evidence for persistent benefits.

VR was not associated with any serious adverse events, although 60% of patients reported some cybersickness during some of the experiences.

 home-based VR therapy is a feasible option for chronic pain sufferers. There remains a pressing need for non-opioid alternatives in the treatment of chronic pain.

Level II

Gold, J. I., & Mahrer, N. E. (2018). Is virtual reality ready for prime time in the medical space? A randomized control trial of pediatric virtual reality for acute procedural pain management. Journal of pediatric psychology.

Would patients playing VR experience significantly less pain and anxiety, and improved satisfaction according to patient, caregiver, and phlebotomist report?

Theory not mentioned in the article

 randomized control trial. 143 triads (patients, their caregiver, and the phlebotomist) were recruited in outpatient phlebotomy at a pediatric hospital and randomized to receive either VR or SOC when undergoing routine blood draw.  measures of pain, anxiety, and satisfaction

Findings showed that VR significantly reduced acute procedural pain and anxiety compared with SOC.

VR is feasible, tolerated, and well-liked by patients, caregivers, and phlebotomists alike for routine blood draw. Given the immersive and engaging nature of the VR

VR is the capacity to act as a preventive intervention transforming the blood draw experience into a less distressing, potentially pain-free routine medical procedure ience

Many new technology and virtual environments are yet to be examined. The future of VR is now, great promise and wide application. However, it is our scientific responsibility to investigate its applications and determine the best match for VR in managing acute procedural pain management and other health-related conditions.

Level II: 

. Gromala, D., Tong, X., Choo, A., Karamnejad, M., & Shaw, C. D. (2015, April). The virtual meditative walk: virtual reality therapy for chronic pain management. In Proceedings of the 33rd Annual ACM Conference on Human Factors in Computing Systems.

Is VR intervention able to reduce perceived pain levels among chronic pain patients in a clinical setting?

May be possible that the long-term benefits for patients learning MBSR to better manage their long-term persistent pain?

Theory not mentioned in the article

Experimental study control group.

Were included 13 patients from the Greater Vancouver area, ranging from 35 to 55 years of age, each had a diagnosis of chronic pain. Six participants (3 male, 3 female) were randomly assigned to the control group, and the other seven (3 male, 4 female) were assigned to the VR group.

VR intervention, in conjunction with MBSR and biofeedback, was better able to invoke positive results in chronic pain patients, compared to MBSR alone. This approach could be an effective non-pharmacological alternative or supplementary method to existing pain management strategies. By teaching mindfulness meditation to patients in this context, we believe that pain patient health may be improved over time.

Were found limitations that

require greater nvestigation. For example, we found that

some patients cannot sit for more than 20 minutes, that

others cannot tolerate the weight or pressure of a head-mounted display (HMD) like the Oculus Rift. It helps to provide how future studies can be better designed to accommodate

customized patient needs.

Level III

Gupta, A., Scott, K., & Dukewich, M. (2018). Innovative technology using virtual reality in the treatment of pain: does it reduce pain via distraction, or is there more to it? Pain Medicine.

Are others mechanisms than distraction by which VR leads to pain relief?

Theory not mentioned in the article

The review looked at articles from 2000 to the present, July 29, 2016, focusing on studies concerning mechanisms by which virtual reality can augment pain relief. The data was collected through a search of MEDLINE and Web of Science.

These results demonstrate that in addition to distraction, there are novel mechanisms for VR treatment in pain, such as producing neurophysiologic changes related to conditioning and exposure therapies. VR may have the ability to help reduce opioid use and misuse among chronic pain patients.

More studies are needed to reproduce results from prospective/pilot studies in large randomized control studies.

Level V

.Hah, J. M., Bateman, B. T., Ratliff, J., Curtin, C., & Sun, E. (2017). Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesthesia and analgesia.

Managing acute pain in the immediate postoperative period can minimizing the risks of persistent opioid use following the surgery?

