Using virtual reality for assessment of physiologic monitoring measures in pediatric pain populations
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Abstract
OBJECTIVE: Recently, virtual reality has garnered attention in clinical medicine by providing new opportunities for treatment. In the current state of the field of virtual reality interventions for pain management, physiologic markers have been deemed “important to consider.” They are not yet recommended mandatory measures because of a lack of research on the most valid and reliable approaches to monitoring physiologic responses to virtual reality interventions. We sought to explore the feasibility of integrating physiologic monitoring into a current study of a virtual reality intervention to promote school functioning in youth undergoing intensive rehabilitative treatment for chronic pain (Logan et al., 2023). The primary goal of this feasibility study was to explore potential physiologic markers to incorporate in subsequent iterations of this virtual reality simulation. To do so, we first explored participants’ response to physiologic monitoring as part of their virtual reality experience, including identifying any hurdles to implementation. The second goal was to identify if cognitive load is an accurate and useful physiological measure to monitor participants’ responses to stressful virtual school environments.
METHODS: A prototype version of the vReal-School intervention was developed in collaboration with our engineering study team at the Massachusetts Institute of Technology Nano Immersion Laboratory. The core hardware system for the prototype was the HP Omnicept G2 virtual reality headset to provide an immersive visual experience through the virtual reality headset and external sensors. This headset is equipped with heart rate monitoring, pulse rate variability, eye tracking, pupil dilation measurement, and insights that provide real-time data on participants’ physiological responses. Additionally, the study incorporates deliberate event timers within the virtual reality scenarios to trigger controlled virtual environmental changes, allowing clinicians and researchers to observe participants’ physiologic reactions and behaviors. These timers are synchronized with the headset’s physiological and eye-tracking data, enabling accurate tracking of participants’ responses within the specific virtual reality events. Together, these integrated tools will support a detailed examination of user experiences, cognitive engagement, physiological reactions in virtual environments, and the feasibility of implementing these measures in a full-scale interventional trial. To measure the level of immersiveness in the pilot intervention, we adapted the Child Presence Questionnaire to gather feedback on participants’ level of engagement with the virtual reality and their perception of the virtual reality experience. Using normalized subjective scores for the average cognitive load, data analysis was performed using a Pearson’s correlation test to indicate any significance between cognitive load as a measure for physiologic monitoring and the Child Presence Questionnaire.
RESULTS: Throughout the duration of this pilot study, all participants were able to successfully complete the simulation, however, we encountered some technical limitations that prevented us from recording the data from Participant 2. The physiological monitoring software used within the virtual reality headset proved to be inconsistent during the data recording process. For future studies, the physiologic monitoring system or the virtual reality headset should be appropriately chosen to minimize any technical difficulties. Additionally, the virtual reality headset that was utilized in this feasibility study (HP Omnicept G2 virtual reality headset), had to be tethered and linked to a computer, thus limiting the user’s range of motion around the pediatric pain rehabilitation center, and making it less user-friendly. The HP Omnicept G2 virtual reality headset was reported as comfortable and tolerable to wear and use. There were no complaints of adverse effects, such as motion sickness, dizziness, or nausea. The pupillometry data obtained on eye gaze showed differences when completing tasks such as “finding locker 22” as compared to scene changes such as “hallway to classroom.” Amongst participants who were able to successfully complete all goals and tasks of the vReal school simulation, there was a higher overall eye gaze while completing the tasks as compared to scene changes. Typically, when there is a higher eye gaze, it indicates that the user is attentive towards the objects of interest–such as finding a notebook in our study’s case–to complete the task at hand. In our findings, we noted that cognitive load may not be the most accurate measure in virtual reality environments. This finding may be attributed to the sensor and headset utilized in this feasibility study. The cognitive load across all patients was found to be higher towards the beginning of the game, particularly during the teleport scene change (Event 3) and while transitioning from the school hallway to a classroom (Event 6). As cognitive load is intended to be a summary indicator of overall physiological arousal, this increase in cognitive load during these particular scene changes could be indicative of the user’s increase in stress in these virtual environments. Lastly, there was a significant finding between the transportation subscale in the Child Presence Questionnaire and the average cognitive load.
CONCLUSION: Further research is needed to validate the potential of cognitive load as a physiologic monitoring parameter. Additionally, further research on the efficacy and feasibility of virtual reality as a clinical tool should incorporate sensitive physiological monitoring parameters, such as electrodermal activity, respiratory rate, body temperature, blood cortisol levels, and blood pressure. With these future studies, physiologic monitoring measures can help document patients' clinical outcomes when using virtual reality psychotherapy treatments and continue to grow a larger evidence base for the use of virtual reality in clinical settings.
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2025