Guided Relaxation-Based Virtual Reality for Acute Postoperative Pain and Anxiety: A Pilot Study in a Pediatric Population (Preprint)

BACKGROUND Distraction-based therapies, such as virtual reality (VR), have been used to reduce pain during acutely painful procedures. However, distraction alone cannot produce the prolonged pain reduction required to manage sustained postoperative pain. Integration of VR with other pain reducing therapies, like guided relaxation, may enhance their clinical impact. OBJECTIVE The goal of this pilot study was to assess the association of a single guided relaxation-based VR (VR-GR) session with a reduction in postoperative pain and anxiety in children. We also explored whether pain catastrophizing and anxiety sensitivity influenced this association. METHODS A total of 51 children and adolescents (7-21 years) with postoperative pain followed by the Acute Pain Service at Cincinnati Children’s Hospital were recruited over an 8-month period to undergo a single VR-GR session. Prior to VR, patients completed pain catastrophizing (PCS-C) and anxiety sensitivity (CASI) questionnaires. The primary outcome was changes in pain intensity following VR-GR (immediately, 15, and 30 minutes). Secondary outcomes included changes in pain unpleasantness and anxiety. RESULTS VR-GR decreased pain intensity immediately (p < 0.001) and 30 minutes (p = 0.04) after the VR session, but not at 15 minutes (p = 0.16) post-session. Reductions in pain unpleasantness were observed during all time intervals (p < 0.001 at all intervals). Anxiety was reduced immediately (p = 0.02) but not at 15- (p = 0.08) or 30- (p = 0.30) minutes following VR-GR. Patients with higher CASI reported greater reductions in pain intensity (p = 0.04) and unpleasantness (p = 0.01) following VR-GR. Pain catastrophizing was not associated with changes in pain and anxiety. CONCLUSIONS A single, short VR-GR session showed transient reductions in pain intensity, pain unpleasantness, and anxiety in children and adolescents with acute postoperative pain. These results encourage a future randomized clinical trial assessing efficacy of VR-GR. CLINICALTRIAL NCT04556747

Guided relaxation-based virtual reality versus distraction-based virtual reality or passive control for postoperative pain management in children and adolescents undergoing Nuss repair of pectus excavatum: protocol for a prospective, randomised, controlled trial (FOREVR Peds trial)

IntroductionVirtual reality (VR) offers an innovative method to deliver non-pharmacological pain management. Distraction-based VR (VR-D) using immersive games to redirect attention has shown short-term pain reductions in various settings. To create lasting pain reduction, VR-based strategies must go beyond distraction. Guided relaxation-based VR (VR-GR) integrates pain-relieving mind–body based guided relaxation with VR, a novel therapy delivery mechanism. The primary aim of this study is to assess the impact of daily VR-GR, VR-D and 360 video (passive control) on pain intensity. We will also assess the impact of these interventions on pain unpleasantness, anxiety and opioid and benzodiazepine consumption. The secondary aim of this study will assess the impact of psychological factors (anxiety sensitivity and pain catastrophising) on pain following VR.Methods and analysisThis is a single centre, prospective, randomised, clinical trial. Ninety children/adolescents, aged 8–18 years, presenting for Nuss repair of pectus excavatum will be randomised to 1 of 3 study arms (VR-GR, VR-D and 360 video). Patients will use the Starlight Xperience (Google Daydream) VR suite for 10 min. Patients randomised to VR-GR (n=30) will engage in guided relaxation/mindfulness with the Aurora application. Patients randomised to VR-D (n=30) will play 1 of 3 distraction-based games, and those randomised to the 360 video (n=30) will watch the Aurora application without audio instructions or sound. Primary outcome is pain intensity. Secondary outcomes include pain unpleasantness, anxiety and opioid and benzodiazepine consumption.Ethics and disseminationThis study follows Standard Protocol Items: Recommendations for Interventional Trials guidelines. The protocol was approved by the Cincinnati Children’s Hospital Medical Center’s institutional review board. Patient recruitment began in July 2020. Written informed consent will be obtained for all participants. All information acquired will be disseminated via scientific meetings and published in peer-reviewed journals.Trial registration numberNCT04351776.