Theory not mentioned in the article

In the paper, they discuss the consequences of chronic opioid use following surgery, and present an analysis of the extent to which surgery has been associated with chronic opioid use.

Opioids are implicated in opioid-induced hyperalgesia or increased pain sensitivity despite increasing doses of opioids. This hyperalgesia has been demonstrated with exposure to both short- and long-term opioids.

Opioid-related adverse effects can manifest as a multitude of symptoms after surgery ranging from sedation, respiratory depression, delirium, ileus, to the paradoxical worsening of pain with higher opioid doses. 

Recommended the used of Nerve blockade, it have been shown to reduce the risk of chronic opioid use following surgery. 

Level VI 

JahaniShoorab, N., Zagami, S. E., Nahvi, A., Mazluom, S. R., Golmakani, N., Talebi, M., & Pabarja, F. (2015). The effect of virtual reality on pain in primiparity women during episiotomy repair: a randomize clinical trial. Iranian journal of medical sciences.

Has virtual reality any effect on pain in primiparity women during episiotomy repair?

Theory not mentioned in the article

Pilot study on 10 parturient women (power: 80%, confidence level: 95%). The estimation led to 13 parturient women; however, the sample size was increased to16 for a higher level of confidence in each group. Of the 178 primiparous referred to the Omolbanin Hospital of Mashhad during May to July 2012, 32 eligible women fulfilled the criteria and were selected for this study 

Virtual reality is an effective complementary non-pharmacological method to reduce pain during episiotomy repair.

In the study, there is a significant difference between the VR group and the non-VR group episiotomy incision depth in episiotomy repair labor, but there was not any statistically significant difference between the duration of repair in both groups.

Similar to other studies, this study had certain limitations. The possibility of a single-blind design and the control of individual differences and previous experience of the patients were not possible.

Level II:  well-designed Randomized Controlled Trial (RCT) 

Jones, T., Moore, T., & Choo, J. (2016). The impact of virtual reality on chronic pain. Plops one.

Has VR any impact of a brief VR session on the experience of pain in patients with chronic pain conditions?

Can chronic pain patients tolerate the VR session without the side effects that sometimes come with VR such as headaches, dizziness or nausea?

Theory not mentioned in the article

Thirty (30) participants with various chronic pain conditions were offered a five-minute session using a virtual reality application called Cool! Participants were asked about their pain using a 0–10 visual analog scale rating before the VR session, during the session and immediately after the session. They were also asked about immersion into the VR world and about possible side effects.

The virtual reality experience was found here to provide a significant amount of pain relief. A head mounted display (HMD) was used with all subjects and no discomfort was experienced.

Only one participant noted any side effects. VR seems to have promise as a non-opioid treatment for chronic pain and further

investigation is warranted.

The selective and focused attention that is elicited during VR appears to be supplemented by emotional and cognitive factors as well. The richness of the sensory and cognitive experience in VR appears to produce more impactful results that simpler and unisensory forms of distraction.

No participant complained about any degree of dizziness or headache with the HMD

Level II:  well-designed Randomized Controlled Trial (RCT)

McSherry, T., Atterbury, M., Gartner, S., Helmold, E., Searles, D. M., & Schulman, C. (2018). Randomized, crossover study of immersive virtual reality to decrease opioid use during painful wound care procedures in adults. Journal of Burn Care & Research, 39(2), 278-285.

What is the effect of immersive virtual reality (IVR) distraction therapy during painful wound care procedures in adults related to the amount of opioid medications required to manage pain?

Theory not mentioned in the article

randomized controlled trial study design, 2 sequential wound procedures were compared, 1 with IVR distraction therapy and 1 without IVR. Total opioid medications administered before and during the wound procedures were recorded and pain and anxiety were rated before and after the 2 wound procedures. 

. IVR significantly reduced the amount of opioid medication administered during painful wound care procedures when IVR was used compared with no IVR.

 Since pain scores were similar before and after the wound procedures with IVR and without IVR, the 39% reduction in opioid medication during IVR supports its use as a pain distraction therapy during painful procedures.

