Virtual Reality as a Nonpharmacological Tool for Acute Pain Management: A Scoping Review

Abstract

Background

Acute pain (AP) is a prevalent symptom in hospital settings, affecting up to 84 percent of the patients seeking healthcare services. It significantly impacts an individual’s quality of life, with inadequate management resulting in slower recovery, increased cost of care, and a greater risk of developing chronic pain. While pharmacological approaches are effective, they are associated with numerous side effects, including nausea, addiction, and the possibility of fatal overdoses. Given this, virtual reality (VR) offers an innovative avenue to manage AP effectively while minimizing the effects of drugs.

Objectives

This study aims to map the extent of literature on utilizing VR as a tool for the nonpharmacological management of AP. Specifically, this review attempts to understand the characteristics of the populations using VR for AP management, the technical specifications and mechanisms used to alleviate AP, and the overall effectiveness of VR in managing AP.

Methods

A scoping review was conducted to identify literature from the following electronic databases: PubMed, ScienceDirect, ERIC, and Google Scholar. To be included in this review, articles had to focus on AP in both adult and pediatric populations and address AP using VR in any clinical or care setting. The search was limited to peer-reviewed, English-language, quantitative research articles published between 2000 and 2024.

Results

A total of 97 studies were identified. Sixty-six percent of studies demonstrated the efficacy of VR as an analgesic, outperforming traditional nonpharmacological approaches (eg, standard of care, mobile phones). Distraction was the most effective VR mechanism for pain management, showing efficacy in 86.9 percent of studies. The most common focus was on needle-related pain (30.9%), followed by dental and perioperative pain (15.5% each). VR was most effective in wound care (87.5%), followed by labor-related (83.33%) and dental (80%) pain.

Conclusion

VR is a promising tool for managing AP, offering considerable benefits in terms of patient care, patient experience, and reduction in drug-related side effects. The high efficacy rates for wound care, labor-related pain, and dental pain highlight the potential for VR to be integrated into standard pain management protocols. However, further research, with rigorous research design, is required to standardize VR interventions and optimize their effectiveness across different patient populations and pain contexts.

The management of pain is a major global healthcare challenge.¹ Specifically, acute pain (AP), pain lasting less than 12 weeks, is the most common type of pain experienced, affecting up to 84 percent of the patients seeking healthcare services.^2–4 AP can arise from invasive or noninvasive medical procedures (eg, postoperative care, wound management), trauma and acute illnesses (ie, as a presenting symptom),⁵ or labor.^6,7 Research indicates that AP can impact an individual’s quality of life, including sleep, physical abilities, and mental health.⁸ Inadequate pain management can contribute to higher morbidity rates, slow recovery, increased cost of care, and a greater risk of developing chronic pain.⁹ Despite these significant impacts, the effective management of AP remains underweighted in the healthcare context.^8,10

Currently, pharmacological treatment is the most widely used option for AP management.^8,10 While pharmacological approaches, especially the use of opioids, are highly effective, they are associated with numerous side effects, including dizziness, respiratory depression, hormonal imbalances, and gastrointestinal issues.^11,12 Furthermore, the increased use of drugs comes with the steep price of an opioid abuse epidemic.¹³ Given these drawbacks of pharmacological treatment, the development of alternative AP management strategies is a pressing need in the field.

Virtual reality (VR) is rapidly emerging as a significant nonpharmacological tool within the holistic patient care framework, particularly in the management of AP. VR involves using a three-dimensional display to provide an immersive experience in which the external environment is excluded.¹⁴ Studies have shown VR to be associated with a reduction in pain perception, anxiety, and distress during various medical procedures, including burn care, chemotherapy, dental work, and other routine interventions.^15–19 VR interventions achieve this by employing techniques such as distraction,^20,21 mindfulness,²² and hypnosis.²³ This approach offers the potential to manage AP effectively while minimizing the side effects of drugs.

Previous research on VR for the management of AP has been limited in scope. First, existing reviews have predominantly focused on specific patient populations, such as burn victims and procedural pain or dental patients,²⁴ or particular age groups, such as adults or children.^25–27 Second, these reviews typically have narrow areas of focus; for instance, Lambert et al²⁶ restricted their scope to interactive VR experiences, overlooking the analgesic effects of noninteractive VR content. Third, in reviews with a broader scope, acute and chronic pain were often examined together,^28–30 even though both are different types of pain and have different mechanisms that drive VR’s efficacy. Most reviews have also overlooked the underlying mechanism of VR in managing AP, which is crucial for improving our understanding of VR’s therapeutic potential. While a few recent reviews^31,32 have attempted to address these drawbacks, they have mainly compiled literature from recent years. Thus, a review of the entire breadth of literature is necessary to identify the full range of VR applications for AP management, understand the state of knowledge, and guide future research to inform how to effectively use VR to address AP. The objective of the present scoping review is therefore to develop a comprehensive overview of the literature on the use of VR for AP management. In particular, we attempt to map the use of VR as a tool for the nonpharmacological management of AP, identify and analyze the current gaps in the literature, and offer suggestions for future research and development.

METHODS

The scoping review was conducted in line with the Joanna Briggs Institute (JBI) methodology for scoping reviews³³ and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR)³⁴ and guidance from the general framework outlined by Arksey et al.³⁵ This review comprised five stages:

1. Formulating research questions;

2. Identifying relevant studies;

3. Study selection;

4. Charting the data; and

5. Collating, summarizing, and reporting the results.

Formulating research questions. The scoping review primarily sought to answer the following question: “To date, what is the extent of literature on utilizing VR as a tool for the nonpharmacological management of AP?” Additional questions were also developed, including: 1) What are the characteristics of the studies included in the review? 2) What are the characteristics of the populations using VR for AP management? 3) What are the technological and experiential characteristics of VR systems used to alleviate AP? 4) What is the effectiveness of VR for AP management? 5) What gaps exist in the literature regarding VR as a nonpharmacological tool for AP management, and how can future research address these gaps?

Identifying relevant studies. Eligibility criteria. The inclusion and exclusion criteria are listed in Table 1. Studies were considered eligible if they involved patients undergoing AP management using VR head-mounted displays with motion-based videos in clinical or care settings. Eligible studies were primary, quantitative, peer-reviewed articles available as full-text that were published from 2000 to 2024 in English.

TABLE 1.

Inclusion and exclusion criteria

CHARACTERISTICS	INCLUSION CRITERIA	EXCLUSION CRITERIA
Population	Patients (adult and pediatric) experiencing any type of acute pain, including procedural pain	Patients experiencing chronic pain without acute pain
Concept	Studies that address acute pain management using virtual reality; have immersive displays that exclude the real-world environment; display an audio or visual multimedia environment with which the participants could view or interact (ie, games and videos)	Studies that address chronic pain, experimentally induced pain, or rehabilitation and physical therapy; display a slideshow of pictures; create virtual environments through projectors or domed ceilings
Context	Any clinical/care setting	Home rehabilitation or laboratory settings
Types of evidence	Published in English; peer-reviewed articles; primary, quantitative research; available as full text; published between 2000–2024	Gray literature; qualitative research; case series, reviews, commentaries, editorials, and non-peer-reviewed theses and dissertations

Information sources and search. A literature search was conducted in March 2024 on the electronic databases PubMed, ScienceDirect, and ERIC. The first 200 results on Google Scholar were used to identify additional potential manuscripts and articles. The full search strategy used for these databases is listed in detail in Appendix 1.

Study selection process. Research articles were considered for inclusion if they related to the use of VR for AP management. The study selection comprised a two-stage screening process, consisting of a title and abstract screening, followed by a full-text review of the articles. The first step involved a screening of the title and abstract of the searched studies using Zotero reference management software and recording the decisions on an eligibility form. After screening for the titles and abstracts, the full articles were independently read for review. The two independent reviewers (HP and SN) screened the articles against the eligibility criteria in both steps. If there was a disagreement between researchers and no consensus was reached, a third researcher (RG) reviewed the article. This process followed the PRISMA guidelines, and the three authors (HP, SN, and RG) verified the final list of included studies.

Charting data. Data charting for the review was adopted from the JBI template³³ to extract data from each study. The authors came to a consensus that the extracted data would include the author(s), year of publication, article title, aim, study design, sample size, population (treatment condition), average/median age, type of pain, type of device, interactive (yes/no), content, clinical approach, outcome measured, scale used, key findings, and limitations. Relevant data were extracted from all included studies by two independent reviewers (HP and SN). The full data extraction form can be found in Appendix 2. The study authors were not contacted for any missing or incomplete data.

Collating, summarizing and reporting the results. To characterize and summarize the results, a map of the data extracted from the included manuscripts was presented in a tabular and graphic format. Three reviewers (RG, HP, and SN) collectively conducted a narrative synthesis based on research questions to present a summary of the nature and distribution of the studies included in this review.

RESULTS

The initial search resulted in a total of 3,553 articles. After a thorough review, 97 studies^{15,17,20,36–129} were found to meet the eligibility criteria and were subsequently included in the review. The article selection process is outlined in Figure 1, and the descriptive data gathered from the eligible studies are presented in Table 2.

FIGURE 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart

TABLE 2.

