Virtual Reality Respiratory Biofeedback in an Outpatient Pediatric Pain Rehabilitation Program: A Pilot Study (Preprint)

BACKGROUND Chronic pain in adolescents is a significant and growing concern, as it can have negative implications on physical and psychosocial development. Management can be complicated by the increasing risks associated with opioid misuse, highlighting the need for effective non-pharmacological interventions. Biofeedback is an empirically supported behavioral intervention for chronic pain that targets the self-regulation of physiological responses. Virtual reality (VR) is a novel delivery method for biofeedback that could serve as an engaging and effective platform for adolescents. OBJECTIVE The goal of this study was to assess the feasibility, acceptability, and preliminary effectiveness of integrating a VR-delivered respiratory biofeedback intervention into an outpatient pediatric pain rehabilitation program (PPRP) for adolescents with chronic pain. METHODS In this pilot study, we recruited nine participants (age 13-18 years old, 89% female, 33% non-Hispanic white) from those enrolled in the PPRP at Nemours Children’s Hospital. Participants underwent 2 VR respiratory biofeedback sessions per week over a 4-week period using AppliedVR’s “RelieVRx” program. Feasibility was defined as: >60% of eligible patients enrolling with at least 80% of VR sessions completed. Acceptability was assessed via validated acceptability questionnaires, with high acceptability defined as an average acceptability rating score >3 on a 5-point Likert scale. Open-ended responses were analyzed via qualitative analysis. Preliminary effectiveness was assessed with questionnaires measuring the quality of life (PedsQL) and level of pain interference in daily activities (FDI) before and after participation in the pain program. Lastly, heart rate (HR) and blood pressure (BP) were measured before and after each VR session. RESULTS Of 14 eligible PPRP patients, 9 (64%) enrolled in the VR respiratory biofeedback study, and 7 (77% of study participants) completed at least 80% of biofeedback sessions. Participants reported high acceptability with average session ratings ranging from 3.89 to 4.16 on post VR program questionnaires. Of 224 open-ended responses, participants reported changes in stress and somatic symptoms (i.e. pain distraction, breathing regulation). There was a statistically significant increase in the average physical functioning score of the PedsQL among participants (p=0.009) from pre- to post- participation in the overall pain program. The cohort’s average emotional functioning score of the PedsQL also increased, though this change was not statistically significant (p=0.176). Participant FDI scores significantly decreased from an average of 25.1 to 11 from before to after the pain program (p=0.002). There were no significant differences between pre vs. post BP or HR for any session. However, decreased BP and HR was observed across most sessions. CONCLUSIONS AppliedVR respiratory biofeedback demonstrated initial feasibility, acceptability, and preliminary effectiveness when implemented as part of a PRPP. This study underscores the need for future larger-scale studies analyzing the use of VR biofeedback in adolescent populations with chronic pain.