Level III 

Ortiz-Catalan, M., Guðmundsdóttir, R. A., Kristoffersen, M. B., Zepeda-Echavarria, A., Caine-Winterberger, K., Kulbacka-Ortiz, K., ... & Pihlar, Z. (2016). Phantom motor execution facilitated by machine learning and augmented reality as treatment for phantom limb pain: a single group, clinical trial in patients with chronic intractable phantom limb pain. The Lancet.

Can phantom motor execution facilitated by machine learning and augmented reality use as treatment for phantom limb pain?

Theory not mentioned in the article

Clinical trial. Patients with upper limb amputation and known chronic intractable phantom limb pain were recruited at three clinics patients were in Sweden.

required to have been treated for phantom limb pain by at least one clinical approach, had not reported pain changes for at least a month after the last session of previous treatments, or due to concurrent medication (steady overall pain perception), and to have at least a controllable portion of the biceps or triceps muscles

Their findings suggest potential value in motor execution of the phantom limb as a treatment for phantom limb pain.

Promotion of phantom motor execution aided by machine learning, augmented and virtual reality, and gaming is a non-invasive, non-pharmacological, and engaging treatment with no identified side-effects at present.

Level IV

Shah, A., Hayes, C. J., & Martin, B. C. (2017). Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015. MMWR. Morbidity and mortality weekly report.

Is long-term opioid use often begins with treatment of acute pain?

Theory not mentioned in the article

A random 10% sample of patient records during 2006–2015 was drawn from the IMS Lifelink+ database, which includes commercial health plan and commercially insured population. the study was not human subject research. Records were selected of patients aged ≥18 years who had at least one opioid prescription during June 1, 2006–September 1, 2015, and ≥6 months of continuous enrollment without an opioid prescription before their first opioid prescription

Transitions from acute to long-term opioids therapy can begin to occur quickly: the chances of chronic use begin to increase after the third day supplied and rise rapidly thereafter.

Consistent with CDC guidelines, treatment of acute pain with opioids should be for the shortest durations possible. Prescribing <7 days (ideally ≤3 days) 

Level VII:

Tashjian, V. C., Mosadeghi, S., Howard, A. R., Lopez, M., Dupuy, T., Reid, M., ... & Rosen, B. (2017). Virtual reality for management of pain in hospitalized patients: results of a controlled trial. JMIR mental health.

Is VR superior to conventional means of pain distraction, such as viewing two-dimensional (2D) images, particularly in diverse populations of hospitalized, acute care patients suffering from varying types of pain?

Theory not mentioned in the article

 Comparative cohort study in a large, urban teaching hospital in medical inpatients with an average pain score of ≥3/10 from any cause. 

Use of VR in hospitalized patients significantly reduces pain versus a control distraction condition. These results indicate that VR is an effective and safe adjunctive therapy for pain management in the acute inpatient setting

Future research should test other control conditions and visualization to understand whether there are unique benefits of the 3D VR experience over other control conditions. 

Level IV 

Won, A., Bailey, J., Bailenson, J., Tataru, C., Yoon, I., & Golianu, B. (2017). Immersive virtual reality for pediatric pain. Children.

Beyond providing distraction and enjoyment, can virtual reality provide a corrective psychological and physiological environment?

Can VR facilitate rehabilitation for pediatric patients suffering from chronic pain, as well as neurorehabilitation for children suffering from stroke and cerebral palsy?

Theory not mentioned in the article

a review evaluating articles that describe the use of VR in pediatric procedural, acute and chronic pain. We included articles detailing case studies or randomized trials of the use of VR. We will discuss the selected articles and themes as they are relevant to the improved care of pediatric patients through VR. These articles can be roughly divided into two main areas of clinical relevance: acute and procedural pain and anxiety, and chronic pain and neurorehabilitation.

VR is a promising new technology that offers unique opportunities to modulate the experience of pain. These opportunities include the management of acute and procedural pain and familiarizing children with future procedures via simulation.

