It was like I was in my own world: -- a qualitative inquiry of patients using virtual reality to mitigate cancer pain

doi:10.21203/rs.3.rs-4824198/v1

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It was like I was in my own world: -- a qualitative inquiry of patients using virtual reality to mitigate cancer pain

https://doi.org/10.21203/rs.3.rs-4824198/v1

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Background: Virtual reality (VR) is a rapidly evolving technology that has been shown to improve pain severity in different disease states, including cancer. To date, VR pain studies have used off-the-shelf products for pain distraction. What are user preferences for VR content to mitigate cancer pain?

Objective: Through qualitative inquiry, to explore and understand user preferences for VR distraction therapies to mitigate cancer-related pain.

Methods: We conducted semi-structured interviews of 12 patients participating in a VR cancer pain therapy clinical trial. Using a grounded theory approach, emerging themes and subthemes were analyzed to elucidate patient experiences and preferences for VR content.

Results: Participants described distinct themes related to VR use, specifically experiences of immersion, distraction, relaxation, and safety. Higher experience of immersion and distraction were associated with improvement in cancer pain severity. Some participants had to adapt to VR technology to use it successfully. Regarding future VR content development, participants voiced preferences for content related to home, childhood, natural environments, and family and friends.

Conclusion: Patients associate higher levels of virtual immersion and familiar, natural virtual experiences with successful VR distraction therapy for cancer pain analgesia.

cancer

pain

virtual reality

distraction therapy

mind body

More than half of patients living with cancer experience disease and treatment-related pain; this figure increases to as many as three-quarters of patients with advanced stages of disease. (1–3) In addition to physical discomfort, under-treated cancer-related pain can also lead to fatigue, emotional health disturbances such as anxiety and depression, diminish social engagement and work productivity, and impaired sleep. (4) Furthermore, such patients are at higher risk of unplanned health care encounters such as hospitalizations or emergency department visits and may be less likely to adhere to cancer treatment regimens. (5–7)

Cancer pain management has traditionally focused on pharmacologic therapies, such as opioids. (8) Nevertheless, evolving clinical evidence coupled with patient preferences continues to support development of non-pharmacologic strategies to mitigate cancer-related pain, such as mindfulness meditation, distraction therapies, and cognitive behavioral therapy. (9, 10) Unfortunately, access to such modalities through expert therapists can be limited by geographic availability and/or payor reimbursement, particularly among under-resourced patient populations, further underscoring the need for better pain management and access to a combination of pharmacologic and complimentary interventions. (9, 11, 12)

A rapidly evolving technology, virtual reality (VR) is capable of momentarily transporting individuals into serene and delightful environments, offering a respite from discomfort while diminishing pain perception. The VR system is an interactive, three-dimensional simulation technology experienced through head mounted displays (headsets) and a feedback system between sensory input and output. (13) Won et al. defined key characteristics of VR, which include presence, interactivity, social interactions, customization, and embodiment. (14) The visual output of VR often features nature imagery or games to distract the user.

VR has demonstrated benefit as a pain management strategy in a myriad of situations: acute procedural pain, chronic neck pain, chronic low back pain, heat-induced pain. (15–17) For neuropathic cancer pain, a pilot study found that a VR intervention led to lower pain severity. (18) A proposed mechanism for VR’s analgesic effect is its ability to immerse the user to an extent that perception of pain temporality is lost. (19) The relaxation and distraction VR provides to patients with chronic cancer pain can lead to profound impacts on improving mood and reducing pain experience. (13, 20, 21)

To explore and understand user preferences for VR distraction therapies to mitigate cancer-related pain, we conducted a qualitative study of patients following a single VR experience within a clinical trial.

Parent study description:

This qualitative study draws from participant experiences related to our research team’s parent study, a randomized controlled trial evaluating the impact of VR to mitigate pain among hospitalized patients with cancer (NCT04572074). (21) Following institutional review board approval at the study site (MedStar Health Research Institute Institutional IRB #2017 − 240), the parent study and this qualitative study took place at a 912-bed tertiary care academic hospital in Washington, D.C. In this parent study, 128 hospitalized patients with active cancer (any type, any stage) reporting moderate-severe disease-related pain at baseline were consented and randomized to 10 minutes of immersive VR distraction therapy or 10 minutes of two-dimensional distraction therapy (enhanced control arm) in addition to usual pharmacologic care.

