Background Distraction-based therapies, such as virtual reality (VR), have been used to reduce pain during acutely painful procedures. However, distraction alone cannot produce prolonged pain reduction to manage sustained postoperative pain. Therefore, the integration of VR with other pain-reducing therapies, like guided relaxation, may enhance its clinical impact. Objective The goal of this pilot study was to assess the impact of a single guided relaxation–based VR (VR-GR) session on postoperative pain and anxiety reduction in children. We also explored the influence of pain catastrophizing and anxiety sensitivity on this association. Methods A total of 51 children and adolescents (7-21 years) with postoperative pain and 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, the patients completed 2 questionnaires: Pain Catastrophizing Scale for Children (PCS-C) and the Child Anxiety Sensitivity Index (CASI). The primary outcome was a change in pain intensity following the VR-GR session (immediately, 15 minutes, and 30 minutes). The secondary outcomes included changes in pain unpleasantness and anxiety. Results The VR-GR decreased pain intensity immediately (P<.001) and at 30 minutes (P=.04) after the VR session, but not at 15 minutes (P=.16) postsession. Reductions in pain unpleasantness were observed at all time intervals (P<.001 at all intervals). Anxiety was reduced immediately (P=.02) but not at 15 minutes (P=.08) or 30 minutes (P=.30) following VR-GR. Patients with higher CASI scores reported greater reductions in pain intensity (P=.04) and unpleasantness (P=.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. The results call for a future randomized controlled trial to assess the efficacy of VR-GR. Trial Registration ClinicalTrials.gov NCT04556747; https://clinicaltrials.gov/ct2/show/NCT04556747

Neonatal tissue damage induces long-term deficits in inhibitory synaptic transmission within the spinal superficial dorsal horn (SDH) that include a reduction in primary afferent-evoked, feedforward inhibition onto adult projection neurons. However, the subpopulations of mature GABAergic interneurons which are compromised by early-life injury have yet to be identified. The present research illuminates the persistent effects of neonatal surgical injury on the function of inhibitory SDH interneurons derived from the prodynorphin (DYN) lineage, a population that synapses directly onto lamina I spinoparabrachial neurons and is known to suppress mechanical pain and itch in adults. The results demonstrate that hindpaw incision at postnatal day 3 (P3) significantly decreased the strength of primary afferent-evoked glutamatergic drive onto DYN neurons within the adult mouse SDH while increasing the appearance of afferent-evoked inhibition onto the same population. Neonatal injury also dampened the intrinsic membrane excitability of mature DYN neurons, and reduced their action potential discharge in response to sensory input, compared with naive littermate controls. Furthermore, P3 incision decreased the efficacy of inhibitory DYN synapses onto adult spinoparabrachial neurons, which reflected a prolonged reduction in the probability of GABA release. Collectively, the data suggest that early-life tissue damage may persistently constrain the ability of spinal DYN interneurons to limit ascending nociceptive transmission to the adult brain. This is predicted to contribute to the loss of feedforward inhibition onto mature projection neurons, and the "priming" of nociceptive circuits in the developing spinal cord, following injuries during the neonatal period.

Objective Virtual reality (VR) is a promising method to manage pain. Distraction-based VR (VR-D) is thought to reduce pain by redirecting attention. While VR-D can reduce pain associated with acutely painful procedures, it is unclear if VR-D can reduce pain after surgery. We assessed the ability of a single VR-D session to decrease postoperative pain and anxiety and explored if pain catastrophizing and anxiety sensitivity influenced these outcomes in children following surgery. Design Single-center, prospective, pilot study Setting Cincinnati Children’s Hospital Medical Center (CCHMC) Subjects 50 children (7-21 years) with postoperative pain followed by the Acute Pain Service Methods Patients received one VR-D session following surgery. Prior to the session, patients completed pain catastrophizing (PCS-C) and anxiety sensitivity (CASI) questionnaires. Primary outcome consisted of changes in pain intensity following VR-D (immediately, 15, and 30 minutes). Secondary outcomes included changes in pain unpleasantness and anxiety. Results VR-D use was associated with a decrease in pain intensity immediately and 15-minutes after VR-D. Reductions in pain unpleasantness were observed up to 30 minutes following VR-D. VR-D was also associated with a reduction in anxiety immediately and at 15-minutes. While patients with higher pain catastrophizing had higher baseline pain intensity and unpleasantness, they did not show larger pain reductions following VR-D compared to those with lower pain catastrophizing. Conclusions VR-D may be beneficial in transiently reducing pain intensity, unpleasantness, and anxiety in children with postoperative pain. This study informs design of larger, randomized, controlled study assessing VR-D for acute postoperative pain and anxiety management.

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.

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.