They propose that virtual reality may assist in the treatment of pediatric chronic pain via neuromodulation, as well as physical therapy

Level VI 

Citation

Question

Search Strategy

Inclusion/ Exclusion Criteria

Data Extraction and Analysis

Key Findings

Recommendation/

Implications

Level of Evidence

Chirico, A., Lucidi, F., De Laurentiis, M., Milanese, C., Napoli, A., & Giordano, A. (2016). Virtual reality in health system: beyond entertainment. a mini‐review on the efficacy of VR during cancer treatment. Journal of cellular physiology.

(1) Is VR an intervention that could support patients during cancer-related treatment?

(2) Is there a type of treatment/condition for which the VR has the best efficacy?

(3) What are the main variables on which VR operates?

A broad search was performed using Scopus database in the date range from January 1993 to December 2013. Search terms included a combination of “VR” and “VR” with “oncology” or “cancer.”

Original research articles ranging from January 1993 to December 2013, describing the use of VR during cancer treatments, were included in the review. Non-English-language studies were excluded.

From 19 studies various data were extracted from each study, these included number of participants, age of patients, experimental design, treatment/ condition, psychological variables, biological variables, used instrument, data analyses, main results, time of VR intervention

These studies found that VR improved patients’ emotional well-being, and diminished cancer-related psychological symptoms. They explored various relevant variables including different types of settings (i.e., during chemotherapy, during pain procedures, during hospitalization).

patients reducing their distress; more over the patients do not need any kind of training to use VR, which is without risk for the patient and very inexpensive for the Health Institution. During studies of painful procedures, results showed a reduction of pain; however, these studies did not use-self reported measure.

Level V

Frieden, T. R., & Houry, D. (2016). Reducing the risks of relief—the CDC opioid-prescribing guideline. New England Journal of Medicine.

Is the rates of opioid prescribing, a tightly correlated epidemic of addiction, overdose, and death from prescription opioids?

Is the use of opioids evolving to increasing use and overdoses of heroin and illicitly produced fentanyl?

Systematic review of the scientific evidence and input from hundreds of leading experts and practitioners, other federal agencies, more than 150 professional and advocacy organizations, a wide range of key patient and provider groups, a federal advisory committee, peer reviewers, and more than 4000 public comments.

the guideline uses the best available scientific data to provide information and recommendations to support patients and clinicians in balancing the risks of addiction and overdose with the limited evidence of benefits of opioids for the treatment of chronic pain.

On March 15, 2016, the Centers for Disease Control and Prevention (CDC) released a “Guideline for Prescribing Opioids for Chronic Pain” to chart a safer, more effective course.2 The guideline is designed to support clinicians caring for patients outside the context of active cancer treatment or palliative or end-of-life care.

Several studies have showed that use of opioids for chronic pain may actually worsen pain and functioning, possibly by potentiating pain perception. After surgery, patients who had received long-term opioid therapy reported higher pain intensity (a rating of 7.6 vs. 5.5 out of 10). Nonpharmacologic therapies can ameliorate chronic pain with less risk to patients. In some instances, other therapies result in better outcomes than opioids. These therapies include exercise therapy, weight loss, psychological therapies..

The evidence review revealed that exercise therapy helped improve, and sustain improvements in, pain and function in patients with osteoarthritis

Management of chronic pain is an art and a science. The science of opioids for chronic pain is clear: for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits.

It is recommended to follow up the CDC opioid-prescribing guideline.

Level VII

Gupta, A., Scott, K., & Dukewich, M. (2018). Innovative technology using virtual reality in the treatment of pain: does it reduce pain via distraction, or is there more to it? Pain Medicine.

Are others mechanisms than distraction by which VR leads to pain relief?

The data was collected through a search of MEDLINE and Web of Science using the key words of “virtual reality” and “pain” or “distraction.” Specific articles were chosen based upon their ability to address factors that improve distraction with virtual reality or give insight into other mechanisms by which VR may interact with pain.