Study, participant, VR, and outcome characteristics of the studies

AUTHOR	STUDY CHARACTERISTICS	PARTICIPANT CHARACTERISTICS	VR INTERVENTION SPECIFICATIONS	VR CONTENT	VR MECHANISM	OUTCOME MEASURES	RESULTS
Du et al36	Location: Asia; Design: RCT No. of groups: 2; Comparators: VR, analgesia	Age: child (mean±SD: 6.3±3.5 years); N: 83; Pain origin: primary tooth extraction	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: HTC Vive	VR familiarization scene, tell-show-do in choice of VR scene (sea, forest, and sakura), relaxing nature magic virtual world	Combination (education and relaxation)	WBFPRS	VR better
Le Du et al37	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR+routine care, iPad+routine care	Age: child (mean±SD: 6.3±3.5 years); N: 83; Pain origin: bone marrow biopsy	Frequency: 1x; Context: before and during the procedure; Duration: <40 minutes; Device: Samsung Gear VR	Exploration of choice of VR scene: Nohara (walk on the countryside), Kaitei (seabed exploration), Uchuu (spacewalk), and Mori (walk in the forest)	Relaxation	VAS	No difference
Hundert et al38	Location: North America; Design: RCT; No. of groups: 2; Comparators: VR+routine care, iPad+routine care	Age: child (mean±SD: 12.4±3.2 years); N: 40; Pain origin: subcutaneous port needle insertion process	Frequency: 1x; Context: before, during, and after the procedure; Duration: N/R; Device: N/R	Aiming rainbow balls at sea creatures while searching for an underwater treasure	Distraction	NRS	No difference
Smith et al39	Location: Australia; Design: RCT; No. of groups: 2; Comparators: VR, routine care	Age: adult (mean: 31.56 years); N: 50; Pain origin: external cephalic version	Frequency: 1x; Context: During the procedure; Duration: N/R; Device: Samsung Gear VR	Sky Lights: lighting lanterns on a starry night with fireworks by focusing their gaze; reward for continued participation; relaxing music	Distraction	NRS	No difference
Thybo et al40	Location: Europe; Design: RCT; No. of groups: 2; Comparators: smartphone or tablet, VR	Age: child (mean±SD: VR, 5.9±1.4 years; control, 5.8±1.4 years); N: 106; Pain origin: venous cannulation	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Meta Oculus	Freddy-the-Frog: interactive game with a frog to blow bubbles that turn into magic hats	Distraction	WBFPRS	No difference
Atzori et al41	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR, routine care	Age: child (mean±SD: 11.78±2.70 years); N: 82; Pain origin: venipuncture	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Sony HMZ T-2	SnowWorld: icy canyon game where one throws snowballs at other characters	Distraction	NRS	VR better
Bosso et al42	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR, 2D computer screen	Age: adult (mean±SD: 43.5±17.2 years); N: 117; Pain origin: minor procedures in the ED	Frequency: 1x; Context: before, during and after the procedure; Duration: N/R; Device: N/R	Zen garden (suggestions for cardiac coherence breathing, relaxing music)	Combination (relaxation and hypnosis)	VAS	No difference
Ran et al43	Location: Asia; Design: RCT No. of groups: 2; Comparators: VR, routine care	Age: child (mean±SD: VR, 5.59±0.92 years; control, 5.66±0.99 years); N: 120; Pain origin: short-term dental procedures	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: HTC Vive	A story of underwater exploration with animals to restore former peace and tranquility	Distraction	WBFPRS	VR better
Rao et al44	Location: Asia; Design: Pre-post single cohort; No. of groups: 1; Comparators: VR	Age: child (mean±SD: 7.77±1.88 years); N: 30; Pain origin: restorative dental treatment	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: ANT VR Phone-glass T2	Cartoons (choose 1 of 3)	Distraction	WBFPRS	Pain reduced
Ferraz-Torres et al45	Location: Europe; Design: Quasi; No. of groups: 1; Comparators: VR, routine care	Age: child (mean: 10.7 years); N: 458; Pain origin: venipuncture procedure in emergency care	Frequency: 1x; Context: during the procedure; Duration: 3.2 minutes; Device: Meta Oculus Go	A sequence of various natural landscape environments and animals; different animal sounds; possibility of interacting through 4 simple games	Distraction	VAS	VR better

Nunna et al46	Location: Asia; Design: RCT; No. of groups: 2; Comparators: analgesia+VR, analgesia+counter-stimulation (CS)	Age: child (mean±SD: CS, 8.80±1.39 years; VR, 8.91±1.44 years); N: 70; Pain origin: LA injection for pulp therapy or tooth extraction	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: ANT VR Phone-glass T2	Cartoon videos of their choice from 6 locally famous characters in native language	Distraction	WBFPRS, VAS	No difference
Almugait and AbuMostafa47	Location: Middle East; Design: RCT CX; No. of groups: 2; Comparators: VR, topical anesthesia gel	Age: adult (mean: female, 35.4 years; male, 34.5 years); N: 21; Pain origin: dental anesthesia injection	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: ANT VR Phone-glass T2	Henry: animated short movie	Distraction	WBFPRS	No difference
Ebrahimian et al48	Location: Middle East; Design: RCT; No. of groups: 3; Comparators: VR, chewing gum, routine care	Age: adult (mean±SD: 24.23±4.44 years); N: 93; Pain origin: labor	Frequency: 2x; Context: during the procedure; Duration: 20 minutes; Device: Samsung Gear VR	Nature landscapes	Distraction	VAS	VR better
Hoag et al49	Location: North America; Design: RCT CX; No. of groups: 2; Comparators: VR, guided imagery	Age: child (median: 13 years); N: 50; Pain origin: venipuncture, port access, or dressing change	Frequency: 1x; Context: during the procedure; Duration: 15 minutes; Device: Samsung Gear VR	Optional active or passive gameplay; passive: observing an underwater scene; active: launching balls at sea creatures	Distraction	VAS	No difference
Zaidman et al50	Location: Middle East; Design: RCT CX; No. of groups: 2; Comparators: anesthesia+VR, anesthesia alone	Age: child (mean±SD: 8.29±1.96 years); N: 29; Pain origin: anesthesia—inferior alverlora nerve block and rubber dam placement	Frequency: 1x; Context: during and after the procedure; Duration: about 30 minutes; Device: Meta Oculus Go	2 cartoon series, 1 children’s show	Distraction	WBFPRS	VR better
Gold et al51	Location: North America; Design: RCT; No. of groups: 2; Comparators: VR, routine care	Age: child (median: 14.7 years); N: 107; Pain origin: PIVC	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Samsung Gear VR	Bear Blast: gaze-controlled firing of cannons to knock down teddy bears	Distraction	FPS-R	VR better
Bal and Kulakaç52	Location: Middle East; Design: RCT; No. of groups: 3; Comparators: VR, mobile-assisted education, routine care	Age: adult (mean±SD: VR, 27.4±3.14 years; routine care, 28.33±4.55 years; mobile-assisted education, 27.84±4.59 years); N: 126; Pain origin: hysterosalpingography	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: N/R	Nature scenes	Distraction	VAS	No difference
Abdelaal Mohamed and Mohamed53	Location: Africa; Design: quasi-experimental; No. of groups: 3; Comparators: VR, routine care, flippit	Age: child (mean: routine care, 7.9 years; VR, 7.8 years; flippits, 8.2 years); N: 120; Pain origin: phlebotomy	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: N/R	3D cartoon series (Tom and Jerry, Snow White, etc.)	Distraction	WBFPRS	VR better
Shetty et al54	Location: Asia; Design: RCT; No. of groups: 2; Comparators: anesthesia+routine care, anesthesia+VR	Age: child (range: 5–8 years); N: 120; Pain origin: inferior alveolar nerve block for pulpotomy	Frequency: 1x; Context: before and during the procedure; Duration: N/R; Device: Estar i-glasses 920 HR	Favorite cartoon shows (Tom and Jerry, Chhota Bheem, ShinChan, Ben 10, etc).	Distraction	WBFPRS	VR better
Felemban et al55	Location: Middle East; Design: RCT; No. of groups: 2; Comparators: VR+anesthesia, anesthesia+2D computer screen	Age: child (mean: 8.4 years); N: 50; Pain origin: buccal infiltration LA	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: LG 360 VR	Choice of cartoons from a list of popular shows	Distraction	WBFPRS	No difference

Zhao et al56	Location: Asia; Design: RCT; No. of groups: 2; Comparators: VR, no intervention	Age: adult (mean±SD: 53.92±14.86 years); N: 37; Pain origin: potassium titanyl phosphate laser procedure	Frequency: 1x; Context: during the procedure; Duration: <15 minutes; Device: N/R	Nature video scenes, including beautiful landscapes and calm music and relaxing movie clips	Distraction	VAS	No difference
Pandrangi et al17	Location: North America; Design: RCT; No. of groups: 2; Comparators: VR, smartphone game	Age: adult (mean: 58.3 years); N: 29; Pain origin: head or neck surgery	Frequency: 1x; Context: postoperative admission; Duration: 15 minutes; Device: Meta Oculus Quest	Angry Birds VR: Isle of Pigs	Distraction	NRS	VR better
Mohanasundari et al57	Location: Asia; Design: RCT; No. of groups: 3; Comparators: VR, routine care, flippit	Age: child (range: 3–12 years); N: 105; Pain origin: IV line, blood sampling, injections	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: GKP Products VR-Box model 223741	Option of famous cartoon comic videos	Distraction	WBFPRS	VR better
Burrai et al58	Location: Europe; Design: RCT; No. of groups: 3; Comparators: VR, routine care, narrative medicine	Age: adult (mean: 59.3 years); N: 74; Pain origin: IV antiblastic therapy	Frequency: 1x; Context: during the procedure; Duration: 30 minutes; Device: Meta Oculus Quest	310 real-world videos divided into various nature-related categories	Relaxation	VAS	No difference
Amali and Chavan59	Location: Asia; Design: Quasi; No. of groups: 2; Comparators: VR, routine care	Age: child (mean±SD: VR, 10.21±3.92 years; control, 9.25± 3.21 years); N: 80; Pain origin: cancer–IV	Frequency: 1x; Context: before and during the procedure; Duration: 20 minutes; Device: N/R	Choice of videos, such as Roller Coaster, Chhota Bheem, Mr. Bean, Tom and Jerry, and scuba diving	Distraction	WBFPRS	VR better
Sharma et al60	Location: Asia; Design: Quasi; No. of groups: 3; Comparators: VR, 2D digital screen, verbal distraction	Age: child (mean: verbal, 6.13 years; VR, 5.75 years; digital screen, 5.73 years); N: 97; Pain origin: dental administration of LA	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: N/R	Age-appropriate videos according to the subject’s choice	Distraction	FLACC	VR better
Joo et al61	Location: Asia; Design: RCT; No. of groups: 2; Comparators: VR+routine care, routine care	Age: adult (mean±SD: 62.6±13.3 years); N: 38; Pain origin: fluoroscopy-guided lumbar sympathetic ganglion block	Frequency: 1x; Context: during the procedure; Duration: 30 minutes; Device: Samsung Gear VR	Relaxing seashore view with Korean language narrations	Hypnosis	NRS	VR better
Hsu et al62	Location: Asia; Design: RCT; No. of groups: 2; Comparators: VR, educational book	Age: child (mean: 10.01 years); N: 134; Pain origin: IV placement	Frequency: 1x; Context: during the procedure; Duration: 10 minutes; Device: HTC Vive Cosmos	Instructional and emotional catharsis play sessions: explanation of procedure with animated character, relaxing music, and an interactive game destroying bacteria	Combination (education and distraction)	WBFPRS	VR better
Wong and Choi63	Location: Asia; Design: RCT No. of groups: 2; Comparators: VR+routine care, routine care	Age: child (mean±SD: 7.21±2.45 years); N: 149; Pain origin: venipuncture	Frequency: 1x; Context: before and during the procedure; Duration: about 4.43 minutes; Device: Google Caredboard Glasses	Character guides patient through the procedure; for patients aged 4–7 years, simple words and sentences; for patients aged 8–12 years, detailed information followed by an interactive game	Combination (education and distraction)	FPS-R	VR better
Ryu et al64	Location: Asia; Design: RCT; No. of groups: 2; Comparators: Routine care+VR education, routine care	Age: child (median: 6.0 years); N: 60; Pain origin: venipuncture	Frequency: 1x; Context: preoperative admission; Duration: 4 minutes; Device: Meta Oculus Go	Animated character from xI movie explains the procedures and reminds them to be brave	Education	CHEOPS	VR better

