The majority of children recruited into this study were White (n=29) and male (n=19), making up 88.2% and 64.7% of the VR group and 77.8% and 44.4% of the control group, respectively (Table 1). Participants in the control group were slightly older, having a mean of 12.3 years compared to 10.7 years in the VR group. Both groups had small burns (median 1% TBSA) and 16 participants in each group had a 2nd degree burn. Participants in both groups played console and computer games before but had little to no experience with VR games.
Table 1: Demographics, burn characteristics and experience with games of study participants
Characteristics
|
Intervention Group
|
VR (n=17)
|
Control (n=18)
|
Demographics
|
|
|
Gender, n (%)
|
|
|
Male
|
11 (64.7)
|
8 (44.4)
|
Female
|
6 (35.3)
|
10 (55.6)
|
|
|
|
Race, n (%)
|
|
|
White
|
15 (88.2)
|
14 (77.8)
|
Black
|
2 (11.8)
|
3 (16.7)
|
Other
|
0 (0)
|
1 (5.6)
|
|
|
|
Age in years, mean (SD)
|
10.7 (2.9)
|
12.3 (3.3)
|
|
|
|
Burn Characteristics
|
|
|
Burn degree, n (%)
|
|
|
Second
|
16 (94.1)
|
16 (88.9)
|
Third
|
1 (5.9)
|
2 (11.1)
|
|
|
|
TBSA (%), median (IQR)
|
1 (1 - 2)
|
1 (0.5 - 1.5)
|
|
|
|
Experience with games, median (IQR)*
|
|
|
VR weekly
|
0 (0 - 0)
|
0 (0 - 0)
|
Console weekly
|
2 (0 - 5.5)
|
2 (0 - 7)
|
Computer weekly
|
7 (2 - 7)
|
5 (2 - 7)
|
Abbreviations: TBSA, total body surface area; VR, virtual reality; n, frequency; SD, standard deviation; IQR, Inter-quartile range
*Days per week playing games on VR, Console (i.e. PlayStation®, Xbox, Nintendo SwitchTM), or Computer (including mobile platforms)
Of the 24 subjects who returned surveys, 11 were in the VR group and 13 were in the control group. There were 2 subjects who did not return medication surveys (Table 2). More subjects in the VR group reported using pain medications for the burn injury in dressings 1-5 than subjects in the control group but did not use any medications after the 5th dressing. Of all the medications used, the vast majority were over the counter medications such as acetaminophen or ibuprofen.
Table 2: Reported pain medication use by dressing number and intervention group
|
VR, N (%)
|
Control, N (%)
|
Dressing #
|
Total
|
No
|
Yes
|
Missing
|
Total
|
No
|
Yes
|
Missing
|
1
|
11
|
3 (27.3)
|
6 (54.6)
|
2 (18.2)
|
13
|
10 (76.9)
|
3 (23.1)
|
0 (0.0)
|
2
|
11
|
4 (36.4)
|
5 (45.5)
|
2 (18.2)
|
13
|
10 (76.9)
|
3 (23.1)
|
0 (0.0)
|
3
|
9
|
4 (44.4)
|
4 (44.4)
|
1 (11.1)
|
13
|
11 (84.6)
|
2 (15.4)
|
0 (0.0)
|
4
|
8
|
5 (62.5)
|
2 (25.0)
|
1 (12.5)
|
13
|
10 (76.9)
|
3 (23.1)
|
0 (0.0)
|
5
|
8
|
6 (75.0)
|
1 (12.5)
|
1 (12.5)
|
13
|
12 (92.3)
|
1 (7.7)
|
0 (0.0)
|
6
|
5
|
5 (100.0)
|
0 (0.0)
|
0 (0.0)
|
11
|
9 (81.8)
|
2 (18.2)
|
0 (0.0)
|
7
|
5
|
5 (100.0)
|
0 (0.0)
|
0 (0.0)
|
8
|
7 (87.5)
|
1 (12.5)
|
0 (0.0)
|
8
|
4
|
3 (75.0)
|
0 (0.0)
|
1 (25.0)
|
6
|
5 (83.3)
|
1 (16.7)
|
0 (0.0)
|
*Only 1 subject used opioid medications. All other reported medications were either Acetaminophen or Ibuprofen
Subjects in the VR group completed at least 2 dressing changes while subjects in the control group completed at least 5 dressing changes (Figure 2). In the VR group, the mean child reported worst pain ranged from 3.6 (standard deviation (SD) 2.7) at the 1st dressing to 0.3 (SD 0.5) at the 8th dressing and in the control group, the range was 3.0 (SD 2.6) at the 1st dressing to 2.3 (SD 2.7) at the 8th dressing. Overall pain ranged from mean 3.2 (SD 2.4) at the 1st dressing to 0.3 (SD 0.5) at the 8th dressing in the VR group and 2.9 (SD 2.3) at the 1st dressing to 2.2 (SD 2.4) at the 8th dressing. The mean time spent thinking about pain ranged from 3.6 (SD 4.1) at the 1st dressing to 0.3 (SD 0.3) at the 8th dressing in the VR group and 3.5 (SD 3.6) at the 1st dressing to 1.7 (SD 2.1) at the 8th dressing in the control group. Children in the VR group reported less pain following the 4th dressing across worst pain, overall pain, and time spent thinking about pain.