Specific articles were chosen based upon their ability to address factors that improve distraction with virtual reality or give insight into other mechanisms by which VR may interact with pain. Overall six studies were identified, four small randomized controlled studies and two prospective/pilot studies 

The review looked at articles from 2000 to the present, July 29, 2016, focusing on studies concerning mechanisms by which virtual reality can augment pain relief. The data was collected through a search of MEDLINE and Web of Science.

These results demonstrate that in addition to distraction, there are novel mechanisms for VR treatment in pain, such as producing neurophysiologic changes related to conditioning and exposure therapies. VR may have the ability to help reduce opioid use and misuse among chronic pain patients.

These results demonstrate that in addition to distraction, there are novel mechanisms for VR treatment in pain, such as producing neurophysiologic changes related to conditioning and exposure therapies. VR may have the ability to help reduce opioid use and misuse among chronic pain patients. More studies are needed to reproduce results from prospective/pilot studies in large randomized control studies.

Level V 

Hah, J. M., Bateman, B. T., Ratliff, J., Curtin, C., & Sun, E. (2017). Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesthesia and analgesia.

Managing acute pain in the immediate postoperative period can minimizing the risks of persistent opioid use following the surgery?

Single descriptive or qualitative study 

The perioperative care team, including surgeons and anesthesiologists, is poised to develop clinical and systems-based interventions aimed at providing pain relief in the immediate postoperative period while also reducing the risks of opioid use longer term.

In the paper, they discuss the consequences of chronic opioid use following surgery, and present an analysis of the extent to which surgery has been associated with chronic opioid use.

Opioids are implicated in opioid-induced hyperalgesia or increased pain sensitivity despite increasing doses of opioids. This hyperalgesia has been demonstrated with exposure to both short- and long-term opioids.

Opioid-related adverse effects can manifest as a multitude of symptoms after surgery ranging from sedation, respiratory depression, delirium, ileus, to the paradoxical worsening of pain with higher opioid doses. 

Recommended the used of Nerve blockade, it have been shown to reduce the risk of chronic opioid use following surgery. 

Level VI

Shah, A., Hayes, C. J., & Martin, B. C. (2017). Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015. MMWR. Morbidity and mortality weekly report.

Is long-term opioid use often begins with treatment of acute pain?

The data are provided in a deidentified format and the institutional review board at the authors’ institution deemed the study was not human subject research. without an opioid prescription before their first opioid prescription

Records were selected of patients aged ≥18 years who had at least one opioid prescription during June 1, 2006–September 1, 2015, and ≥6 months of continuous enrollment

A random 10% sample of patient records during 2006–2015 was drawn from the IMS Lifelink+ database, which includes commercial health plan information from a large number of managed care plans and is representative of the U.S. commercially insured population.

Transitions from acute to long-term opioids therapy can begin to occur quickly: the chances of chronic use begin to increase after the third day supplied and rise rapidly thereafter

Consistent with CDC guidelines, treatment of acute pain with opioids should be for the shortest durations possible. Prescribing <7 days (ideally ≤3 days) 

Level VII

Won, A., Bailey, J., Bailenson, J., Tataru, C., Yoon, I., & Golianu, B. (2017). Immersive virtual reality for pediatric pain. Children.

Beyond providing distraction and enjoyment, can virtual reality provide a corrective psychological and physiological environment?

Randomized trials of the use of VR.

We included articles detailing case studies or randomized trials of the use of VR. These articles can be roughly divided into two main areas of clinical relevance: acute and procedural pain and anxiety, and chronic pain and neurorehabilitation

This review evaluating articles that describe the use of VR in pediatric procedural, acute and chronic pain. We will discuss the selected articles and themes as they are relevant to the improved care of pediatric patients through VR..

VR is a promising new technology that offers unique opportunities to modulate the experience of pain. These opportunities include the management of acute and procedural pain and familiarizing children with future procedures via simulation.

They propose that virtual reality may assist in the treatment of pediatric chronic pain via neuromodulation, as well as physical therapy

Level VI