Biofeedback VR Feasible for Pediatric Perioperative Pain
Key Takeaways
- Among children and adolescents undergoing surgery, trial completion and participation with assigned perioperative technologies were high across both the ForeVR and control-app arms.
- Most responding patients and caregivers were satisfied with ForeVR, and few VR-BF participants rejected using it again.
- VR-BF recipients reported mild, transient adverse events, but no serious adverse events occurred.
- Symptomatic VR-BF participants had short-term within-session reductions in pain intensity, pain unpleasantness, and anxiety.
Lin and colleagues enrolled 70 English-speaking patients aged 12–18 years at Nationwide Children’s Hospital and Nemours Children’s Health, Delaware, in a prospective, two-arm, parallel-group, single-blind pilot randomized trial of perioperative biofeedback-based virtual reality. Eligibility required surgery with expected moderate-to-severe postoperative pain, Acute Pain Service management, and more than one overnight admission.
Intended equal randomization assigned patients to custom ForeVR, which integrated respiratory biofeedback into a Meta Quest environment, or the commercially available Manage My Pain pain-tracking app as an active digital control. Participants and caregivers knew their assignment, and outcome assessors and analysts were masked. The schedule called for one 10-minute session daily on five preoperative days and three 10-minute sessions daily on seven postoperative days, including at home after discharge. Feasibility measures covered recruitment, enrollment and randomization, retention, adherence, and outcome-data collection; satisfaction and tolerability were secondary, while within-session postoperative pain intensity, pain unpleasantness, and anxiety were exploratory.
Across both assigned technologies, 65 of 70 enrollees (92.9%) completed the trial. More than one assigned session and diary entry was completed preoperatively by 64 of 70 (91.4%); this threshold did not require completion of every scheduled session. The Results report that 60 of 70 (85.7%) completed more than one postoperative session and diary entry, and VR-BF use lasted a median of four days. Opioid-use and pain-score capture was nearly complete at both institutions. VR-BF recipients used ForeVR across multiple preoperative days and postoperative sessions. Most responding ForeVR patients and caregivers expressed satisfaction, and few responding VR-BF participants said they would not use it again.
9 of 60 participants with postoperative diaries reported at least one adverse event, all in the VR-BF arm; at the final visit, 6 VR-BF participants described mild, transient events directly to investigators. No serious adverse events occurred, and the reported events were not all established as device-caused. Exploratory symptom analyses included VR-BF sessions with presession pain or anxiety of at least 2 on a 0–10 numeric rating scale. Median pain intensity, pain unpleasantness, and anxiety each decreased by 1 point immediately after sessions, with similar decreases observed at 15 and 30 minutes. These repeated within-arm observations did not compare symptom effects against Manage My Pain.
The authors characterized feasibility and acceptability, not clinical efficacy or between-group symptom differences, as the trial’s focus. Operations and recovery trajectories varied, although orthopedic procedures predominated. Frequent postoperative sessions burdened some participants, while intermittent first-generation hardware and connectivity problems disrupted use. Satisfaction ratings collected retrospectively may have been affected by recall, and families willing to enroll in a technology trial may have been especially receptive to digital tools. These constraints limit interpretation of the exploratory symptom pattern without establishing a comparative benefit.
According to the authors, perioperative VR-BF was workable and acceptable under the pilot conditions. They identified less burdensome scheduling and device refinements for future testing, alongside a larger, adequately powered evaluation of whether the observed within-session symptom changes translate into clinical benefit.
Clinician Questions
Which adolescents were excluded from perioperative ForeVR biofeedback-based VR testing?
The perioperative ForeVR trial enrolled English-speaking surgical patients aged 12–18 years with expected moderate-to-severe postoperative pain and an inpatient stay. Exclusions included chronic pain, epilepsy or seizure disorders, significant motion sickness, developmental delay, psychiatric conditions associated with hallucinations or delusions, and conditions preventing headset use. The findings do not directly characterize those excluded populations.
How did ForeVR deliver breathing biofeedback to adolescents during surgical recovery?
ForeVR used a Bluetooth-connected Meta Quest headset and a breathing-synchronized Mysterious Island game. Breathing synchronized with visual prompts and controlled in-game actions; ForeVR also captured respiratory and cardiac data to assess physiological responses; matching the breathing target advanced gameplay and earned rewards. Investigators designed the training to slow breathing and increase heart-rate variability and vagal tone, but did not establish physiologic improvement as a trial outcome.
Why were symptom analyses limited to perioperative VR-BF sessions with presession ratings of at least 2?
Investigators measured postoperative pain intensity, pain unpleasantness, and anxiety on a 0–10 numeric rating scale in the VR-BF arm. Presession pain or anxiety below 2 indicated adequate symptom control with little room for detectable improvement. Selecting those sessions did not create a comparison with Manage My Pain.