147 VR for pain relief in HSG 6 Strengths and limitations Our study is, to our knowledge, the first to report on the efficacy of VR as additional pain relief during HSG. In addition, our study was performed in a multicentre setting. Both locations of our university hospital, as well as a non-academic teaching centre, have recruited participants, resulting in a varied study population. The questions on expectations of the use of VR prior to the procedure and the experience of patients in the intervention group afterwards enabled us to get a better understanding of the expectations and preferences women have. Our study also has weaknesses. A significant number of eligible women (50 of the 211 screened women) declined participation in this study, which might have generated selection bias. Most women who disclosed a reason for not wanting to participate in the study, mentioned that they preferred to have more control over the situation and would like to be able to see the physician perform the HSG. Others said they were already nervous to undergo the procedure and did not want to add to that with additional questionnaires. On the other hand, some women that were nervous to undergo the HSG procedure were more inclined to participate in the study, in the hopes of reducing their discomfort. It is possible that anxiety resulting in renunciation of study participation, has led to the selection of a more homogenous study group in terms of anxiety prior to the procedure. However, anxiety scores were relatively high in both the intervention group and control group (9.2 and 10.1 respectively) which is consistent with literature (25). In addition, since women were also more inclined to participate in the study because of their anxiety, and this study was randomized, we expect that this effect is small. Another weakness of our study is the relatively low level of VR immersion reported by women in the intervention group. On a scale of 1-5, the mean self-reported distraction posed by VR was rated 3.54 (SD 0.76), the mean ability to focus on VR was 3.19 (SD 0.93) and the lack of sound was rated 2.50 (SD 1.30). As women had to lay still in supine position during HSG, VR games requiring physical movement were disabled. Women were therefore able to choose from nature movies and relaxation exercises. This might have lowered the level interactivity of VR, while interactivity is one of the factors known to stimulate immersion and attentional involvement (26, 27). Stimulation of multiple senses at once is also thought to increase attentional involvement, since in our study sound was enabled to promote communication between the physician and woman this might further decrease immersion into VR. It might also be that, because both groups used analgesics the night before and 2 hours prior to the HSG procedure, the effect of VR on pain reduction was too small to exceed the effect of the analgesics. In conclusion, Virtual Reality does not reduce pain experience during HSG when added to regular self-administered analgesics. Women with higher expectations of the effectiveness of VR prior to the procedure, reported higher pain levels afterwards.
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