Comparing the effects of a mindfulness versus relaxation intervention on romantic relationship wellbeing

There is increasing scientific interest in the potential association between mindfulness and romantic relationship wellbeing. To date, however, experimental studies using active control groups and testing dyadic effects (i.e. examining both actor and partner effects) are lacking. In the current study, romantically involved individuals engaged for 2 weeks daily in either guided mindfulness exercises, or guided relaxation exercises. Participants, and their partners, completed measures of relationship wellbeing at pre- and post-intervention, and at 1-month follow up. The mindfulness intervention significantly promoted relationship wellbeing, for both participants (i.e. actor effects) and their partners (i.e. partner effects). However, these findings did not significantly differ from changes in relationship wellbeing in the relaxation condition. Theoretical implications of these findings for understanding the association between mindfulness and romantic relationship wellbeing are discussed. Moreover, the findings are discussed in light of recent debates about the relative lack of proper control groups in mindfulness research.

Guided relaxation-based virtual reality transiently reduces acute postoperative pain and anxiety in a pediatric population

Background: Virtual reality (VR)-based immersive games and content can distract or redirect attention. Distraction-based therapies, such as VR, have been used to reduce pain from acutely painful procedures. However, it is unlikely that distraction alone can produce the prolonged pain reduction required to manage sustained postoperative pain. Integration of VR with other pain reducing therapies, including mind-body techniques, may enhance their clinical impact. Slow breathing and relaxation techniques are used clinically to reduce pain in children. Incorporating techniques such as these into the immersive audio-visual VR experience has the potential to produce synergistic effects. The current pilot study assessed the ability of a single guided relaxation-based VR (VR-GR) session to decrease acute postoperative pain and anxiety in children and adolescents. We also explored whether pain catastrophizing and anxiety sensitivity influenced the ability of VR-GR to reduce these outcomes. Methods: A total of 51 children and adolescents (ages 7-21 years) with postoperative pain followed by the Acute Pain Service at Cincinnati Childrens Hospital Medical Center were recruited over an 8-month period to undergo a single VR-GR session. Prior to VR, patients completed pain catastrophizing (PCS-C) and anxiety sensitivity (CASI) questionnaires. The primary outcome was changes in pain intensity following VR-GR (immediately, 15, and 30 minutes). Secondary outcomes included changes in pain unpleasantness and anxiety. Results: Based on mixed effects models, VR-GR decreased pain intensity immediately (p < 0.001) and 30 minutes (p = 0.04) after the VR session, but not at 15 minutes (p = 0.16) post-session. Reductions in pain unpleasantness were observed during all time intervals (p < 0.001 at all intervals). Anxiety was reduced immediately (p = 0.02) but not at 15- (p = 0.08) or 30- (p = 0.30) minutes following VR-GR. Adjustment for covariates showed that patients with higher CASI reported greater reductions in pain intensity (p = 0.04) and unpleasantness (p = 0.01) following VR-GR. Pain catastrophizing did not impact changes in pain and anxiety following the VR session (all ps > 0.10). Conclusion: A single, short VR-GR session produced immediate and acute reductions in pain intensity, pain unpleasantness, and anxiety in children and adolescents with acute postoperative pain. These results encourage future randomized clinical trials to compare the effectiveness of VR-GR and mind-body based treatments to reduce postoperative pain outcomes and to reduce requirements for opioid medications during this period.

