Use of virtual reality in children in a broad range of medical settings: a systematic narrative review of recent meta-analyses

1. Inclusion criteria

Meta-analyses reporting the effects of VR on pediatric patients were considered eligible for review. For this study, pediatric patients were defined as those aged 18 and under, and no differentiation was made between the active and passive VR techniques. There were no limitations regarding study timing, setting, language, or date, and all studies involving a medical setting were included.

2. Exclusion criteria

Studies other than meta-analyses were not eligible for review. Meta-analyses that aimed to study the effects of tools other than VR were excluded. Meta-analyses of the use of VR in adult patients and studies with unverifiable data or that were lacking full-text availability were also excluded. Studies conducted outside medical settings were also excluded.

Some studies involved adults and children but provided a breakdown of their data according to age. If this was the case and a separate analysis of adults and children was possible, the pediatric data were extracted and analyzed.

3. Search strategy

Two authors conducted sequential searches of the PubMed, PMC, ScienceDirect, SpringerLink, and Cochrane Library databases. Multiple databases were searched to reduce selection bias. Furthermore, both British and American English spellings of “pediatrics” were used to avoid missing studies. The search terms used were: paediatric, pediatric, child, children, VR, virtual reality, and meta-analysis. Titles and abstracts were independently reviewed by 2 authors. In cases of disagreement, the decision to include a study was resolved through discussion. The full texts were examined by the same authors, and their acceptance or rejection was based on discussion. The references lists of the selected studies were manually reviewed to search for additional meta-analyses.

4. Data

Searches of various databases resulted in 653 matches (ScienceDirect, 127; SpringerLink, 237; Cochrane Library, 0; PubMed, 64; PMC, 225). Of these, 48 (ScienceDirect, 7; SpringerLink, 5; Cochrane Library, 0; PubMed, 27; and PMC, 9) were retained based on the title screening. Five additional studies were excluded based on the abstract screening. After duplicates were removed, 29 studies remained for review (ScienceDirect, 7; SpringerLink, 4; Cochrane Library, 0; PubMed, 24; PMC, 8). Four studies were excluded after the full-text review. The first was on the grounds of not being a meta-analysis,the second was on the grounds of containing only a single pediatric randomized control trial, and the last was because it was retracted after publication.

Fig. 1 shows a flowchart of the article selection process according to PRISMA guidelines.

Fig. 1.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) article selection flowchart. *Including other than needle-involving procedures. **Data unavailable or containing errors.

1. CP patients may benefit from VR use in physical therapy

According to the Centers for Disease Control and Prevention, CP is among the most common motor disabilities in childhood, with an estimated prevalence of 1–4/1,000 births. All individuals with CP have motor function problems, resulting in struggles with posture, coordination, and balance, and often experience perception, cognition, and communication disturbances [8,9].

Zhang et al. [10] analyzed 17 randomized controlled trials (RCTs) incorporating 853 children with CP (aged approximately 2.8–11.8 years) that compared VR with conventional therapy or a control group to evaluate its effects on gross motor function, hand grip, and activities of daily living. The results revealed that VR had a positive impact on all 3 outcomes.

Abdelhaleem et al. [9] investigated 19 RCTs comprising 645 participants with a mean age of 7.05–11.67 years in the experimental VR group and 7.25–12.4 in the no VR control group [9]. Their meta-analysis identified moderate evidence of fine motor coordination in favor of VR therapy over usual care or no intervention; however, there evidence was conflicting regarding gross motor coordination.

Ghai and Ghai [11] included 14 studies (ages 6–16.1 years) in a meta-analysis that revealed the positive effects of VR training on gait velocity, stride length, cadence, and gross motor function in children with CP. A subgroup analysis found that a duration of 20–30 minutes per session ≤4 times per week across ≥8 weeks allowed maximum enhancements in gait velocity. However, the authors warned against cautiously interpreting this result because the subgroup analysis included only 6 studies.

Liu et al. [12], who compared 470 patients (ages 4–18 years) across 16 studies in a meta-analysis, found that VR therapy positively improves balance function in children with CP [12]. A subgroup analysis suggested that at least 20 minutes per session twice a week for 6 weeks or more of regular VR therapy is more effective at improving balance function in children with CP. However, it should be noted that 4 of the 16 studies did not support VR treatment over conventional treatment [12].

VR motor training in children with CP helps them overcome the specific challenges associated with traditional face-to-face rehabilitation: no appointment shortage, flexible training, easier progress monitoring, and increased motivation through game features, to name a few examples [8,10].

2. VR may benefit ADHD patients by increasing their attention

The use of VR in mental-health research has steadily evolved. First reserved for adults and applied mainly to the treatment of phobic disorders, its use has expanded to pediatric psychiatry. More fields are being explored, and ADHD is no exception [13,14]. This is particularly important, as ADHD is among the most common childhood and adolescent neurobehavioral disorders, with a prevalence of approximately 5.3% [15].

Romero-Ayuso et al. [16] performed a meta-analysis of 4 studies that included 125 diagnosed children that administered immersive VR-based interventions. Looking at 5 outcomes (omissions, commissions, correct hits, reaction time, and perceptual sensitivity), Romero-Ayuso et al. [16] reported improvements in attentional vigilance measures, which meant better cognitive performance, but no improvements in impulsive responses. The population had an average age of 12.9 years (range, 8–18 years), with 92% being male [16].

