Impact of non-immersive virtual reality on procedural pain, anxiety, and satisfaction in chronic low back pain patients: A quasi-experimental study

1. Introduction

Chronic lower back pain (CLBP) is a huge public health issue that has an impact on people’s lives (Huang et al., 2020). CLBP is a highly disabling disorder that significantly lowers the quality of life (Baykara et al., 2013; Weiss et al., 2017).

Back pain is a common ailment among adults. According to previous studies, up to 23% of people worldwide experience CLBP. Additionally, this cohort has demonstrated a 24% to 80% 1-year recurrence rate (Balagué et al., 2012; Hoy et al., 2010). CLBP describes the pain between the lower edge of the ribs and the buttocks, which persists beyond 3 months of symptoms.

CLBP is treated with a range of pharmaceuticals, such as nonsteroidal opioids, antidepressants, anti-inflammatory drugs (NSAIDs), and anticonvulsants (Wójcik and Rogalska, 2022). However, a study from Scotland, specifically the Grampian region of the UK, showed that two-thirds of chronic pain sufferers were unsatisfied with pharmacological remedies (Elliott et al., 2002). Additionally, those who take painkillers may become physically dependent and develop an addiction (Martel et al., 2018; Müller-Schwefe, 2011).

Pain interventions (including spine injection procedures, such as lumbar sympathetic ganglion block), despite their minimal invasiveness, are still distressing and painful for chronic pain patients (Ryu et al., 2018). During interventions, pain physicians have tried to reduce pain and anxiety associated with painful procedures.

Chronic pain and depression have a bidirectional relationship. Patients with an extended history of pain suffering are more likely to experience symptoms of anxiety and depression (Gorczyca et al., 2013). In addition, current research indicates that chronic pain might result in functional and anatomical modifications in the brain (Reckziegel et al., 2019).

All those notions can conclude that chronic pain refers to a multidimensional feeling that might lead to sleep disruptions, depression, anxiety, decreased quality of life, and elevated healthcare expenses (Andrew et al., 2014; Leadley et al., 2014; Park and Hughes, 2012). Along with the unpleasant sensation, chronic pain can impair emotional and cognitive functions. Indeed, multiple studies have shown that this illness includes symptoms of depression as well as deficiencies in verbal memory, executive functions, and attention (Moriarty et al., 2011).

Prior studies have focused on young patients to develop effective distraction strategies during needle-related procedures. Numerous distracting methods have been tested, and behavioral therapy, massage, and breathing exercises are potentially useful distraction techniques (McKenna et al., 2015; Nguyen et al., 2010; Post-White et al., 2009).

Ongoing neurological discoveries have inspired new concepts for developing non-pharmacological rehabilitation to manage pain. Minor psychological manipulations, such as distracting attention, have the potential to decrease the intensity of pain as patients’ emotional and mental conditions can influence their perception of pain (Wong et al., 2022).

One of the options that has had rapid implementation in various healthcare settings is virtual reality (VR) technology, ranging from acute pain-related procedures to rehabilitation of chronic pain conditions (Chuan et al., 2021; Won et al., 2017).

VR is a new technology-generated, interactive environment that mimics reality (Chuan et al., 2021; Li et al., 2017). VR generates an experience that is enhanced in terms of several sensory feedback (visual, auditory, and tactile). VR rehabilitation uses a moving avatar and an enriched environment to engage numerous cortical and subcortical neural pathways that enhance the patient’s learning and recovery (Ito and Doya, 2011; Kommalapati and Michmizos, 2016; Solouki and Pooyan, 2016).

VR could be a significant resource for managing pain through the enhancement of psychological wellness. Users can experience multi-sensory stimulation and 3D environments through VR. The use of VR for therapeutic purposes can produce therapeutically useful scenarios (Bush, 2008).

According to a previous report, the application of VR in pain management during medical procedures has shown promising results (Atzori et al., 2018). Brown and colleagues (2020) examined the acceptability and feasibility of VR in pain and anxiety in patients suffering from CLBP and receiving a spinal injection under fluoroscopy. Following the injection, there was no statistically significant difference in pain in patients who received VR glasses (intervention) compared to those who did not (control) (Brown et al., 2020).

Young Joo and colleagues investigated the effect of VR immersion on chronic pain patients undergoing minimally invasive procedures as guided by fluoroscopy. The VR and the control group were randomly assigned to patients who received nerve ganglion blocks. In the VR group, a 30-min session of the hypnotic video was applied along with infiltration of local anesthetic. However, the other group received only a local anesthetic while the VR device was switched off. After assessing the pain score, anxiety, patient satisfaction, local anesthetic dosage, and hemodynamic stability, a significant decrease in pain and post-procedural anxiety levels in the VR group was reported. The control group, however, requested higher doses of local anesthetic, and there was no discernible difference in the two groups’ levels of patient satisfaction (Joo et al., 2021).

