There were no significant differences between the virtual reality and non–virtual reality groups with respect to heart rate or mean arterial blood pressure at any of the measured time points.
Scores for anxiety and fun, but not for pain, were significantly different in virtual reality versus non–virtual reality patients at each time point (Fig. 2). Because anxiety is one of the major reasons patients are dissuaded from wide-awake surgery, we separately analyzed the patients with self-reported anxiety disorder to see whether virtual reality is useful in reducing anxiety in these patients. Among patients with preexisting anxiety, use of virtual reality achieved a statistically significant decrease in anxiety during the procedure. At both time points, during and at the end of the procedure, anxiety levels were comparable to those seen in patients without preexisting anxiety (Fig. 3). Among patients with preexisting anxiety, pain scores during the injection phase were significantly lower in the virtual reality compared with the non–virtual reality group and were comparable to the scores of patients without preexisting anxiety (Fig. 4).
Likert score answers to the question, “How much did you enjoy your experience today?” showed that virtual reality patients enjoyed their experience more than non–virtual reality patients, 8 of 10 compared to 3 of 10, respectively (p < 0.01). Over 80 percent of virtual reality patients reported that virtual reality was a good experience, it helped them relax, and they would recommend it. The patient who disagreed that the virtual reality experience was good and disagreed that she or he would recommend it was older than 82 years and represented the oldest individual in the virtual reality group.
Among virtual reality patients, three experienced dizziness, two reported nausea, and none reported vomiting. Patients’ comments regarding virtual reality technology were also recorded (Table 3).
This study suggests the patient experience of wide-awake local anesthesia no tourniquet surgery is enhanced by virtual reality. Many patients are not comfortable with the idea of undergoing wide-awake surgery, even though wide-awake local anesthesia no tourniquet surgery is a more convenient, more safe, and more cost-effective option for many upper extremity surgical procedures.3 Coupling wide-awake local anesthesia no tourniquet surgery with virtual reality may increase the likelihood that patients will select the office procedure room as the location to undergo their surgery.
This study suggests also that virtual reality may be of particular help during administration of local anesthesia. Synchronizing the moment of needle puncture with an experience of relief within the virtual reality environment may dissociate the patient from the discomfort of the procedure. Virtual reality may therefore have applicability to procedures performed in the emergency department, and bedside procedures in the in-patient setting.
We found few disadvantages to using virtual reality. Although cybersickness has been reported in the literature, we did not observe significant levels in our study.27–29
As pointed out by Lalonde, physician-patient interaction may provide an opportunity for education and allow interaction to assess surgical hand function.3 Concern could be raised that this interaction is compromised by the virtual reality experience. We found that our virtual reality patients’ cooperation with perioperative instructions to move the hand and arm was easy and immediate.
Virtual reality may not be helpful for all patients. The dissatisfaction that an 82-year-old patient reported suggests that virtual reality may be less suitable for individuals who may be unfamiliar with this technology. One patient reported preference for communicating with the surgeon rather than wearing the virtual reality device. We could not use virtual reality reliably on five occasions because of overheating of the Galaxy S7; this model is already superseded at the time of publication. Thus, we were unable to obtain data on the aforementioned five patients.
One patient in the virtual reality group had previously used virtual reality technology. This study thus reflects the reactions of patients for whom this technology is a novelty.
The virtual reality experience should be personalized. One patient reported disliking the content because she or he was water phobic and the media included several underwater diving experiences. Currently, there are few recordings of 360-degree panoramic virtual reality–formatted media matching the duration of a typical operation. Thus, there is a need for the industry to expand and diversify the available content to provide patients a wider selection of choices.
As technology progresses, it may be possible for patients not only to experience the benefits of distraction by virtual reality, but also to view and interact with their operation in real time. Augmented reality can reduce the potentially alarming experience of looking at the hand during surgery. In addition, by using augmented reality, the patient may be able to follow visual guidance for hand functions to assist with procedures such as tenolysis and tendon transfer.
This study demonstrates that readily available virtual reality hardware and software can be used to provide a passive and immersive experience that reduces patient anxiety both during the injection of local anesthetic and during surgical procedures. Our experience also reflects that the technology is still occasionally unreliable. Because virtual reality may be of particular help during administration of local anesthesia, virtual reality may have wider application to procedures performed in the emergency department, and bedside procedures in the in-patient setting.
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