Dalir et al65	Location: Middle East; Design: RCT; No. of groups: 2; Comparators: VR, routine care	Age: adult (mean±SD: VR, 54.5±8.3 years; routine care, 52.3±11.5 years); N: 70; Pain origin: chest tube removal	Frequency: 1x; Context: before and during the procedure; Duration: >5 minutes; Device: VR Shinecon G04BS	Choice between 5 nature landscape videos	Distraction	VAS	VR better
Ashley Verzwyvelt et al66	Location: North America; Design: RCT CX; No. of groups: 3; Comparators: VR, green therapy, no intervention	Age: adult (mean±SD: 59.03±13.2 years); N: 33; Pain origin: chemotherapy infusion	Frequency: 1x; Context: during the procedure; Duration: about 53 minutes; Device: Meta Oculus Quest	Choice between 9 interactive natural environments	Relaxation	Unknown	No difference
Xiang et al67	Location: North America; Design: RCT; No. of groups: 3; Comparators: active VR, passive VR, routine care	Age: child (mean: 11.3 years); N: 90; Pain origin: dressing pain for pediactric burn wounds	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Google Caredboard Glasses	Active VR: Virtual river cruise with otter targeting balls at snow-emitting creatures; Passive VR: river cruise without the interactive aspect	Distraction	VAS	VR better (active and passive)
Bahrololoomi et al68	Location: Middle East; Design: RCT CX; No. of groups: 2; Comparators: anesthesia+VR, anesthesia alone	Age: child (range: 6–8 years); N: 30; Pain origin: bilateral mandibular molar pulpotomy	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Leji VR Mini Glasses	Tom and Jerry animation	Distraction	WBFPRS	VR better
Chang et al69	Location: North America; Design: RCT; No. of groups: 2; Comparators: analgesia+VR, analgesia alone	Age: adult (mean±SD: 59.4±16.7 years); N: 15; Pain origin: laryngoscopy	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Samsung Gear VR	Relaxing beach virtual environment with the sound of waves crashing onto a shore	Relaxation	VAS	No difference
Jain et al70	Location: North America; Design: RCT; No. of groups: 3; Comparators: active VR, passive VR, standard of care	Age: child (mean: 11.6 years); N: 90; Pain origin: pediatric burn dressing care	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: N/R	Active: virtual river cruise with otter targeting balls at snow-emitting creatures with scoreboard and thermometer; passive: same environment without interaction	Distraction	VAS	No difference
Olbrecht et al71	Location: North America; Design: pre-post single cohort; No. of groups: 1; Comparators: VR	Age: child (mean±SD: 14.6±3.2 years); N: 51; Pain origin: postoperative pain	Frequency: 1x; Context: postoperative admission; Duration: 10 minutes; Device: Lenovo Mirage Solo	“Mindful Aurora” guided relaxation in alpine meadow	Relaxation	NRS	Pain reduced
Kumari et al72	Location: Asia; Design: RCT; No. of groups: 2; Comparators: anesthesia+immersive VR, anesthesia+nonimmersive VR	Age: child (mean: immersive VR, 8.55 years; nonimmersive VR, 8.66 years); N: 200; Pain origin: intraoral injections in children undergoing dental procedures	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Meta Oculus Go	Immersive VR: video games like Temple Run, roller coaster games; Nonimmersive IVR: choice of five cartoon movies (adventure/superhero and princess stories)	Distraction	VAS, WBFPRS	Pain reduced
Hoffman et al73	Location: North America; Design: RCT CX; No. of groups: 2; Comparators: analgesia+VR, analgesia alone	Age: child (mean: 12 years); N: 48; Pain origin: burn wound care for children with large severe burns	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: NVIS MX90 VR	SnowWorld: icy canyon game to throw snowballs at other characters with music	Distraction	GRS	VR better
Chang et al74	Location: Asia; Design: RCT; No. of groups: 2; Comparators: VR, routine care	Age: child (median: 6 years); N: 30; Pain origin: immunization	Frequency: 1x; Context: during the procedure; Duration: 2 minutes; Device: Meta Oculus Quest	Burp’s Magic Tower: animated character to tap child’s shoulder at point of injection	Distraction	FPS-R	VR better
Careus et al75	Location: Middle East; Design: RCT; No. of groups: 2; Comparators: VR, standard of care	Age: adult (mean±SD: VR, 31.0±2.6 years; control, 31.8±3.6 years); N: 42; Pain origin: labor	Frequency: 2x; Context: during the procedure; Duration: 20 minutes; Device: Meta Oculus Quest All-in-one	A choice between several nature environments, (eg, orange sunset, green meadows, etc).	Distraction	WBFPRS	Pain reduced
Chiu et al76	Location: Asia; Design: quasi-experimental; No. of groups: 2; Comparators: VR, no intervention	Age: child (range: 6–17 years); N: 14; Pain origin: L-asparaginase chemotherapy with intramuscular injections	Frequency: 1x; Context: before and during the procedure; Duration: 20 minutes; Device: N/R	Tour of a virtual landscape with nature, snow, aquariums, and dinosaurs	Distraction	NRS	Pain reduced
Perenic et al77	Location: Europe; Design: Quasi; No. of groups: 2 Comparators: standard of care+VR, standard of care	Age: adult (mean: 66.95 years); N: 153; Pain origin: transrectal prostate biopsy	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Meta Oculus Go	Subjects chose between 3 360° landscapes: snow world, forest walk, or Zen garden	Combination (relaxation, hypnosis, and music therapy)	VAS	No difference
Ong et al78	Location: North America; Design: pre-post single cohort; No. of groups: 1; Comparators: VR	Age: adult (mean: 50 years); N: 46; Pain origin: postoperative surgical/trauma ICU	Frequency: <7x, 1 per day; Context: postoperative admission; Duration: <20 minutes; Device: Google Daydream	PEARL (orientation to VR) followed by calm immersive scenes (eg, rolling waves on a beach) with voice-guided meditation	Relaxation	DVPRS	No difference
Łuczak et al79	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR, no intervention	Age: adult (mean: 66.4 years); N: 103; Pain origin: cystoscopy	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: N/R	Static scene of the Skogafos waterfall in Iceland with dynamic animal activity, plant movement, and flowing water	Distraction	NRS, FLACC	VR better
Soret et al80	Location: Europe; Design: quasi-experimental; No. of groups: 2; comparators: anesthesia+ VR, anesthesia alone	Age: adult (median: VR, 66.7 years; control, 66.4 years); N: 36; Pain origin: bone marrow aspiration	Frequency: 1x; Context: during the procedure; Duration: about 15 minutes; Device: Meta Oculus Go	Choice of 3 relaxing environments (Zen garden, forest, or beach)	Combination (relaxation, hypnosis, and music therapy)	NPRS	No difference
Canares et al81	Location: North America; Design: RCT; No. of groups: 3; Comparators: VR+child life specialist support (CLSS), CLSS alone, no intervention	Age: child (mean±SD: 14.1±4.1 years); N: 55; Pain origin: venipuncture (pediatric ED)	Frequency: 1x; Context: during the procedure; Duration: about 11.6 minutes; Device: Meta Oculus Go	Commercially available VR games: Bait!, Epic Roller Coasters, Temple Run	Distraction	VAS	No difference
Barry et al82	Location: North America; Design: Quasi; No. of groups: 2; Comparators: anesthesia+VR, anesthesia alone	Age: adult (mean: 74 years); N: 54; Pain origin: total hip arthroplasty, total knee arthroplasty	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Pico G2 4K Enterprise	Choice of the 4 different visual content environments with voice-guided hypnosis techniques	Hypnosis	NRS	No difference
Armstrong et al83	Location: North America; Design: RCT; No. of groups: 3; Comparators: active VR, passive VR, routine care	Age: adult (median: 38.4 years); N: 14; Pain origin: burn wound care	Frequency: <3x, 1 per day; Context: during the procedure; Duration: <46 minutes; Device: N/R	Active VR: projectile games (Town and Cave), rhythm games (City and Forest); Passive VR: automated tour of same environments without the interaction	Distraction	VAS	VR better (active and passive)

