Efficacy of a virtual reality headset for managing severe pain during sickle cell vaso-occlusive crisis: A single-center study in adults.

Abstract

Abstract Background: In adult patients with sickle cell disease (SCD), regular use of opioid analgesics during a vaso-occlusive crisis (VOC) is necessary but can sometimes cause adverse effects and a risk of drug dependence. The use of virtual reality (VR) as a non-pharmacological measure could reduce pain, but data are scarce in this population. Objective: To study the efficacy of VR in reducing pain and anxiety during VOC with severe pain in adult patients with SCD. Methods: Open-label, prospective, monocentric, uncontrolled study including patients with SCD (≥ 18 years) hospitalized between January 1, 2020, and July 31, 2023, for VOC with or without acute chest syndrome (ACS). Patients were included if the pain intensity was ≥ 5 on a numerical rating scale (NRS, from 0 (no pain) to 10 cm (intolerable pain), validated in adults), despite treatment with intravenous (IV) morphine administered by patient-controlled analgesia. After signing a consent form, a 20-minute VR session was conducted using a headset, offering at the patient's choice soothing, meditative, visual, and animated 3D sound environments (beach, forest, etc.). Pain, anxiety (simple, non-validated 5-point Likert scale, from 0 (not at all) to 5 (extreme)), and the dose of morphine received (milligrams (mg)) were recorded before, immediately after, and 1 hour after the session (by a nurse or a clinical study technician). Side effects were also recorded at the end of the session. Groups were compared in pairs using the Wilcoxon test, and the Friedman test was used to study the distribution of variables between the 3 groups. Results: Sixty-three patients (44 (69.8%) women, median age 28 [IQR 24; 35] years, 56 (88.9%) with SS genotype) were included. VR resulted in a significant reduction in pain scores: NRS decreased from 6.4 ± 1.3 before the session to 5.3 ± 1.8 immediately after (p = 0.001), then to 5.6 ± 1.6 one hour after (p = 0.001 vs NRS “before”; p = 0.121 vs NRS “immediately after”). Most patients (46/63, 76%) did not require morphine during the VR session. The median dose of morphine received in the hour before or after the session was identical (2 [0;4] mg). The proportion of patients with the highest anxiety scores (≥ 3/5 on the Likert scale) decreased significantly, from 27/63 (42.9%) before the session to 11/62 (17.8%) immediately after (p = 0.001), and 4/41 (9.8%) 1 hour after the session (p = 0.003 vs “before”; p = 0.374 vs “immediately after”). The reduction in anxiety was greater when the initial level of anxiety was higher (Spearman's coefficient ρ = 0.692, p < 0.001). Adverse effects, always benign, were reported in 15/63 (24%) patients. The most common were a local sensation of heat (3/15, 20%), ocular pain (2/15, 13.3%), and nausea (2/15, 13.3%). Forty patients (64%) considered the duration of the session to be appropriate, while 15/63 (23.8%) found it too short and 8 (12.7%) too long. Surprisingly, given the initial pain, most patients (42/63, 66.7%) fell asleep during the 20-minute session. Most patients (50/60, 83.3%) reported that they “very much” or “extremely” enjoyed their session (≥ 4/5 on the Likert scale). Conclusion: A 20-minute VR session significantly reduces pain and anxiety for at least 1 hour, with excellent tolerance, in adult patients with SCD hospitalized with severe pain despite IV treatment with morphine. To the best of our knowledge, the only study (also open-label) on the effect of VR on acute pain in SCD has been conducted by Agrawal et al. in 2019 in 30 pediatric and young adult patients (median age 16 [13,3;20] years), showing a similar reduction in pain1. By providing relevant data on the reduction of pain and anxiety in a large sample of 63 adult patients, we contribute significantly to the existing literature. Although this uncontrolled study does not rule out a placebo effect of the intervention, it paves the way for a multicenter randomized trial and highlights the importance of non-pharmacological measures for the treatment of VOC, which have been insufficiently studied in SCD. REFERENCE Agrawal AK, Robertson S, Litwin L, et al. Virtual reality as complementary pain therapy in hospitalized patients with sickle cell disease. Pediatr Blood Cancer. 2019;66(2):e27525. Key words: sickle cell disease, virtual reality, pain, anxiety.