Participants assigned to the VR intervention used the Meta Quest 2 (Meta, Inc., Menlo Park, CA), due to its portability, ease of use at the bedside (in either private or semi-private rooms within the study site) and built in tracking which allows users to rotate their line of vision 360 degrees if they chose. For the virtual reality intervention experience, we chose NatureTreks VR (Greener Games, https://www.greenergames.net), software providing non-competitive experiences in natural environments that can be played from a standing, seated, or fixed position, including within a hospital bed or chair (Fig. 1: Example of NatureTreks virtual reality experience). Participants were able to select from 9 different environments, such as a forest, beachscape, underwater ocean, and outer space. Many of the virtual environments featured different animals, opportunities to engage with and move through the environments, and music or nature-based audio. We provided over-the-ear headphones to assure high sound quality for the experience. Participants were encouraged to use any prescribed corrective eyewear, including eyeglasses, and/or corrective earpieces, to facilitate full engagement with the experience. Participants assigned to the VR arm reported greater reduction in pain immediately after intervention compared to the enhanced control (p = 0.03) as well as improvements in pain bothersomeness (p = 0.05) and general distress (p = 0.03).

This qualitative study set out to describe the experiences and perceptions related to immersive VR for relief of cancer pain.

Study design and recruitment:

We purposively approached a subgroup of participants assigned to the VR intervention arm who were English-speaking and able to complete an interview lasting approximately 30 minutes. Because we were interested in the patient experience of immersive VR to mitigate pain, we did not sample participants assigned to the enhanced control arm. All participants were age 18 years and older, capacitated, admitted to the study site hospital for any indication, had an active diagnosis of cancer, and reported baseline moderate-severe pain related to their cancer. Individuals were approached by members of the research team and asked to participate in an interview about the VR intervention experience including VR content that improved the participant’s sense of peace and well-being and suggestions for future content development. (Table 1) Potential participants were told the interview data would be de-identified, transcribed, analyzed, and disseminated. Data collection took place between September 2021 and March 2022. Participants were given a $50 gift card upon interview completion. Twelve participants completed the interviews.

Table 1

Interview Questions and Content Categories
Category	Questions
Relaxation Inquiry	•Think about a time in your life when you felt most relaxed. o Where were you? o What were you doing? o Who was around? o What could you see? Hear? Smell? Taste? o What could you see? Hear? Smell? Taste?
Peaceful Inquiry	•Think about a time in your life when you felt most peaceful. o Where were you? o What were you doing? o Who was around? o What could you see? Hear? Smell? Taste? o What could you see? Hear? Smell? Taste?
VR Experience	•In your own words, how would you describe the VR experience you had today? o How did it make you feel overall? o What did you like the most about it? o What did you like the least about it? •What words would you use to describe the way you felt during the VR experience? o How about after it was over? Was that different? o What stood out to you the most?
VR Expectations	•What did you expect from this VR experience? o How was this different?
Changes to VR	•What would you change if you were creating this VR experience? o What would you change in terms of what you saw? o What would you change in terms of what you heard?
Recommendation of VR	•What do you think others like you would think of this VR experience? o Why? What in particular about this makes you think so? •How likely are you to recommend this VR experience to others like you? o Why/Why not?

Analysis:

Our research team followed the Consolidated criteria for reporting qualitative research (COREQ) process through this qualitative study. (22) Interview notes were segmented into discrete statements and categorized by question, utilizing a grounded theory approach. Two researchers (one human factors expert and one medical student) discussed each statement and coding was accomplished via group consensus. The codebook was iteratively developed based on the existing data. Emerging themes (and subthemes) and exemplary quotes were extracted from the data and served to support our findings.