Caregiver reported pain followed a similar trend as the child report pain (Figure 3). In the VR group, the mean caregiver reported worst pain ranged from 4.1 (SD 3.0) at the 1st dressing to 0.0 (SD 0.0) at the 8th dressing and in the control group, the range was 2.9 (SD 2.8) at the 1st dressing to 2.7 (SD 3.0) at the 8th dressing. Overall pain ranged from mean 3.2 (SD 2.6) at the 1st dressing to 0.0 (SD 0.0) at the 8th dressing in the VR group and 2.4 (SD 2.1) at the 1st dressing to 2.3 (SD 2.6) at the 8th dressing. Caregivers in the VR group also reported less pain following the 4th dressing across worst pain and overall pain.
The AUC for the control group was higher than the VR group for both child and caregiver reported overall and worst pain (Figure 4). The % decrease in child reported overall pain (33.3%) and caregiver reported worst pain (31.6%) between the control group and VR group reached clinical significance (Table 3). The % decrease in child reported worst pain (25.9%) and caregiver reported overall pain (28.5%) neared the 30% clinical significance threshold.
Table 3: Percent change of AUC for child and caregiver reported overall and worst pain by intervention group
|
Control
|
VR
|
% Change
|
Child reported
|
Overall pain
|
15.6
|
10.4
|
33.3%
|
Worst pain
|
18.5
|
13.7
|
25.9%
|
Caregiver reported
|
Overall pain
|
15.1
|
10.8
|
28.5%
|
Worst pain
|
18.7
|
12.8
|
31.6%
|
All children in the VR group reported their satisfaction with the VR-PAT after each dressing (Figure 5). As dressing changes progressed over time, children reported increased realism (Did you feel like you were inside the game?) and engagement (How engaging did you think the game was?) with the VR-PAT. Both realism and engagement started at a mean of >5 at the first dressing and increased to >7 at the last dressing. Children’s happiness (Are you happy with the game?) and fun (How much fun did you have with it?) stayed constant at a mean of >6 across the week of dressings.
Following the week of dressing changes, children in the VR group were asked about their experience using the VR-PAT (Table 4). When asked about what they liked about the VR game, 54.5% liked the game itself, 36.4% liked that it was a distraction, and 27.3% found the VR-PAT to be calming. When asked what they did not like about the VR game, the most common responses were a desire for more levels or goals (36.4%) or nothing (27.3%). Only one child didn’t understand how to play the game at first. Finally, children were asked if there were any challenges with the VR-PAT and the majority did not express any challenges (54.5%). Of those who did report challenges, there were some technological issues with downloading the game application (18.2%), getting the system set-up (18.2%), and one found the game to be difficult to play (9.1%).
Table 4: Child Reported VR-PAT utilization experience
|
N (%)
|
What do you like about the VR game?*
|
|
Playing the game
|
6 (54.5)
|
Distraction/not thinking about pain
|
4 (36.4)
|
Calming
|
3 (27.3)
|
|
|
What do you not like about the VR game?
|
|
Wanted to stop boat or steer
|
2 (18.2)
|
Wanted more levels or goals
|
4 (36.4)
|
Didn’t understand how to play at first
|
1 (9.1)
|
Wanted to watch dressing
|
1 (9.1)
|
Nothing
|
3 (27.3)
|
|
|
Challenges faced during VR-PAT Utilization
|
|
Game was difficult
|
1 (9.1)
|
App download challenges
|
2 (18.2)
|
Setting-up the system
|
2 (18.2)
|
No challenges
|
6 (54.5)
|
*Percentages do not add up to 100% as subjects answered multiple options