Guided relaxation-based virtual reality versus distraction-based virtual reality or passive control for postoperative pain management in children and adolescents undergoing Nuss repair of pectus excavatum: protocol for a prospective, randomized, controlled trial (FOREVR Peds trial)

Introduction: Virtual reality (VR) offers an innovative method to deliver nonpharmacological pain management. Distraction-based VR (VR-D) using immersive games to redirect attention has shown short-term pain reductions in various settings. To create lasting pain reduction, VR-based strategies must go beyond distraction. Guided relaxation-based VR (VR-GR) integrates pain-relieving mind-body based guided relaxation with VR, a novel therapy delivery mechanism. The primary aim of this study is to assess the impact of daily VR-GR, VR-D, and 360 video (passive control) on pain intensity and opioid consumption. We will also assess the impact of these interventions on pain unpleasantness, anxiety, and benzodiazepine consumption. The secondary aim of this study will assess the impact of psychological factors (anxiety sensitivity, pain catastrophizing) on pain following VR. Methods and analysis: This is a single center, prospective, randomized, clinical trial. Ninety children/adolescents, ages 8 to 18 years, presenting for Nuss repair of pectus excavatum will be randomized to 1 of 3 study arms (VR-GR, VR-D, 360 video). Patients will use the Starlight Xperience (Google Daydream) VR suite for 10-minutes. Patients randomized to VR-GR (n=30) will engage in guided relaxation/mindfulness with the Aurora application. Patients randomized to VR-D (n=30) will play 1 of 3 distraction-based games, and those randomized to the 360 video (n=30) will watch the Aurora application without audio instructions or sound. Primary outcomes are pain intensity and opioid consumption. Secondary outcomes include pain unpleasantness, anxiety, and benzodiazepine consumption. Ethics and dissemination: This study follows SPIRIT guidelines. The protocol was approved by the Cincinnati Childrens Hospital Medical Center Institutional Review Board. The trial has not yet begun recruiting (recruitment to begin July 2020). Written informed consent will be obtained for all participants. All information acquired will be disseminated via scientific meetings and published in peer-reviewed journals. Trial registration number: ClinicalTrials.gov NCT04351776, registered April 3, 2020.

Immediate Effects of Yoga Based Relaxation Technique Yoga Nidra on Heart Rate Variability in Young and Healthy Volunteers

Introduction: Cardiovascular autonomic functions are affected by the negative influences of stress which bring about alterations in heart rate variability (HRV). Yoga based relaxation techniques like Yoga Nidra have been found to relieve stress as shown by improved HRV. This study was conducted to assess the immediate effects of a yoga based guided relaxation technique, Yoga Nidra on HRV parameters in young and healthy volunteers. Methods: This was an interventional study conducted in the Department of Clinical Physiology, Institute of Medicine, Maharajgunj. Fifty two male medical students were divided into supine rest group (n=26) and Yoga Nidra group (n=26). HRV indices were recorded before and after supine rest and Yoga Nidra. Intra-group and inter-group comparisons of the HRV parameters were done before and after the interventions. Results: In comparison to the supine rest, Yoga Nidra produced significant increase in values of HF (1460.72 Vs 3272.99; p=0.03) and HFnu (50.32 Vs 62.68; p=0.004); and significant reduction in the values of LFnu (49.68 Vs 37.32; p=0.004) and LF:HF ratio (0.99 Vs 0.59; p=0.004), which suggested that the parasympathetic modulating response of Yoga Nidra was better than that of supine rest. Conclusion: Yoga Nidra, a yoga based relaxation technique brings better relaxation response than supine rest as indicated by the significantly improved HRV indices.

Conservative and non-surgical management of lumbar disc herniation

A case of a 16-year-old Indian adolescent with discal herniation in L4 – L5 region with classical sign of ‘foot drop’ was successfully managed by conservative, non-surgical approach following principles of yoga intervention. Patients practised yoga under supervision of yoga expert, four times a day for first two weeks followed by once a day for consecutive two years. Yoga protocol included gentle yoga based loosening practices, simple asanas, yogic breathing techniques and yogic guided relaxation, pranayama and meditation. One year and two-year follow-ups showed complete revival of normal function and healing of the affected spinal cord disorder. A case which was recommended for surgery recovered with yoga intervention.