Participants described several distinct themes related to VR use – experiences of immersion, distraction, relaxation, and safety: ‘it was like was in my own world.” (Table 2) These characteristics of the experience facilitated improvement in cancer pain during VR use:

Table 2

Qualitative Themes and Subthemes
Themes and Subthemes (N)	Reported by Single Participant (n = 1)	Reported by Multiple Participants (N)
VR Experience
General feelings about VR	Safe	Distracting (7) Relaxed (5) Immersive (3)
Liked about VR experience	Vividness	Immersive/distraction (6) Nature scenes (6) Flexibility/customization (4) Interactivity (2)
Disliked about VR experience	Lack of objective goal in selected game Association with unwanted memories Space scene Usability with respect to required body position Large animal approaching
General Relaxation
Location of relaxation (7)	Movies Sporting events	Beach/Coast (4) Home (2)
State of relaxation (5)	Resting Exercising	Childhood (3)
Senses of relaxation
Visual (3)	Animals	Ocean (2)
Auditory (6)	People Street noise Music	Ocean/waves (2) Nature/animals (3)
Olfactory (30	Ocean Food Honeysuckle Salt air
Tactile (1)	Wind
People related to relaxation (8)		Immediate family (6) Extended family/friends (5)

"I was so happy, I was so relaxed because for a brief moment I didn’t feel my pains again, I didn’t feel that I was feeling pain."

"I forgot that I was sitting here… At that moment my mind had already been captured by that [VR] environment. Even though I had pains, I was not feeling pain."

"You look around and you’re just basically in the world so it kind of keeps you focused, and it can really help take your mind off the pain."

One participant reflected that regular VR use might help them need less pain medication: “In the long run, I think you could probably be like ‘well let’s try to do the virtual reality’ like instead of me taking my meds. I think maybe you could use this to relax because really pain is only you trying to relax yourself.”

Participants shared appreciation of the flexibility of the user experience in VR, allowing different virtual environments and activities that promoted deeper engagement:

"It was very exciting to see how you can change things … you can bring in anything that you want."

"You can go to one [naturescape setting] and then back out and then you can go to another one and just kind of experience all the different places."

Interactivity and the vividness of the imagery were also highlighted as positive features.

"It really made me feel a recollection of nature that I have been affiliated to… when I saw those pictures, it was really appealing to me. It gave me some type of sentiment that I felt that I was very touched with nature."

There were two…[VR] interventions where it was very relaxing: a forest and an autumn scenery. It made you feel as if you were walking, virtually. The effects from the forest, everything, everything was beautiful. You feel good because being in [a hospital] bed but seeing as if you were walking, that’s a bit of a distraction.

Participants also noted several limitations with this VR experience that could be improved upon for future use. In the parent trial, most participants randomized to the VR intervention arm found VR more difficult to use at first, although after adapting to this technology, most would use it again. (21) Here, participants shared challenges adapting to the portable VR hardware. For example, "my hands [were] a little weak… I tried to change some of the settings on it and I had a little stumble there."

Finally, participants reflected on what VR content might promote comfort and relaxation. Common preferences included content related to home, childhood, natural environments, and family and friends.

I might hear sounds of ocean, calmness of the water and things like that, maybe some birds in there, like in early in the morning…then you relax.

For one participant, childhood memories connected to the VR experience that improved relaxation and physical comfort: “When I vacationed at the summertime down my grandparents’ house, we would go to the beach. We would get up and our uncle would just drop us off at the beach. And we were just having the time of our lives and that was like one of the most relaxing times that I can just remember as a kid. Basically I was free….[In VR] I’ll meditate. I look at the [virtual] fish tank and I’ll sit there and that’s my tranquil. Watching the fish swim and you know, looking at the fish interact with each other you know and that to me is a form of meditation.”

Many unanswered questions remain regarding the ideal delivery of VR to best mitigate cancer-related pain, including optimal “dose”, frequency of use, and perhaps of greatest interest, VR experiences developed specifically for symptom management. Patients dealing with cancer come from diverse backgrounds and may have a range of preferences for virtual environments, however we hypothesize that hospitalized patients with cancer-related pain share some common thematic interests and preferences for VR technology. Participants in this cohort reported significant overlap in relaxation themes and desired VR experiences, with enjoyment of nature, ocean, and beach-based locations being reported by multiple participants. Conversely, participants reported unique dislikes regarding the VR experience that were not expressed by other participants (i.e., desire to avoid ocean or lake scenery or heights in a mountain scene due to previous negative experiences or phobias). Desire for flexibility, ability to customize the VR experience, and immersive experiences were also frequently reported during the interviews. As one participant reported, “I like the idea that you get to change what you’re looking at when you want”.