VR has also been studied as a potential aid in the diagnosing of ADHD [17,18]. Parsons et al. performed a meta-analysis to compare traditional continuous performance tests (CPTs) to VR-classroom CPTs [18]. The CPT is an assessment tool for attentional processing often used to support or rule out a diagnosis of ADHD [18]. Parsons et al. [18] hypothesized that, compared to traditional computerized 2-dimensional CPTs, 3-dimensional virtual classrooms offer a real-world dynamic simulation with distractors that mimic the conditions found in a youth classroom, thus offering more precise differentiation between persons with ADHD and typically developing controls. To remedy heterogeneity issues, the meta-analysis compared populations (i.e., control vs. ADHD) using each CPT modality. Six studies included both main comparisons, and 2 additional studies were included in the population comparison for VR-CPT [18]. The patients were 8–14 years old, and studies reported 28%–100% males [18]. The virtual classroom CPTs are relatively effective at differentiating between individuals with ADHD from a neuropsychological perspective [18]. However, general group differences were similar using traditional CPT, and the authors could not estimate the impact of the diagnostic and task reliability of virtual classroom CPTs [18].

3. Burn patients may benefit from VR during wound changes

Despite the awareness of the prevalence of burns in children and the severity of the associated pain, burn pain remains undertreated. To mitigate this issue, the medical community has investigated complementary analgesic methods to traditional pharmacological approaches for pain. Therefore, the widespread use of regional anesthesia and novel technologies such as VR have been increasingly investigated [19].

Patient immersion in interactive VR distracts them from painful stimuli and can decrease their pain perception [20].

In their meta-analysis of 4 studies with 104 patients, Lauwens et al. [21] reported that VR adjuvant to standard care reduced pain during dressing changes in children and adolescents with second- and third-degree burns. However, it should be noted that the timing of VR application and self-reported pain assessment varied among studies [21].

Although we had to exclude the meta-analysis by Czech et al. [22] because its quantitative meta-analysis included both children and adults, the majority of the 13 articles examining VR and burn injuries in only children (6 months to 18 years) revealed that overall pain ratings were lower in groups of children additionally exposed to VR than in those who solely received the usual analgesics during burn care and postburn rehabilitation.

4. Preoperative anxiety may be reduced by VR use

Preoperative anxiety is a common problem affecting approximately 80% of surgical patients [6]. Preoperative anxiety can lead to worse outcomes and increased anesthesia requirements, making attempts to reduce it worthwhile [6,23]. To overcome this, VR can expose patients to a virtual operating room and surgical environment, helping dispel fears that may arise by habituating them in advance [6].

Furthermore, preoperative anesthesia involves many triggers of pediatric anxiety, including fear of the unknown, fear of potential pain, and parental separation [23]. By reducing the need for pharmacological forms of sedation, VR also reduces the potential risks [23]. VR is relatively simple and easy to implement in this use case, with no increase in healthcare costs [23].

In a meta-analysis of 7 studies that included 602 patients aged 4–12 years, Simonetti et al. [23] found that VR reduced preoperative anxiety in children undergoing surgery. However, it did not improve compliance, pain, behavioral disturbances, or the emergence of delirium.

In a meta-analysis by Koo et al. [6] of 5 studies with a total of 409 patients aged 5–8 years, VR decreased preoperative anxiety in children but not adults. This is consistent with the findings of other studies, probably because children have higher baseline anxiety levels. It was concluded that the reasons for VR reducing anxiety included the ability to experience the operating environment beforehand, increasing their familiarity with it, and allowing them to dispel their imagined fears by picturing reality [6]. They also suggested that VR may be effective at causing distraction, making patients forget about their preoperative anxiety [6].

5. VR may reduce fear and anxiety about needle-involving procedures

Czechet al. [24] examined the effects of VR onpainand fear/anxiety in children undergoing needle-related procedures in 7 studies. A statistically significant result was found in children regarding pain, showing that VR had a beneficial impact according to the Wong-Baker scale [24]. This positive effect was not found with the Faces Pain Scale-Revised, although the studies included in each analysis differed [24]. They could not pool data from studies that looked at fear and anxiety due to the large heterogeneity and the fact that they used different scales, making them unable to draw conclusions [24]. Their meta-analysis found no differences in patient satisfaction between the VR and standard care groups regarding patient satisfaction [24].

Saliba et al. [25] studied the effects of VR on pain and fear/anxiety in 10 studies including 930 patients aged 4–12 years who underwent needle-related procedures. They found that it reduced pain and fear/anxiety in patients undergoing needle-related procedures [25]. After examining the meta-regressions, they found that, contrary to the literature, passive cartoons seen in VR were more effective than active VR, but only for reducing fear [25]. Using meta-regressions, we also found that age did not have an effect, which contrasts with the literature.

However, this could be explained by the considerable age range in these studies [25]. In contrast to Czech et al. [24], Saliba et al. [25] did not find that the scale significantly reduced pain due to the effects of VR. They did not find a significant difference in the impact of VR on pain or fear/anxiety between phlebotomy and intravenous access placement [25]. Contrary to previous studies,they did not find that the sex of the patients significantly affected the effectiveness of VR [25].

6. Limitations

This systematic narrative review had some limitations. The heterogeneity in the results of various meta-analyses was due to differences in hardware, software, and protocols used among studies. This was echoed by all the meta-analyses, which draws attention to the fact that no standard protocol has been established and a lack of best practices prevents uniformity; thus, a direct comparison of the studies was impossible. This was further complicated by the vast array of hardware and software possibilities, with none being favored by researchers, a problem that will likely only increase as options broaden. Participant blinding is another problem, as it is impossible to do so with VR headsets, making it a likely unavoidable issue. Finally, most studies included in the meta-analyses had a limited number of participants, a fact recognized by most authors in their own analyses.

7. Recommendations

Standardized protocols and best practices must be developed and applied to address these problems. One example is the application protocol for VR glasses and the timing of the VR experience before the procedure. As it is impossible to standardize hardware and software among research groups, this is unlikely to occur anytime soon. However, developing best practices to create a standard protocol is essential for future research to make studies more comparable and increase the quality of future meta-analyses.