In the past 5 years, most studies done on VR highlighted its effectiveness. The results promote its application in a range of clinical settings for positive outcomes (Brown and Foronda, 2020). Despite emerging interest in using VR for managing CLBP, the current evidence is insufficient to support non-immersive VR applications. The limited number of studies, inconsistent results, methodological concerns, and variability in treatment approaches all as previously recommended, contribute to the conclusion that more comprehensive research is needed before VR can be considered a reliable treatment option for CLBP (Nagpal et al., 2022)

Meanwhile, to the best of our knowledge, no sufficient studies have been done in Saudi Arabia to assess the effect of VR on pain and anxiety, as well as satisfaction in CLBP. Therefore, the current study was designed to assess and compare the effects of VR distraction technologies versus midazolam-based sedation among patients undergoing painful interventions on pain (preoperative, intraoperative, and postoperative) and anxiety levels (preoperative and postoperative), along with hemodynamic parameters. Furthermore, post-procedure patients’ comfort and satisfaction, as well as patient experiences, were also evaluated.

2. Materials and Methods

A prospective quasi-experimental study was conducted at King Fahad Hospital of the University (KFHU) in Khobar, Saudi Arabia, from May 2022 until April 2023. CLBP patients were screened during their visit to the pain clinic, and those who were already scheduled to receive spinal injections for CLBP were asked to participate in the study.

3. Results

A total of 50 patients were initially screened for the study. Of these, 20 were excluded for not meeting the inclusion criteria or declining to participate. Ultimately, 30 patients were deemed eligible to take part in the study. During the study, 29 patients completed the protocol. However, one patient from the VR group was excluded after allocation as she decided to discontinue participation. As a result, the final analysis included data from 29 patients, 15 in the positive control (SD group) and 14 in the intervention (VR) group (Fig. 1).

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Fig. 1.

Participants flow chart.

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3.2 Procedural features

Fig. 2 shows the different procedures done for both groups. There were no significant variations in the procedural features in both study groups. However, the Epidural Steroid Injection was the most common procedure done in both groups, with eight patients in VR cases against six in SD. Right piriformis injection was given to three patients in the VR group against two of the SD patients. A total of two patients and one, respectively, in both groups received a bilateral sacroiliac joint injection (BSJI).

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Fig. 2.

The different procedures done for both study groups.

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Of the rest of the VR group, a single patient got thoracic facet injections, meanwhile two patients of SD received Bilateral Sacroiliac Joint Block + Fucet Block. Other procedures have been shown in Fig. 2.

4. Discussion

To the best of our knowledge, this is the first study done in Saudi Arabia that investigated the feasibility of non-immersive VR intervention on patients undergoing painful lower back procedures. Our results showed that both interventions (VR and SD) demonstrated significantly reduced post-intervention pain intensity and anxiety scores, compared to the baseline values. Notably, the VR group exhibited a significant decrease in intra-operative scores compared to baseline values.

An interesting observation, comparative analysis for the overall effects between both interventions (VR and SD), did not show any significant differences in their effects, suggesting comparable effects of both interventions against pain and anxiety. Furthermore, our results showed that patients’ satisfaction did not differ significantly between the VR and the standard treatment (SD) groups.

These findings align with previous studies demonstrating that VR can improve CLBP and enhance body position perception as well as movement (Alemanno et al., 2019). The significant improvements observed in pain and anxiety during the CLBP procedure suggest that VR intervention led to substantial proprioceptive and functional enhancements (Solouki and Pooyan, 2016). In the context of chronic neuropathic pain, VR intervention may lead to analgesia while also enhancing the sensation of embodiment (Ekman et al., 2018).

A recent systematic review of 17 peer-reviewed articles corroborates the findings of the current study. The review suggests that VR can enhance chronic pain management outcomes. However, the magnitude of VR impacts may vary depending on the specific approach and study design employed (Wong et al., 2022).

Also, HYPERLINK \l “bib46” \o “BIB(bib46)”Veldhuijzen et. al. (2020) used VR glasses in colonoscopy procedures and found that comfort, anxiety, and pain were similar (non-significant changes) in both the VR and non-VR groups (Veldhuijzen et al., 2020). In previous trials, VR diversion games were frequently utilized to treat acute procedural pain, with positive results (Won et al., 2017).