Exploring and identifying such preferences is an important first step in developing patient-informed VR environments. Although this will need to be confirmed in future studies, we suspect that patient-informed technology will enhance both engagement and analgesic response to the VR experience. Participants reported feeling transported from the hospital environment, further underscoring the immersive impact of the technology.

The moment when I look at the picture, I forgot that I was sitting here. I forgot that something was worrying me because my mind was just focused on seeing those animals.

I don’t feel the cage that I am in at the moment.

“Because to be on a bed, but being able to see as if you were walking, that helps a lot."

One participant found the experience to be so immersive that she was initially unsettled by the animals featured in the program, telling the coordinator that an animal approaching her in the virtual environment was going to knock her down. Once she realized that she could interact with the environment and re-direct the animal using the handheld controls, her nervousness dissipated, and she was able to enjoy the experience.

It is reasonable to anticipate that patient preferences may evolve over time, rather than remaining static, i.e., patients may prefer “active” technology with opportunities to interact with the environment and make choices that drive the experience at times, while at other times selecting “passive” environments that require minimal user-input. Thus, having multiple virtual environments and types of programming will be important if virtual reality is to become a relavent analgesic modality for those living with cancer-related pain throughout their disease course.

Other research questions of interest include whether the provision of choices is more important to participant-engagement than the specific virtual environment featured, if participant-reported degree of immersion changes as individuals become more accustomed to the technology and the sense of novelty dissipates, and how VR may impact use of pharmacologic analgesics. “If they told me [we had to do VR] every day and then I could take my meds; I think being in that relaxed state that it helps you get to, toward the end I was feeling more comfortable, more relaxed, more into it where I would have liked to have a couple days to see how that would have worked [along] with taking pain pills.”

Study participants reported satisfaction with the VR intervention and willingness to use the intervention again, however it is important to acknowledge there was an initial learning curve to navigating use of the device and VR software, which was not intuitive to all users. One participant reported “I didn’t think it was very user friendly. And then I had to be sitting in a certain position just to see the stuff and I wasn’t able to change it very easily”. The study coordinator was essential in assisting with such challenges. Access to resource personnel will be essential to facilitating early engagement if VR is incorporated into routine in-patient and/or outpatient pain management regimens.

Study participants reported several shared thematic preferences for VR content, particularly coastal/beach locations, and nature-based auditory input. Positive reactions to the experience were shared by many participants, particularly the degree of immersion and distraction provided by the technology, exposure to nature, and options for customization and interaction within the virtual environment. While participants did report aspects of the experience that they disliked, each of the reported dislikes was unique to a single participant and the cohort was overwhelmingly likely to recommend VR for future use.

The results of this study provide a foundation for the development of patient-informed VR content intended to analgesic benefit and support user engagement. We envision applying the Sequential Multiple Assignment Randomized Trial (SMART) research design (23) to iterative VR content development such that end-user feedback is integrated throughout the study and yields an optimal VR software that can be utilized for pain management across various patient-care settings.

Author Contribution

HG and DV directed study design, development, and data collection. NA and KG completed data analysis. All authors participated in manuscript preparation and reviewed the final manuscript.

Acknowledgement: This study was funded by the American Cancer Society (PEP-20-057-01-PCSM).The authors would like to thank research coordinator Maria Hurtado for her contribution to the entire study as well as Karen Chavez for her work transcribing interviews. The authors also thank members of the Smith Center for Healing and the Arts (Washington, DC) who participated in our study advisory council.

Ethics Declaration: This study was approved by the MedStar Health Research Institute Institutional Review Board (#2017-240) and conducted by standards in accordance with the Declaration of Helsinki.

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No competing interests reported.

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It was like I was in my own world: -- a qualitative inquiry of patients using virtual reality to mitigate cancer pain

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Background

Methods

Parent study description:

Study design and recruitment:

Analysis:

Results

Discussion

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Author Contribution

References

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