Droc et al84	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR+routine care, routine care	Age: adult (>50 years); N: 51; Pain origin: major abdominal surgery	Frequency: 2x, 1 per day; Context: postoperative admission; Duration: <8 minutes; Device: N/R	Choice between nature landscapes, such as hills, forests, and seas, and/or plain images	Distraction	VAS	VR better
Toledo del Castillo et al85	Location: Europe; Design: quasi-experimental; No. of groups: 2; Comparators: no intervention, VR, (optional VR+analgesia)	Age: child (median: 10 years); N: 58; Pain origin: extraction of blood sample, lumbar puncture	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Woxter Neo VR1	Previously reviewed videos based on the age and tastes of the patient	Distraction	WBFPRS, VAS, NRS	VR better
Sweta et al86	Location: Asia; Design: RCT; No. of groups: 2; Comparators: anesthesia+VR, anesthesia alone	Age: adult (mean±SD: 39.72±15.93 years); N: 50; Pain origin: administration of anesthesia for dental procedures	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: N/R	Relaxation videos developed for the VR format	Distraction	VAS	VR better
Sooriyaghandan et al87	Location: Asia; Design: RCT; No. of groups: 2; Comparators: anesthesia+ VR, anesthesia alone	Age: adult (median: intervention, 67 years; control, 64 years); N: 80; Pain origin: flexible bronchoscopy	Frequency: 1x; Context: before and during the procedure; Duration: 10 minutes; Device: Meta Oculus Quest	3D nature video scenes from various countries coupled with instrumental music via surround sound speakers	Distraction	VAS	No difference
Butt et al88	Location: North America; Design: RCT; No. of groups: 2; Comparators: VR, passive distraction with iPad	Age: child (mean±SD: VR, 15±1.3 years; iPad, 15±1.5 years); N: 110; Pain origin: pediatric ED, acute mild-to-moderate traumatic/nontraumatic pain	Frequency: 1x; Context: preoperative admission; Duration: 5 minutes; Device: Meta Oculus Go	Take-pause software	Relaxation	WBFPRS	No difference
Orhan and Bülez89	Location: Middle East; Design: RCT; No. of groups: 2; Comparators: anesthesia+VR, anesthesia alone	Age: adult (mean±SD: 20.5±3.56 years); N: 50; Pain origin: episiotomy repair	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Schulzz Vrg Pro	Video images with relaxing music, musical videos (underwater, nature landscape)	Relaxation	VAS	VR better
Karaveli Çakır and Evirgen90	Location: Middle East; Design: RCT; No. of groups: 2; Comparators: VR, routine care	Age: adult (mean±SD: 56.33±11.7 years); N: 60; Pain origin: colonoscopy	Frequency: 1x; Context: during the procedure; Duration: <13 minutes; Device: N/R	A Walk on the Beach licensed software	Distraction	VAS	VR better
JahaniShoorab et al91	Location: Middle East; Design: RCT; No. of groups: 2; Comparators: VR+Routine care, routine care	Age: adult (mean±SD: 24.1±4.1 years); N: 30; Pain origin: episiotomy repair	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Vuzix Wrap 920	3D film (IMAX Dolpine and Whales 3D 1080p)	Distraction	NRS	VR better
Ghobadi et al92	Location: Middle East; Design: RCT CX; No. of groups: 2; Comparators: VR, routine care	Age: adult (mean±SD: 44.29±12.98 years); N: 73; Pain origin: dental implant surgery for molars	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Meta Oculus Quest	Nature content (observing natural scenery)	Distraction	NRS	VR better
Pelazas-Hernández et al93	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR, routine care	Age: adult (mean±SD: routine care, 47.19±8.7 years; VR, 49.20±11.8 years); N: 154; Pain origin: hysteroscopy	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Samsung Oculus Go	A Night Sky: linking stars and getting rewarded	Relaxation	VAS	VR better
Fadholi and Mustofa94	Location: Asia; Design: quasi-experimental; No. of groups: 2; Comparators: VR, routine care	Age: N/R; N: 32; Pain origin: appendectomy	Frequency: 1x; Context: postoperative admission; Duration: N/R; Device: N/R	Videos in combination with Murottal Al-Qur’an therapy (sound recording of surah Al-Rahman verses)	Distraction	NRS	VR better

Das et al95	Location: Australia; Design: RCT; No. of groups: 2; Comparators: analgesia+VR, analgesia alone	Age: child (mean±SD: boys, 10±3.7 years; girls, 10±4.1 years); N: 9; Pain origin: burn wound care	Frequency: varied; Context: during the procedure; Duration: N/R; Device: IO Glasses	A game where participants used a pointer to aim and shoot at monsters	Distraction	WBFPRS	Pain reduced
Erdős and Horváth96	Location: Europe; Design: RCT CX; No. of groups: 2; Comparators: VR, mobile phone	Age: child (mean±SD: 13.66±3.61 years); N: 29; Pain origin: chemotherapy	Frequency: 1x; Context: during the procedure; Duration: <30 minutes; Device: Samsung Gear VR, Meta Oculus Go	A Night Sky: linking stars and getting rewarded	Distraction	VAS	No difference
Asl Aminabadi et al97	Location: Middle East; Design: RCT CX; No. of groups: 2; Comparators: VR+anesthesia, anesthesia alone	Age: child (mean: 5.4 years); N: 120; Pain origin: inferior alveolar nerve block injection	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Ilixco i-glasses 920 HR	Single episode of Tom and Jerry	Distraction	WBFPRS	VR better
Brown et al98	Location: North America; Design: RCT; No. of groups: 3; Comparators: VR, 2D computer screen, no intervention	Age: adult (mean±SD: 61.9± 17.7 years); N: 45; Pain origin: lumbar spinal injection	Frequency: 1x; Context: preoperative admission; Duration: 5 minutes; Device: Meta Oculus Go	Nature relaxation video	Relaxation	NRS	No difference
Riska et al99	Location: Asia; Design: quasi-experimental; No. of groups: 2; Comparators: VR, routine care	Age: adult (N/R); N: 60; Pain origin: intrauterine device placement	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: N/R	Underwater scenery, roller coaster rides, museums, and overseas trips environments	Distraction	VAS	VR better
Gil Piquer et al100	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR, routine care	Age: child (mean±SD: 9.7±1.7 years); N: 83; Pain origin: venipuncture	Frequency: 1x; Context: during the procedure; Duration: 12 minutes; Device: Meta Oculus Quest	Short film Henry (cartoon hedgehog celebrating his birthday with animal-shaped balloons that come alive)	Distraction	VAS	VR better
Specht et al101	Location: North America; Design: RCT; No. of groups: 2; Comparators: standard of care (iPad), VR	Age: child (mean±SD: 12.25±3.2 years); N: 73; Pain origin: postoperative pain in postanesthesia care unit (general, spine, orthopedic, burn)	Frequency: 1x; Context: postoperative admission; Duration: <30 minutes; Device: Meta Oculus Go	Nature Treks VR application (different settings ranging from outer space to the deep sea)	Relaxation	WBFPRS, VAS, FLACC	VR better
Atzori et al102	Location: Europe; Design: RCT CX; No. of groups: 2; Comparators: VR, standard of care	Age: child (mean±SD: 10.92±2.64 years); N: 15; Pain origin: venipuncture	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Sony HMZ T-2	SnowWorld: icy canyon game to throw snowballs at other characters	Distraction	VAS	Pain reduced
Hoffman et al103	Location: North America; Design: RCT; No. of groups: 2; Comparators: analgesia+VR, analgesia alone	Age: child (range: 6–17 years); N: 50; Pain origin: burn wound care	Frequency: 10x, 1 per day; Context: during the procedure; Duration: N/R; Device: NVIS MX90 VR	SnowWorld: icy canyon game to throw snowballs at other characters	Distraction	GRS	VR better
Atzori et al15	Location: Europe; Design: RCT CX; No. of groups: 2; Comparators: VR, routine care	Age: child (mean±SD: 13.20±2.39 years); N: 5; Pain origin: dental filling/extraction	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Meta Oculus Rift	SnowWorld: icy canyon game to throw snowballs at other characters	Distraction	GRS	Pain reduced
Rousseaux et al104	Location: Europe; Design: RCT; No. of groups: 4; Comparators: routine care+VR distraction, routine care+VR hypnosis, routine care, routine care+hypnosis	Age: adult (mean±SD: 66±11.5 years); N: 100; Pain origin: postoperative pain due to cardiac surgery	Frequency: 2x; Context: before and after the procedure; Duration: 20 minutes; Device: Oncomfort	VR distraction: mountain lake cabin sunrise, relaxing moment in the cloud with ambient audio. VR hypnosis: added recorded hypnosis session	Relaxation or hypnosis	VAS	Pain reduced

Payne et al105	Location: Australia; Design: RCT CX; No. of groups: 2; Comparators: active then passive VR, passive then active VR	Age: adult (mean±SD: group 1, 39.27±10.20 years; group 2, 41.67±12.92 years); N: 34; Pain origin: laparoscopy	Frequency: 1x; Context: postoperative admission; Duration: 20 minutes; Device: Meta Oculus Go	Active distraction: Sky Lights 2 (lighting lanterns on a starry night with fireworks); passive meditation: Cosmic You (guided meditation, relaxing background music while looking at colorful shooting stars in the night’s sky)	Distraction, relaxation	NRS	Pain reduced
Goergen and Freitas106	Location: South America; Design: RCT; No. of groups: 2; Comparators: anesthesia+VR, anesthesia alone	Age: adult (mean±SD: VR, 62.11±13.35 years; control, 65.09±11.95 years); N: 159; Pain origin: rigid cystoscopy	Frequency: 1x; Context: during the procedure; Duration: about 5.33 minutes; Device: Trust Urban Exos 3D	Video playing that simulated a ride on rails	Distraction	VAS	VR better
Vázquez et al107	Location: North America; Design: quasi-experimental; No. of groups: 2; Comparators: anesthesia+VR, anesthesia alone	Age: adult (median: non-VR, 53.2 years; VR, 47.6 years); N: 115; Pain origin: gastrointestinal endoscopy	Frequency: 1x; Context: during and after the procedure; Duration: N/R; Device: N/R	Immersive virtual scenarios (Enchanted Forest, Magic Cliff, Enchanted Castle, and Shell Island)	Relaxation	VAS	VR better
Ding et al108	Location: Asia; Design: RCT; No. of groups: 2; Comparators: VR+routine care, routine care	Age: adult (mean±SD: 45.8±12.6 years); N: 182; Pain origin: dressing change post-hemorrhoid surgery	Frequency: 1x; Context: during the procedure; Duration: about 21.2 minutes; Device: eMagin Z800 3D Visor	SnowWorld version 2.1	Distraction	VAS	No difference
Pandya et al109	Location: North America; Design: Quasi; No. of groups: 2; Comparators: VR+routine care, routine care	Age: adult (median: non-VR, 67 years; VR, 69 years); N: 14; Pain origin: preoperative adrenocortical carcinoma insertion	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Hypervision 2D virtual reality glasses	Titans of Space (move through solar system using eye-fixation to bring up information about planets); Lanterns (lantern festival at night); SeaWorld (underwater scuba dive)	Distraction	NRS	VR better
Veldhuijzen et al110	Location: Europe; Design: quasi-experimental; No. of groups: 2; Comparators: VR+standard of care, standard of care+only VR glasses	Age: adult (median: control, 64 years; intervention, 65 years); N: 19; Pain origin: colonoscopy	Frequency: 1x; Context: during the procedure; Duration: about 22.60 minutes; Device: Samsung Gear VR	Real-world short videos of tropical islands and forests in the Caribbean	Relaxation	NRS	No difference
Zheng and Liu111	Location: Asia; Design: RCT No. of groups: 2; Comparators: VR+routine care, routine care	Age: adult (mean±SD: 45.6±8.6 years); N: 172; Pain origin: dressing change post-surgical drainage of perianal abscess	Frequency: 1x; Context: during the procedure; Duration: about 23.2 minutes; Device: Pico G2 4K	Favorite immersive 360° Cine-VR scene of movies	Distraction	VAS	No difference
Eijlers et al112	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR, care as usual	Age: child (median: VR, 9.0 years; care as usual, 7.5 years); N: 191; Pain origin: maxillofacial, dental, or ear, nose, and throat day care surgery	Frequency: 1x; Context: preoperative admission; Duration: 15 minutes; Device: HTC Vive	Simulation of real operating theater and medical staff with the option to choose the different medical instruments for explanations	Education	FPS-R	No difference
Deo et al20	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR, routine care	Age: adult (mean±SD: routine care, 31.3±5.2 years; VR, 31.1±5.4 years); N: 40; Pain origin: hysteroscopy	Frequency: 1x; Context: during the procedure; Duration: 8 minutes; Device: Meta Oculus Go	“Forest of Serenity” narrated by Sir David Attenborough, calming rainforest and a lake setting with animated wildlife	Relaxation	NRS	VR better

