Every year, over 500,000 individuals in the United States undergo cardiothoracic surgery
for heart and lung disease. Cardiothoracic surgery can be an extremely traumatic
experience for the patient. Their chest wall muscles and tissues can be cut, crushing the
intercostal nerves and irritating the pleura. During the perioperative period, over 16%
of patients suffer from clinically significant anxiety, and up to 57% of patients
experience stabbing and throbbing chest and shoulder pain that can persist for months to
years.
Currently, perioperative pain is most often treated with opioids, and treatments for
perioperative anxiety are limited and can have severe side-effects. Interventions using
virtual reality may be a promising alternative to opioids and benzodiazepines in the
treatment of perioperative pain and anxiety. Virtual Reality consists of immersing
patients into a computer-generated environment and exposing users to visual and audio
sensory inputs. Through visual and audio cues that modulate pain-related brain activity
in the thalamus, VR can increase pain tolerance. Encouragingly, studies have demonstrated
the ability of VR to decrease pain intensity and increase pain tolerance in patients
suffering from chronic pain. In addition, olfactory stimuli play a crucial, yet distinct,
role in pain perception and relaxation. The olfactory bulb projects directly and without
thalamic relay to brain regions that are involved in the processing of emotion and pain.
Studies have shown that there is significant overlap between brain regions activated by
painful stimuli and olfactory stimuli. When an individual smells a pleasant scent,
olfactory stimuli activate the amygdala and alter its connectivity and functional
coupling with brain regions linked to pain perception.
There is potential for an intervention combining VR and OS to lead to a greater reduction
in pain and anxiety. Pain and anxiety are characterized by multiple neural pathways. Pain
results from the activation of a widely distributed brain network, including the
thalamus, insular cortex and secondary somatosensory cortex. Anxiety results from a
combination of neuroendocrine, neurotransmitter, and neuroanatomical disruptions in the
limbic system. Of note, studies have shown that although pain and anxiety have distinct
neural pathways, anxiety modulates the perception of pain, and preoperative anxiety is
associated with increased postoperative pain. However, current treatments for
perioperative pain and anxiety are often ineffective because they only address one of the
many pathways that contribute to pain and anxiety. As such, multimodal interventions are
necessary to achieve optimal pain and anxiety control. Although OS and VR both reduce
pain and anxiety, they have been shown to activate different regions of the brain. VR
reduces pain and anxiety by directly modulating pain-related brain activity in the
prefrontal cortex and primary and secondary somatosensory cortex, decreasing pain
intensity and increasing user's ability to tolerate pain. OS activates the limbic system,
including the amygdala and hippocampus, reducing pain and anxiety by altering its
connectivity and functional coupling with brain regions linked to pain perception.
The aim of this study is to evaluate the feasibility of a VR and OS multimodal
intervention in patients undergoing cardiothoracic surgery. In addition, the
investigators will evaluate the preliminary effects of the VR/OS intervention on patient
pain and anxiety before and after cardiothoracic surgery. This is a prospective,
randomized study. A total of 80 patients are anticipated to participate in this study.
All patients are expected to be enrolled at Massachusetts General Hospital (MGH).
Eligible patients will be randomized 1:1 to the VR/OS intervention or usual care
approximately 2-4 weeks prior to their scheduled cardiothoracic operation.
