Opportunities for Managing Pain and Anxiety in the Intensive Care Unit Using Virtual Reality: Perspectives from Bedside Care Providers.

The emergence of digital therapeutics offers a promising avenue to expand and improve the prevention and treatment of a multitude of diseases. Therapeutics in the form of software for computers, mobile devices, and technologies such as virtual reality (VR) have the potential to expand access to care and offer noninvasive, nonpharmacological, and nonaddictive methods to treating conditions such as chronic pain. Defined as pain with a continual duration greater than 6 months, chronic pain is a debilitating condition that can be treatment-resistant. While existing therapies such as nonsteroidal anti-inflammatories, physical therapy, implanted spinal cord stimulators, and transcutaneous electrical nerve stimulators are often prescribed, their efficacy is often inadequate and temporary. Opioids are commonly prescribed due to demonstrated effectiveness for acute pain, however, opioids are largely ineffective for chronic pain and come with inherent risk of addiction and overdose. In this context, more efficient treatment options are necessary for managing and treating chronic pain. One of the most effective treatment strategies up to date is functional restoration programs that combine traditional treatments with biofeedback, pain psychology, and cognitive behavior therapy in an intensive inpatient setting, for example, 6 h/day for up to 5 weeks. While functional restoration programs are promising, they require a large time commitment, are expensive, and not widely accessible. Recently, delivering therapies and treatment in VR has demonstrated effectiveness for chronic pain. Rapid improvements in VR technologies offer a promising opportunity to expand treatment accessibility for patients with chronic pain because patients can receive therapies and treatments from their home. Meanwhile, the COVID-19 global pandemic has elucidated the need to leverage telemedicine for the treatment of chronic pain. Telemedicine is the practice of delivering care to patients remotely over the internet using technologies such as smartphones and personal computers. Various therapies, such as psychotherapy and cognitive behavioral therapy, which have been shown to be effective treatments for chronic pain, lend themselves well to a telemedicine approach. Other treatments, such as physical therapy, may be delivered remotely in patients’ homes if technology can be developed that incorporates techniques and principles used in the clinic. Physical therapy delivered in VR has been shown to be effective for pediatric burn victims, and people suffering from Parkinson’s disease, with VR demonstrating superiority over conventional physical therapy. Chronic pain is described as a biopsychosocial phenomenon resulting from a combination of psychological and physical factors, in the presence or absence of an identified pathology that increases the sensitivity of the nervous system to pain. Maladaptive plasticity in the central nervous system has been demonstrated in response to persistent pain, where synaptic plasticity occurs in sensory pathways that are active in the presence of injury and pain. Specifically, long-term potentiation in the anterior cingulate cortex has been proposed as a significant mechanism leading to a chronic pain state where pain thresholds are shifted due to heightened response of the brain region that is active when anticipating painful stimuli. Distraction during painful states modulates activation within the anterior cingulate cortex relative to a painful state without distraction. A proposed mechanism of the analgesic effects of VR is alteration of activity of the anterior cingulate cortex, a region of the brain that is involved in attentional processes related to pain perception. In addition, VR hardware has demonstrated accurate motion tracking capabilities, affording the ability to deliver functional exercises and track performance. In addition, the use of VR has been shown to reduce pain and depression symptoms in patients with fibromyalgia while also adding an increase in positive affect, the experience of positive emotions. Immersive VR has demonstrated improvements in subjective pain relief and improvements in daily function in patients suffering from upper limb complex regional pain syndrome. In patients with phantom limb pain, immersive VR decreased phantom limb pain and elicited the transfer of sensation of the amputated limb.