The anxiety scores were significantly decreased within and between the study groups. These findings are in line with a recent randomized control trial (RCT) conducted by Turan et. al. (2021), who found that VR was an effective tool in reducing the level of anxiety during surgical procedures done under spinal anesthesia (Turan et al., 2021). Moreover, a recent Saudi study showed that VR significantly lowered anxiety and stress in women undergoing cesarean section under regional anesthesia (Almedhesh et al., 2022). Along the same lines, in a systematic review of four RCTs, VR was found to be more effective than the controls and comparable to typical pharmaceutical sedation (Găină et al., 2022). Furthermore, another RCT found that VR was effective in the reduction of post-procedure-related anxiety in chronic pain patients receiving intervention with minimal invasive guided by fluoroscopy (Joo et al., 2021).

Conversely, some reports found that there was no discernible difference in patients’ anxiety scores between the VR and control groups among patients undergoing bone marrow aspiration and cystoscopy (Glennon et al., 2018; Walker et al., 2014). The difference could be explained by many technological aspects and study design as well as the audiovisual content accessible through VR glasses, which could increase the level of VR distraction to decrease anxiety and stress (Wong et al., 2022).

Hemodynamic parameters did not differ significantly, except that SBP, VR, and SD all led to a decrease in sympathetic tone, resulting in reduced blood pressure. However, VR exhibits an early effect compared to midazolam. Similarly, this view is supported by the results of a prior report (Vorwerg-Gall et al., 2023). These results suggest that VR intervention may generate an early positive feeling thus decreasing the patient’s anxiety and then helping in decreasing the SBP by reducing the sympathetic tone, since VR has been shown to significantly reduce anxiety and stress in various medical procedures, such as cesarean sections and carotid artery stenting, which can contribute to the early decrease in sympathetic tone and blood pressure (Almedhesh et al., 2022).

On the other hand, midazolam induces hypotension through vasodilation and decreased vascular resistance, which may take longer to manifest compared to the immediate calming effect of VR on anxiety and stress levels (Modanlou and Beharry, 1997).

Regarding the other hemodynamic parameters (DPB, HR, and SpO₂%), there were no significant differences at any given time among the two study groups. In line with the present study, a prior report studied the VR effectiveness in decreasing anxiety in patients receiving spinal anesthesia. They found that VR did not affect the SpO₂ significantly or the other hemodynamic measures (Tharion and Kale, 2021). Another study was conducted to investigate the impact of VR on preoperative anxiety before septorhinoplasty through a quasi-experimental study, which found that SPO₂100% did not change significantly, while SBP and SBP decreased significantly among the participants (Baytar and Bollucuo Lu, 2023). According to Sahin et. al. (2020), the utilization of VR during procedures could aid in hemodynamic stability due to the mechanism of stress reduction (Sahin and Basak, 2020). The same controversial reports were reported in the recorded HR (Baytar and Bollucuo Lu, 2023) (Frey et al., 2019).

The effects of VR on hemodynamic parameters are not uniform and depend on a complex interplay of the VR content, user characteristics, measurement techniques, and psychological factors. This duality highlights the need for further research to clarify the hemodynamic impact of VR intervention.

Nowadays, collecting data on patient satisfaction is important for evaluating and improving the standard of healthcare; therefore, various studies have found that VR improved patient satisfaction during endoscopic procedures (Umezawa et al., 2015). In the current study, scores for patient satisfaction and comfort did not significantly change between the two study groups. Although both groups recorded high levels of satisfaction and comfort scores, VR plays a significant role, like sedation, in the control group. These results are comparable to those of two VR trials conducted on burn wound patients. The authors of those trials proposed that the diversity of results could be resolved by creating a customized VR system rather than using pre-made VR gear (Kipping et al., 2012; Morris et al., 2010).

Finally, both immersive and non-immersive VR interventions have shown promise in managing pain; however, the accessibility, ease of use, and potential for greater efficacy make non-immersive VR a superior choice for healthcare professionals in CLBP management (García-López et al., 2021).

5. Limitations

Our study was a single-center trial with a limited sample size. In addition, due to the nature of the procedure, in this study, blindness cannot be applied during the data collection. Also, certain uncontrollable factors can contribute to anxiety, such as equal gender in both arms, education, previous experience in the operating room, and waiting time before the procedure. Thus, we could not find significant differences between the two groups.

6. Conclusions

Both interventions (VR and SD) demonstrated significantly reduced post-intervention pain intensity and anxiety scores and succeeded in distracting patients and reducing chronic low back pain when compared to the baseline values. Both groups had equal satisfaction and comfort scores. Notably, the VR group exhibited a significant decrease in intraoperative scores compared to baseline values. When we compared the overall effects between VR and SD groups, the results showed non-significant differences in pain and anxiety levels, as well as post-procedure patients’ comfort and satisfaction, suggesting comparable effects of both interventions agonist CLBP.