David et al113	Location: Europe; Design: pre-post single cohort; No. of groups: 1; Comparators: VR	Age: adult (mean±SD: 49.9±10.6 years); N: 17; Pain origin: botulinum toxin injection	Frequency: 1x; Context: during the procedure; Duration: <24 minutes; Device: N/R	Calm visual environments (walking on the beach, diving among colored fishes, or traveling in space) with relaxing music	Hypnosis	NRS	Pain reduced
Bernaerts et al114	Location: Europe; Design: pre-post single cohort; No. of groups: 1; Comparators: VR	Age: child (mean: 10.88 years); N: 51; Pain origin: patients in need of distraction or meditation before medical procedure	Frequency: 1x; Context: preoperative admission; Duration: >14 minutes; Device: Meta Oculus Go	Relaxation VR: breathing exercises, meditation exercises (eg, a body scan), scene with different interactive animations and objects (catching falling apples, popping bubbles, playing fetch with a dog)	Combination (relaxation and distraction)	FPS-R	Pain reduced
Ellerton et al115	Location: Australia; Design: RCT; No. of groups: 2; Comparators: VR+routine care, routine care	Age: child (median: 48 months); N: 87; Pain origin: immunization	Frequency: 1x; Context: before and during the procedure; Duration: 1 min; Device: Google Daydream View	Marine adventure: starts with a relaxation sequence and progresses to underwater scenes, including gaze-based tracking of virtual fish	Combination (relaxation and distraction)	FPS-R, VAS	No difference
Spiegel et al116	Location: North America; Design: RCT; No. of groups: 2; Comparators: VR, TV	Age: adult (mean: VR, 51.6 years; control, 50.0 years); N: 120; Pain origin: somatic and visceral	Frequency: 6x, 3 per day; Context: hospitalization for various reasons; Duration: 10 minutes; Device: Samsung Gear VR	Guided relaxation: Bear Blast (firing cannons to knock down teddy bears), Crossing Worlds (American desert landscape spectrum), Feeding Frenzy (launching food to hungry animals on a timer), and 120 other options	Variety	NRS	VR better
Tashjian et al117	Location: North America; Design: quasi-experimental; No. of groups: 2; Comparators: 2D Computer screen, VR	Age: adult (mean: VR, 54.58 years; control, 47.7 years); N: 100; Pain origin: hospitalized patients	Frequency: 1x; Context: hospitalization for various reasons; Duration: 15 minutes; Device: Samsung Gear Oculus	Fantasy world target game, shooting balls by maneuvering head, motivational music, positively reinforcing sounds, animation, and direct messages to patients	Distraction	NRS	VR better
Birrenbach et al118	Location: Europe; Design: pre-post single cohort; No. of groups: 1; Comparators: VR+analgesia	Age: adult (median: 42 years); N: 52; Pain origin: traumatic and nontraumatic pain in emergency room	Frequency: 1x; Context: hospitalization for various reasons; Duration: 20 minutes; Device: Pico G2 4K Enterprise	Beach or forest landscape accompanied by a relaxing sound universe	Relaxation	NRS	Pain reduced
Roxburgh et al119	Location: Europe; Design: quasi-experimental; No. of groups: 2; Comparators: analgesia+VR, analgesia alone	Age: adult (mean: VR, 63 years; control, 64.5 years); N: 99; Pain origin: atrial fibrillation ablation	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Deepsen VR	Choice from among 5 3D computer-simulated scenarios with music therapy and gamification elements preceded by cardiac coherence breathing	Combination (relaxation and distraction)	VAS	VR better
O’Sullivan et al120	Location: Europe; Design: pre-post single cohort; No. of groups: 1; Comparators: VR+analgesia	Age: child (median: 10.5 years); N: 22; Pain origin: needle procedure in ED	Frequency: 1x; Context: during and after the procedure; Duration: 10 minutes; Device: Samsung Gear VR	Video featuring a hypnotherapist: favorite place hypnotic induction and the switches method with suggestions of hypnoanxiolysis and analgesia	Hypnosis	CAS	Pain reduced

Patterson et al121	Location: North America; Design: RCT; No. of groups: 3; Comparators: analgesia+VR hypnosis, analgesia+VR distraction, analgesia alone	Age: adult (mean: 31.8 years); N: 21; Pain origin: treatment for physical trauma (internal injuries, long bone fractures, gunshot wounds, etc.)	Frequency: 1x; Context: hospitalization for various reasons; Duration: <40 minutes; Device: N/R	VR hypnosis: descent into icy, Arctic canyon with starry sky, gently flowing river below, and vertical canyon walls with hypnotic suggestions; VR distraction: same environment with shooting snowballs at objects, such as snowmen, penguins, and igloos, and soothing music	Hypnosis, distraction	GRS	VR better
de Araújo et al122	Location: South America; Design: RCT CX; No. of groups: 2; Comparators: VR+routine care, routine care	Age: adult (N/R); N: 17; Pain origin: chronic wound dressing change	Frequency: 1x; Context: during the procedure; Duration: 22 minutes; Device: Meta Oculus Go	Real-world video images and location-specific spatial sounds of beaches, rural areas, and national parks	Distraction	WBFPRS, VAS	VR better
Vasquez et al123	Location: North America; Design: quasi-experimental; No. of groups: 2; Comparators: VR, no intervention	Age: adult (mean: VR, 41.14 years; non-VR, 31.17 years); N: 44; Pain origin: gynecological surgery	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: N/R	Enchanted Forest: Clinically validated navigatable relaxation world	Relaxation	VAS	VR better
Laghlam et al124	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR, analgesia	Age: adult (median: 68 years); N: 200; Pain origin: ICU after cardiac surgery	Frequency: 1x; Context: before, during and after the procedure; Duration: N/R; Device: Deepsen VRx Helmet	A choice between 5 different immersive environments: snowy mountain; landscape in India or Camargue, France; balloon ride; canoe descent	Distraction	NRS	VR worse
Bruno et al125	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR, no intervention	Age: adult (median: 83 years); N: 32; Pain origin: transcatheter aortic valve implantation	Frequency: 1x; Context: during the procedure; Duration: about 30.5 minutes; Device: MEDION® ERAZER® X1000 MR	A choice between nature scenery, an aquarium, flying over a green landscape, diving underwater, or walking through a calm forest	Distraction	VAS	No difference
Chiu et al126	Location: Asia; Design: RCT; No. of groups: 2; Comparators: VR+routine care, routine care	Age: adult (mean: 46.34 years); N: 74; Pain origin: elective surgery	Frequency: 1x; Context: preoperative admission; Duration: 8 minutes; Device: Meta Oculus Quest	Virtual tour simulating the entire journey of the perioperative process	Education	VAS	No difference
Mohammadi et al127	Location: Europe; Design: RCT; No. of groups: 3; Comparators: VR, routine care, narrative medicine	Age: adult (N/R); N: 130; Pain origin: labor	Frequency: varied; Context: during the procedure; Duration: 20 minutes; Device: Samsung Gear VR	A game featuring a seashore simulation of the individual floating in a boat with the pleasant sound of water; once started, correct choices of objects related to babies enable moving to the next level	Distraction	VAS	VR better
Althumairi et al128	Location: Middle East; Design: quasi-experimental; No. of groups: 2; Comparators: VR, standard of care	Age: child (mean: VR, 5.38 years; standard of care, 5.18 years); N: 104; Pain origin: routine vaccinations	Frequency: varied; Context: during the procedure; Duration: 2 minutes; Device: Melko Future Sight all-in-one	3D animated adventure story	Distraction	WBFPRS	VR better
Gullo et al129	Location: Europe; Design: RCT; No. of groups: 2; Comparators: VR+routine care, routine care	Age: adult (mean: 47.4 years); N: 100; Pain origin: peripheral endovascular interventions under LA	Frequency: 1x; Context: during the procedure; Duration: N/R; Device: Samsung Gear VR	An underwater world: whale swimming in front of user encourages user to breathe at its tail's frequency, prerecorded autohypnosis, binaural beats, and breath exercises based on cardiac coherence	Combination (relaxation and hypnosis)	VAS	No difference

