Designing and developing a nature-based virtual reality with heart rate variability biofeedback for surgical anxiety and pain management: evidence from total knee arthroplasty patients

AbstractObjectives Total knee arthroplasty (TKA) is one of the most common joint surgeries, with over a million procedures performed annually in the US. Over 70% of patients report moderate to high pain and anxiety surrounding TKA surgery, and 96% are discharged with an opioid prescription. This population requires special attention as approximately 90% of TKA patients are older adults and one of the riskiest groups prone to misusing opioids. This study aimed to develop and compare the efficacy of nature-based virtual reality (VR) with heart rate variability biofeedback (HRVBF) to mitigate surgical pain and anxiety.Methods This randomized control trial recruited 30 patients (mean age = 66.3 ± 8.2 years, 23 F, 7 M) undergoing TKA surgery and randomly assigned to a control, 2D video with HRVBF, or VR with HRVBF group. A visual analog scale (VAS) was used to measure pain levels before and after the intervention. In addition, a second VAS and the State-Trait Anxiety Inventory (STAI) were used to measure anxiety before and after the intervention. Electrocardiogram (ECG) was used to continuously measure HRV and respiration rate in preoperative and postoperative settings.Results VR and 2D-video with HRVBF decreased pain and anxiety post-intervention compared with the control group, p's <.01. On analyzing physiological signals, both treatment groups showed greater parasympathetic activity levels, and VR with HRVBF reduced pain more than the 2D video, p < .01.Conclusions Nature-based VR and 2D video with HRVBF can mitigate surgical pain and anxiety. However, VR may be more efficacious than 2D video in reducing pain.Keywords: Virtual realitybiofeedbackpainanxietytotal knee arthroplasty AcknowledgementsWe would like to thank Courtney Linder, Haleh Barmaki, Josh Biro, Daniel Petty, Jeff Bertrand, and the Florence-Darlington Technical College for their support.Author contributionsVG, LS, RM, BS Conceptualization, Methodology, Data curation, Formal analysis, Funding Acquisition, Writing – original draft and review & editing.Disclosure statementNo potential conflict of interest was reported by the author(s).Additional informationFundingThis work was supported by the South Carolina Research Authority #2012746 and PRISMA Health grants #2012600 and #2012672.