2D: two-dimensional; 3D: three-dimensional; CAS: Color Analog Scale; CHEOPS: Children's Hospital of Eastern Ontario Pain Scale; DVPRS: Defense and Veterans Pain Rating Scale; ED: emergency department; FLACC: Face, Legs, Activity, Cry, and Consolability Scale; FPS-R: Faces Pain Scale–Revised; GRS: Graphic Rating Scale; ICU: intensive care unit; IV: intravenous; LA: local anesthesia; No.: number; NPRS: Numeric Pain Rating Scale; N/R: not reported; NRS: Numeric Rating Scale; PIVC: peripheral intravenous catheter; RCT: randomized, controlled trial; RCT CX: randomized controlled trial cross-over design; SD: standard deviation; VAS: Visual Analog Scale; VR: virtual reality; WBFPRS: Wong-Baker’s FACES Pain Rating Scale

Study characteristics. Table 3 indicates a notable increase in research on VR for AP management in recent years, with over 73.2 percent of the total studies published between 2021 and early 2024. Geographically, the majority of the studies were conducted in Europe (28.9%), followed by North America (24.7%) and Asia (23.7%). Middle Eastern countries accounted for 15.5 percent of the publications, while South America, Australia, and Africa collectively accounted for the remaining studies (7.2%). The studies were predominantly some form of controlled trials (randomized, controlled trials [RCT], 60.8%; quasi-experimental designs, 18.6%; RCT cross-over designs [RCT CX], 13.4%), with only 7.2 percent utilizing a pre-post single cohort design. Of the controlled trials, a majority (84.4%) of the studies used one control group, 14.4 percent had two comparators, and 1.1 percent had three comparators. Among the controlled trials, a majority of the studies that offered the intervention had VR alone. However, other studies also offered the VR intervention as an adjunct to standard of care (SOC; 15.4% of total studies), analgesia/anesthesia (18.5% of total studies), and other interventions (1% of total studies). Most (46.2%) of the studies had routine care/SOC as a control group, while other comparators included analgesia/anaesthesia (18.3%), no intervention (7.7%), a two-dimensional digital screen (6.7%), and alternate VR programs (4.8%). As for the sample size, most studies (29.9%) had between 31 to 60 participants, followed by over 100 participants (27.9%), 61 to 100 participants (21.6%) and less than 30 participants (20.7%).

TABLE 3.

Numbers and percentages of characteristics of the VR protocols

CATEGORY	TOTAL (%)
Study design (n=97)
RCT	59 (60.8%)
RCT CX	13 (13.4%)
Quasi	18 (18.6%)
Pre-post single cohort	7 (7.2%)
VR mechanism (n=100)
Distraction	62 (62%)
Relaxation	18 (18%)
Hypnosis	6 (6%)
Education	3 (3%)
Combination	10 (10%)
Variety	1 (1%)
VR headset (device specification) (n=97)
N/R	23 (23.7%)
Meta Oculus Go	15 (15.5%)
Samsung Gear VR	13 (13.4%)
Meta Oculus Quest	10 (10.3%)
Others	36 (37.1%)
VR headset (type) (n=97)
Mobile VR headset	36 (37.1%)
PC VR Headset	16 (16.5%)
Standalone VR headset	35 (36.1%)
Option (standalone or mobile VR headset)	1 (1%)
Unknown	2 (2.1%)
N/R	7 (7.2%)
VR type of interaction (n=97)
Interactive	55 (56.7%)
Noninteractive	33 (34%)
Both	6 (6.2%)
Optional	3 (3.1%)
VR intervention context (n=97)
During the procedure	65 (67%)
Before and during the procedure	8 (8.2%)
Postoperative admission	7 (7.2%)
Preoperative admission	6 (6.2%)
Other contexts	11 (11.3%)
VR content (category) (n=104)
Entertainment	18 (17.3%)
Game	26 (25%)

VR content (category), cont. (n=104)
Guided relaxation/meditation/hypnosis	15 (14.4%)
Medical procedure explanation	3 (2.9%)
Nature	16 (15.4%)
Real world	6 (5.8%)
Others	5 (4.8%)
Combination	5 (4.8%)
Variety	6 (5.8%)
Unknown	4 (3.8%)
VR intervention duration (n=97)
<5 minutes	6 (6.2%)
5–15 minutes	21 (21.6%)
>15 minutes	25 (25.8%)
Unknown	45 (46.4%)
VR intervention dosage (n=97)
1x	86 (88.7%)
2x	3 (3.1%)
>3x	5 (5.6%)
Varied	3 (3.1%)
Outcome measures (n=106)
VAS	41 (38.7%)
WBFPRS	24 (22.6%)
NRS	23 (21.7%)
FPS-R	6 (5.7%)
FLACC	3 (2.8%)
GRS	4 (3.8%)
CAS	1 (0.9%)
CHEOPS	1 (0.9%)
DVPRS	1 (0.9%)
NPRS	1 (0.9%)
Unknown	1 (0.9%)
Results (n=97)
VR better	50 (51.5%)
VR worse	1 (1%)
Pain reduced	14 (14.4%)
No difference	32 (33%)
Other hardware (n=86)
Audio device	28 (32.6%)
Display device	28 (32.6%)

Other hardware, cont. (n=86)
Controller	26 (30.2%)
Other	4 (4.7%)
Type of pain (origin category) (n=97)
Dental	15 (15.5%)
Drug infusion/chemotherapy	3 (3.1%)
Labor-related	6 (6.2%)
Needle-related	30 (30.9%)
Perioperative	15 (15.5%)
Others	9 (9.3%)
Procedural (endoscopy)	11 (11.3%)
Procedural (endovascular)	1 (1%)
Wound care	7 (7.2%)
VR developer (n=97)
Commercial (for pain)	33 (34%)
Commercial (general/entertainment)	33 (34%)
Study specific	15 (15.5%)
Unknown	16 (16.5%)
Year of publication (n=97)
Early 2024	6 (6.2%)
2023	25 (25.8%)
2022	18 (18.6%)
2021	22 (22.7%)
2020	7 (7.2%)
2019	9 (9.3%)
2018	2 (2.1%)
2017	4 (4.1%)
2015	1 (1%)
2012	1 (1%)
2010	1 (1%)
2005	1 (1%)
Sample size (n=97)
<10	2 (2.1%)
11–30	18 (18.6%)
31–60	29 (29.8%)
61–100	21 (21.6%)
101–150	18 (18.6%)
>150	9 (9.3%)
Comparators (n=107)
Routine care/standard of care	49 (45.8%)
Analgesia/anesthesia	20 (18.7%)
Comparators, cont. (n=107)
Nothing	9 (8.4%)
2D screen	10 (9.3%)
Alternate VR	7 (6.5%)
Others	12 (11.2%)
Location (n=97)
South America	2 (2.1%)
Europe	28 (28.9%)
Asia	23 (23.7%)
North America	24 (24.7%)
Australia	4 (4.1%)
Middle East	15 (15.5%)
Africa	1 (1%)
CAS: Color Analog Scale; CHEOPS: Children’s Hospital of Eastern Ontario Pain Scale; DVPRS: Defense and Veterans Pain Rating Scale; FLACC: Face, Legs, Activity, Cry, and Consolability Scale; FPS-R: Faces Pain Scale–Revised; GRS: Graphic Rating Scale; NPRS: Numeric Pain Rating Scale; N/R: not reported; NRS: Numeric Rating Scale; RCT CX: randomized, controlled trial cross-over design; RCT: randomized, controlled trial

The clinical endpoint of pain was assessed using a range of validated tools across the studies (Table 3). Among the 97 studies included in this review, a total of 106 pain assessment tools were used, as some studies employed multiple scales. Specifically, 89 studies used only one scale to assess pain levels, five studies used two different scales, two studies used three different scales, and one study did not specify the validated measure used. The Visual Analog Scale (VAS) was the most frequently utilized, appearing in 41 studies (38.7%), followed by the Numerical Rating Scale (NRS) in 23 studies (21.7%) and the Wong-Baker FACES Pain Rating Scale (WBFPRS) in 24 studies (22.6%). Additionally, 17 studies employed other measures, including the Revised FACES Pain Scale (FPS-R), Graphic Rating Scale (GRS), Face, Leg, Activity, Cry, Consolability Scale (FLACC), Color Analog Scale (CAS), Defense and Veterans Pain Rating Scale (DVPRS), and Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS).

Sample characteristics. Study participants. In total, the reviewed studies included 7,380 participants. As seen in Table 3, 53.6 percent of studies (n=52/97), examined adult populations, while 45.4 percent (n=44/97) focused on pediatric populations. Among the studies that examined adult populations, only 19.2 percent (n=10/52) included older adults.

Origin of pain. Participants reported a range of reasons for experiencing AP. About 30.9 percent of studies (n=30/97) included participants with needle-related pain, which included pain related to venipunctures, blood sampling, intravenous (IV) placement, and immunization. Dental pain (n=15/97) and perioperative pain (n=15/97), such as that experienced during postoperative care, each accounted for 15.5 percent of the study populations. Of the remaining studies, 12.3 percent (n=12/97) assessed procedural pain, 7.2 percent (n=7/97) assessed pain associated with wound care, 6.2 percent (n=6/97) assessed labor-related pain, and 3.1 percent (n=3/97) assessed pain management during drug infusion/chemotherapy. The nine remaining studies encompassed other miscellaneous origins of pain.

VR characteristics. Technical specifications. Studies have primarily used three types of headsets to administer VR to the participants, which included mobile VR headsets, PC VR headsets that require connection to a powerful gaming PC, and standalone VR headsets with built-in processors for the VR experience. Of the 97 studies, 37 used mobile VR headsets to simulate the virtual environment, 36 studies used untethered, standalone headsets, and 16 used PC headsets. Nine studies did not report the specifics of the VR device used. Among the studies that specified the technical specifications, 58 of them also utilized additional hardware, such as external audio devices (eg, headphones), controllers (eg, mouse, joystick), and display devices (eg, laptops, smartphones) to curate the VR environment. Apart from controllers, audio, and display devices, some studies also used other external hardware, such as foam rubber⁴⁰ to help the headset better fit younger participants, light sensors,⁴⁶ and a robot-like goggle arm holder^103,104 in studies looking at pain management for burn wound care.

Intervention specifications. The VR intervention was administered across diverse clinical contexts (Table 3). Notably, the majority of studies utilizing VR for pain management implemented the intervention during medical procedures (67%; n=65/97), where the VR exposure would be in line with the length of the procedure. Other studies administered the intervention immediately before and during the medical procedure (8.2%; n=8/97), only postoperatively (7.2%; n=7/97), or only preoperatively (6.2%/ n=6/97). A few studies (11.3%; n=11/97) extended the use of VR across broader clinical settings, such as throughout the entire perioperative phase or during hospitalization for various conditions.

Overall, the duration of the VR intervention was highly varied. A considerable proportion of the studies (46.4%) did not report the duration of the intervention, and of those that did, session duration ranged from one minute to a maximum of 53 minutes. Of the studies reporting duration, 48.1 percent (n=25/52) involved interventions exceeding 15 minutes, 40.4 percent (n=21/52) lasted between 5 and 15 minutes, and 11.5 percent (n=6/52) reported durations of less than five minutes. Most studies (88.7%; n=86/97) administered VR in a single session over the course of the study, while a smaller proportion employed two sessions (3.1%; n=3/97) or more than three sessions (5.6%; n=5/97). A limited number of studies (3.1%; n=3/97) offered variable session numbers, tailored to the specific needs of the patients.

The type of content encountered by the participants encompassed both active and passive engagement (Table 3). Active VR, in which participants actively interacted with the virtual environment, was used in a total of 56.7 percent of the studies. Passive VR, employed in 34 percent of the studies, offered content for passive observation. Twenty-five percent of the studies involved games like Snow World, Temple Run, and Angry Birds, followed by 17.3 percent of the studies employing entertainment videos (eg, movies, cartoons, roller coaster experiences). A total of 15.4 percent of the studies included nature-related videos, and 14.4 percent used guided relaxation/meditation/hypnotherapy content designed for specific goals. Additionally, 5.8 percent of studies utilized real-world recordings, and another 2.9 percent used medical procedure explanations. A total of 4.8 percent of studies had other types of content, 5.8 percent offered a variety of different content categories to participants, 4.8 percent combined various types of content for the VR experience, and 3.8 percent had uncategorized content.

Of these studies, 68 percent of them used commercially available content for the VR intervention, split equally between content developed specifically for pain (34%) and content developed as commercial entertainment (34%). A few of the studies (15.5%) used content developed exclusively for the purpose of the study, and the remaining studies (16.5%) did not report the origin of development for the content used.

VR mechanism. The studies explored various approaches to influence AP using VR. Distraction emerged as the most common mechanism, utilized in 68.9 percent of the studies (n=62/97). A relaxation approach was adopted by 18.6 percent of the studies (n=18/97), while hypnotherapy was used by 6.2 percent (n=6/97) and psychoeducation by 3.1 percent (n=3/97). Of the remaining studies, 10 used a combination of more than one of these approaches, and one offered options to participants of content that utilized a variety of approaches.

Effect of VR on AP management. Overall, 66 percent of studies (n=64/97) in this review demonstrated a statistically significant reduction in pain during VR utilization (Table 3). Among these 64 studies, 78.1 percent (n=50) found VR to be more effective in reducing pain, compared to a non-VR control group, while 21.9 percent (n=14) observed significant pain reduction in within-subject comparisons and comparisons with VR control groups (eg, VR distraction vs. VR hypnosis). Thirty-three percent of the studies (n=32/97) did not find a significant reduction in AP with VR utilization. Of these 32 studies, 90.6 percent (n=29) involved comparisons with a non-VR control group, and 9.4 percent (n=3) involved within-subject comparisons. Notably, one study reported that the VR intervention was less effective than the control group in reducing pain.

Common study limitations. In the studies selected for the review, several common limitations were identified. The most prevalent of them were design- and procedure-related issues (44.3%), including single-center studies, partial or lack of blinding, nonrandomized studies, and the absence of control or within-subject comparison groups. Study sample issues were the second-most common limitation (24.8%), with small sample sizes, sample heterogeneity, and convenience sampling methods being reported. The intervention-related limitations (9.4%) included the VR environment being too simple or too complex for the respective population and mismatched durations between VR interventions and procedures, necessitating last-minute procedural changes. Outcome measures–related concerns (6.7%) involved the use of nonobjective measures of pain using self-report tools or questions being too complex for younger children. Hardware issues (1.3%), such as inconvenient or loose-fitting devices for younger participants and a narrow field of vision, were also observed. Other limitations were diverse, such as cultural differences in reporting pain and anxiety and unaccounted for environmental factors. Notably, 7.4 percent of the studies did not report any challenges.

DISCUSSION

By analyzing 97 studies, this review aimed to explore the extent of research on the use of VR as a nonpharmacological tool for AP management. Specifically, the review attempted to understand five questions: 1) What are the characteristics of the research in this review? 2) What are the characteristics of the populations for whom VR is used in managing AP? 3) What are the technological and experiential characteristics of VR systems used to alleviate AP? 4) What is the effectiveness of VR for AP management? and 5) What gaps exist in the literature regarding the use of VR as a nonpharmacological tool for AP management, and how can future research address these gaps?

What are the characteristics of the studies included in this review? Spanning over two decades of research, from 2000 through early 2024, the review identified a surge in research from 2021 onward (73.3% of the studies). This might be attributed to factors such as the growing need for nonpharmacological pain management approaches and the publication of influential meta-analyses and reviews,^14,25,118 which have highlighted the efficacy of VR for AP management. Research on VR for AP management shows a concentrated distribution across North America, Europe, Asia and the Middle East (92.8% of the studies), reflecting regional disparities potentially influenced by cultural contexts and varying levels of technological infrastructure and interest.

With regard to research design, the majority of the studies (74.2%) employed variations of RCTs, indicating rigorous practices and high-quality studies. Many studies (46.2%) compared the effectiveness of VR against routine care or SOC, but the SOC protocols at hospitals/institutions might not be uniform, limiting our ability to compare the findings across studies. While 49.5 percent of the studies included in this review had over 60 participants, the remaining studies (50.5%) had fewer than 60 participants, which suggests caution in generalizing the findings to a broader population. The present review also only focused on studies utilizing standardized pain scales. The VAS, WBPRS, and NRS were the most prevalent tools used, accounting for 83 percent of the included studies. This indicates a shift toward standardizing pain measurement in VR research, facilitating consistent and comparable findings across different VR interventions for AP management.

What are the characteristics of the populations for whom VR is used in managing AP? In the current review, there was almost an equal distribution of pediatric and adult populations exploring the use of VR in managing AP. However, it is notable that only 19.2 percent of the studies investigating the adult demographic included subjects over the age of 65 years in their research. This is a concern, as older adults tend to be more affected by pain, which has a significant impact on physical capacity, strength, and performance in their daily lives.¹¹⁹

The reviewed studies identified a broad spectrum of AP origins for which VR is used as a management tool, reiterating the applicability of the findings to real-world settings. The majority of the studies focused on needle-related pain (30.9%), which is a common experience in medical procedures, highlighting VR’s applicability to alleviate this frequent source of AP. Dental and perioperative pain were also significant focuses (15.5% each), suggesting that VR can be utilized in these contexts to improve patient comfort and reduce reliance on pharmacological relief. Other categories included endoscopy (11.3%), wound care (7.2%), labor pain (6.2%), chemotherapy (3.1%), and other sources (9.3%), demonstrating VR’s versatility as a noninvasive, nonpharmacological pain management tool. However, this also highlights the disproportionate distribution of research, with a significant focus on certain types of pain, such as needle-related pain, while other contexts, such as labor pain and chemotherapy, are less frequently studied.

What are the technological and experiential characteristics of VR systems used to alleviate acute pain? Technical specifications of VR for AP management. In the present review, it was observed that the Oculus Go (Meta; Menlo Park, California), a standalone head-mounted display, was the most commonly used VR headset, and overall, mobile VR headsets and standalone VR headsets were the most prevalent type of headsets used for AP management in clinical practice. Mobile VR headsets, often disposable, offer greater accessibility and affordability, making it more feasible for clinical settings for clinical adoption. This addresses the primary challenges of the high cost of the setup¹²⁰ and the risk of cross-contamination between patients.¹³³ Standalone head-mounted displays are equipped with integrated graphics processing units, as opposed to PC VR headsets, enhancing portability and user experience.¹³⁴ Additional hardware, including audio devices, display devices, and controllers, were used to improve usability, though they could sometimes interfere with treatment procedures and might often be prohibited in clinical settings. Notably, a significant proportion of studies did not report key VR device characteristics, such as device specification (23.7%) and type of headset used (7.2%). Future research must specify the details of the VR equipment to ensure replicability and standardization.

Intervention specifications of VR for AP management. Intervention context. The application of VR interventions across diverse clinical contexts highlights the flexibility of VR technology in medical settings for acute pain management. The present review identified that VR is often explored as a tool to modulate pain perception in real-time. Indeed, this targeted application of VR during medical procedures aligns with the notion that immersive technologies can effectively redirect patients’ attention during short-term painful stimuli, helping reduce their overall perception of pain. A smaller proportion of studies implemented VR in pre-, post-, and other perioperative phases, highlighting the underutilization of VR’s potential for reducing other aspects of acute pain management such as preprocedural anxiety and postoperative recovery.

VR mechanism. Distraction emerged as the predominant mechanism (62% of the studies) for the management of AP using VR. This is likely due to its inherent ability to divert the attentional resources away from the nociceptive stimuli toward more engaging sensory inputs, leaving fewer resources available for pain perception.^15,88,116 Relaxation (18% of the studies) has also been a mechanism utilized for AP relief, as pain often co-occurs with anxiety and physical tension, enhancing overall positive affect.¹³⁵ However, relaxation can also be considered a form of distraction since distraction encompasses any cognitive or behavioral strategy that diverts one’s attention away from nociceptive stimuli toward more engaging or attractive stimuli, thereby reducing pain and anxiety.^124–126 The literature shows some ambiguity regarding whether relaxing content primarily utilizes relaxation^58,98,101 or distraction as the primary mechanism,^48,65,75 or both. Establishing clear subcategories or distinctions between various mechanisms would help identify the most effective approach for managing AP using VR. Nonetheless, our findings align with those of other reviews^25,31,32 that highlight the popularity of VR distraction as a tool for AP management.

VR content. Interactive or active VR, utilized in 56.7 percent of the reviewed studies, engages users by actively involving them in the VR environment, improving both the level of distraction and immersion experienced by users.⁷⁰ This approach also provides users with a sense of control over their environment, which is beneficial for managing pain.^118,127 However, its applicability might be limited in contexts where mobility is restricted (eg, burn victims, dental procedures) and/or hand controllers cannot be used. Technologies such as head tracking or eye tracking offer potential solutions, but affordable variations of such prospects are currently constrained by a lack of precision¹³⁹ and the risk of lowering the sense of presence.¹⁴⁰

Noninteractive or passive VR, utilized in 34 percent of the studies, involve the user watching or observing VR content, such as films, cartoons, or nature-related environments. While passive VR has a lower distraction potential due to its noninteractive nature, it is particularly apt to promote relaxation and has broader applicability to different populations.^81,82,97 Most studies (68%) used commercially available content either developed for pain management or entertainment purposes, and studies rarely relied on content specifically developed for the study. This highlights a gap in the literature regarding the potential for tailored VR interventions that could optimize pain management outcomes.

Intervention dosage. In the present review, a wide variation of session duration and frequency was identified regarding the VR interventions for AP management. There is little consensus on the optimal duration of a VR session or the frequency of the intervention to maximize the benefits. Nearly half of the studies failed to report the session duration, and those that did displayed a broad range, from one minute to 53 minutes. When analyzing by mechanism and context of use, most studies with under five minutes of intervention focused on the mechanism of distraction during the procedure. If the purpose of the intervention is to modulate pain perception through relaxation or hypnosis, less than five minutes might not be sufficient. Indeed, the present review noted a higher proportion of longer duration sessions (>15 minutes) focusing on mechanisms such as relaxation and hypnosis during medical procedures or postoperative admissions. Therefore, further research is required to evaluate VR interventions for AP management based on the purpose and expected outcomes to identify optimal timing.

In addition to the lack of a clear trend in the optimal intervention duration, the most effective number of sessions also have not been identified. The current review observed that 88.7 percent of the studies utilized only one session. Studies that administered two or more sessions predominantly addressed procedural pain, such as labor^48,75,127 or multiple burn dressing changes,^73,95,141 with the aim of distracting patients from prolonged AP. Meanwhile, relaxation- and hypnosis-based VR interventions with multiple sessions were more common in postoperative settings, aiming to reduce pain perception through relaxation.^78,104 Thus, for most procedurally caused AP, a single session that aligns with the length of the procedure might be sufficient for maximizing the benefits. In the context of prolonged procedural pain, such as labor or extensive surgery, it might be advisable to take a 10-to-15-minute break every 30 minutes.¹⁴² Nevertheless, if VR is to become a mainstream treatment for modulating AP, further research is needed to evaluate the effectiveness of session dosage based on the specific goal of the intervention.

What is the effectiveness of VR for AP management? Overall, the results of the scoping review suggest that VR is a useful tool for managing AP, with 66 percent of studies demonstrating the efficacy of VR as an analgesic. Studies comparing VR to other forms of pain management, such as routine care, or other distraction methods, such as two-dimensional computer screens^60,117 and/or tools including smartphones and tablets,^17,101 demonstrated that VR was more effective as an analgesic than traditional nonpharmacological approaches. These results are consistent with other reviews done on the efficacy of VR in AP management.^25,32 It is noteworthy that one study reported that pain scores were significantly higher in the VR group, but the study compared VR with 50-percent nitrous oxide/oxygen premix, a pharmacological pain management method.

Distraction was identified as the most effective VR mechanism for pain management, demonstrating efficacy in 86.9 percent of studies. Within the distraction category, all types of content—including games, nature scenes, entertainment, real-world settings, and others—were nearly equally effective, with efficacy demonstrated in 75 percent to 77.77 percent of the studies. Indeed, other reviews have also indicated that for pain lasting for shorter durations, distraction can play a significant role in VR-associated pain relief.¹⁴¹ In contrast, only 55.56 percent and 50 percent of the studies using relaxation and hypnosis, respectively, reported efficacy, highlighting potential but underutilized opportunities for these approaches in managing AP. The limited effectiveness might be due to the current VR experiences for relaxation and hypnosis lacking the necessary engagement, immersion, and customization, as many of these studies relied on commercially available content. To improve outcomes, future research must focus on developing and evaluating VR experiences specifically designed to enhance relaxation and hypnosis for AP management.

Notably, effectiveness was most pronounced in studies where the VR content used was specifically designed for the purpose of the study, with an efficacy rate of 73.33 percent. This was followed by commercially available VR designed for general use or entertainment, which showed 69.69 percent effectiveness. The least effective were studies wherein commercially available VR was specifically intended for pain management (57.57% effectiveness). This suggests that tailored VR content developed with a focus on a research study’s objectives might offer better outcomes than generic or even purpose-built pain management VR, highlighting the importance of customized, purpose-driven VR solutions to achieve the best pain management results.

Among the various categories of pain explored, VR was reported to be most effective in wound care, with 87.5 percent of studies showing positive results. This was followed by labor-related pain (83.33%) and dental pain (80%). Extensive research has been conducted in the field of VR for burn care, and some of the earliest studies associated with using VR for AP management focused on burn care, further supporting its effectiveness.^16,141,142 Similarly, there is a substantial body of literature on the usage of VR in dental settings, where procedures are relatively simple but often induce high levels of anxiety and discomfort in patients.⁹² It is important to note that limited research has been conducted for certain categories of pain, indicating the need for more studies to confirm the effectiveness of VR in such contexts. Nevertheless, these findings highlight VR’s potential in diverse pain management scenarios and the need for continued research to refine and optimize VR applications for various types of AP.

What gaps exist in the literature regarding the use of VR as a nonpharmacological tool for AP management, and how can future research address these gaps? This review reveals several significant shortcomings in the literature on VR for AP management. Despite an increased utilization of RCTs, other study design issues remain, including reliance on single-center studies, lack of standardized comparison groups, and small sample sizes recruited through convenience sampling methods. These issues, combined with an underrepresentation of older adults and a disproportionate focus on needle-related pain compared to other contexts, limit the generalizability of findings. Furthermore, the literature often lacks detailed information on VR device specifications, affecting replicability and standardization. The literature also reveals ambiguity in distinguishing between relaxation and distraction mechanisms in VR-based interventions. To address these limitations, future research should focus on diversifying populations and pain contexts, employing rigorous randomization and blinding procedures and utilizing larger sample sizes with systematic sampling methods. Detailed reporting on VR device specifications and clearer definitions of VR mechanisms are necessary as well. The present review also noted a heavy dependence on commercially available VR content, rather than content specifically tailored for AP management contexts, which might not fully address the unique needs of different patient populations. While interactive VR has been extensively studied, passive VR content, which could benefit patients with mobility restrictions, remains underexplored. Advanced VR technologies, such as eye tracking and head tracking, which could enhance user interaction and immersion, are also underutilized due to issues with precision and cost. Therefore, exploring tailored VR content, assessing the sustained effects of VR, and evaluating cost-effectiveness compared to traditional methods should be prioritized. Future research should also investigate the feasibility and adoption of VR in clinical settings, along with conducting usability studies in collaboration with VR developers and healthcare professionals to ensure comprehensive and practical advancements in VR applications for AP management. Addressing these limitations is crucial for advancing research and optimizing VR applications for AP management.

Limitations. While the present study is one of the first to comprehensively review the literature on VR as a tool for AP management, there are a few limitations that must be acknowledged. First, the search strategy was restricted to databases with free articles and the first 200 pages of Google Scholar, potentially missing seminal studies published in subscription-based journals or beyond the initial search scope. Second, the review might have misinterpreted the results. Effect sizes were not considered; instead, the review relied on frequency counts to identify the number of studies with effective and ineffective interventions. This approach lacks rigor and does not account for aspects of study designs that might affect the significance of the effectiveness, such as sample size and overall design quality (risk of bias). Additionally, the results of this review could be subjected to publication bias, as it has been demonstrated that approximately 90 percent of literature in fields such as psychiatry, psychology, and clinical medicine report positive findings,¹⁴³ which might lead to an overestimation of VR’s analgesic effects. There also might have been misinterpretations of the underlying mechanism of VR. While the studies that utilized distraction often mentioned it in their article, those utilizing other mechanisms were not reported clearly. There is also a lack of consensus on what constitutes specific mechanisms; some researchers classify relaxation as a form of distraction, while others differentiate between the two mechanisms. Third, the review did not consider secondary measures, such as adverse outcomes of VR, anxiety, and physiological parameters. Including these could have identified more objective measures rather than focusing solely on subjective self-reports, though this was outside the scope of the review. Finally, in some studies, VR was used as an adjunct to conventional pharmacological or nonpharmacological treatments, making it difficult to establish the extent of the therapeutic effects attributable specifically to VR.

CONCLUSION

Clinical implications. The present review highlights VR’s considerable potential as an effective nonpharmacological tool for managing AP across diverse contexts. Given the high effectiveness rates, particularly for needle-related pain, wound care, dental pain, and labor-related pain, VR might be a valuable tool in reducing the reliance on pharmacological pain relief methods. The near-equal distribution of studies on pediatric and adult populations suggests VR’s versatility, though the underrepresentation of older adults highlights a need for further research in this demographic, who might particularly benefit from VR interventions. However, it is important to note that older adults tend to have considerable visual and hearing impairments that might affect the utilization of VR technology. The higher efficacy rates of tailored VR content emphasize the importance of developing customized VR experiences that address specific patient needs and contexts. Furthermore, the preference for mobile and standalone VR headsets indicates that there may be a necessity for a practical solution that balances affordability, accessibility, and user experience in clinical settings. The review’s findings on the effectiveness of distraction as a primary mechanism for pain relief suggest that clinicians and VR developers should be mindful of designing and selecting appropriate VR content based on individual patient needs. Addressing gaps in VR research, such as the need for more diverse pain context studies, larger sample sizes, and detailed device specifications, is also crucial for advancing the field. Therefore, while VR implementation provides benefits, such as reduced reliance on pharmacological interventions and enhanced patient comfort, it is important to consider potential challenges, such as device maintenance, individualization of VR experiences for patients, affordability of the device for individuals from different socioeconomic backgrounds, and the potential side effects (eg, eye strain, cybersickness, headaches, and nausea), especially in children.

APPENDIX

To access the appendix, please visit https://innovationscns.com/wp-content/uploads/Gopalan_Appendix.docx.