Anxiolytic effect of virtual reality headset in upper extremity surgery: a prospective randomized trial

Abstract

Background

This study investigated whether virtual reality (VR) headsets reduce anxiety in patients undergoing upper extremity orthopedic surgery with regional anesthesia. The postoperative State-Trait Anxiety Inventory (STAI)-1 score was defined as the primary outcome. Secondary outcomes included pre–postoperative change in STAI-1, recovery quality, hemodynamics, sedation requirements, postoperative pain, analgesic use, and satisfaction.

Methods

In this single-center, prospective, randomized, controlled, single-blind study, patients aged ≥ 18 years, ASA status I–III, Turkish-literate, and scheduled for elective upper extremity surgery under peripheral nerve block were enrolled. Preoperative demographic data were collected, and anxiety and recovery were assessed using the STAI and Quality of Recovery-15 (QoR-15) questionnaires. After baseline assessments, patients were randomized to either the VR group or control group. The VR group received a VR headset intervention preoperatively, during brachial plexus block, and throughout the intraoperative period, while the control group received standard care without VR. Postoperative pain, anxiety, recovery quality, and patient and surgeon satisfaction were recorded.

Results

Seventy-nine patients were included. No significant differences were found between groups in demographic data, education level, case type, or surgery duration. Preoperative STAI-1 and STAI-2 scores were similar (p > 0.05). Postoperatively, VR group showed significantly lower STAI-1 scores and greater reductions in STAI compared to control group (p < 0.05). Intraoperative anxiety was also significantly lower in VR Group. No significant differences were observed between groups for NRS pain scores, QoR-15 scores, hemodynamic variables, or satisfaction levels.

Conclusions

Our findings indicate that VR videos used from the preoperative period to the end of surgery are associated with reduced perioperative anxiety. However, this anxiety reduction did not translate to improvements in pain, haemodynamic stability, recovery quality, and satisfaction.

Trial registration

ClinicalTrials.gov, TRN: NCT06244654, Registration date:2024-01-19.

Background

Preoperative anxiety affects 60–80% of surgical patients [1, 2]. This condition has been associated with increased postoperative pain, greater analgesic requirements, and higher rates of morbidity and mortality [3]. In recent years, advances in anesthesiology have broadened its focus beyond morbidity, mortality, and surgical outcomes to include quality of care, patient comfort, and overall satisfaction [4]. Pharmacological methods, such as benzodiazepines, propofol, or opioids, have traditionally been favored for sedation and anxiolysis during regional anesthesia [4]. However, these agents carry potential risks including over-sedation, hypotension, airway obstruction, apnea, and other perioperative complications [5]. As a result, non-pharmacological interventions like aromatherapy, breathing exercises, meditation, yoga, autogenic training, and guided imagery, alongside paramedical approaches such as music therapy, video distraction and virtual reality headset, have been increasingly utilized to reduce anxiety [6, 7].

Virtual Reality (VR), an advanced human-computer interface, immerses users in simulated real environments. Within these immersive settings, individuals can navigate, change perspectives, and interact with virtual objects [8]. This sense of presence modulates brain areas such as the anterior cingulate cortex, insula, and amygdala-areas critically involved in attention and emotional processing of pain [9]. VR has been shown to effectively reduce pain and anxiety across various medical contexts, including pediatric procedures, burn rehabilitation, and obstetric interventions. Functional magnetic resonance imaging (fMRI) studies further corroborate its analgesic effects [4]. Prior work suggests VR in regional anesthesia (RA) for surgery may decrease anxiety and sedation requirements [6, 10]. Yet, VR’s effect on anxiety and recovery quality in orthopedic upper limb surgery under regional anesthesia is still poorly understood.

Studies investigating the effect of VR on reducing anxiety during peripheral RA procedures are limited. Additionally, to the best of our knowledge, this is the first study to evaluate the minimal clinically important difference (MCID) of VR on intraoperative and postoperative anxiety. In the current study, it was hypothesized that VR intervention during awake regional anesthesia for upper extremity orthopedic surgery could reduce postoperative anxiety and improve the overall quality of recovery compared with controls. The postoperative State-Trait Anxiety Inventory (STAI)-I score was defined as the primary outcome. Secondary outcomes included the pre- to postoperative change in STAI-I, Quality of Recovery-15 (QoR-15) scores, intraoperative hemodynamics, sedative requirements, postoperative pain intensity, analgesic consumption, and patient satisfaction.

Methods

Trial design

This prospective, randomized, controlled, single-blind (assessor-blinded) study was conducted at a single center and approved by the Clinical Research Ethics Committee of the University of Health Sciences Ankara City Hospital (approval number E2-23-4787) on August 23, 2023. This trial was prospectively registered on ClinicalTrials.gov (NCT06244654) on January 19, 2024, and the first participant was enrolled on January 25, 2024. Written informed consent was obtained from all participants prior to inclusion. Data collection was carried out between January 25 and June 30, 2024.

Patient selection and randomization

Patients were eligible for inclusion if they voluntarily agreed to participate, were aged 18 years or older, scheduled for elective upper extremity surgery in the supine position under peripheral nerve block, and able to speak, read, and write Turkish. Exclusion criteria included the presence of an active infection or open wound on the face or eyes; a history of seizures (epileptic or otherwise); the presence of a pacemaker or other implanted medical device; migraine; droplet or airborne infectious disease; unsuitability for the procedure as determined by the surgeon; a history of psychosis or claustrophobia; visual or hearing impairment; and unwillingness to participate or wear VR glasses.

Participants were randomly assigned in a 1:1 ratio to either the VR intervention group or the standard care control group. Randomization was performed using a computer-generated random sequence, and group allocation was concealed in sequentially numbered, opaque, sealed envelopes that were opened only after enrollment.

Equipment

In VR group, patients were equipped with Oculus Quest 2 VR headsets and Sony MDRZX110APB wired headphones to enhance auditory immersion and minimize ambient operating room noise. In accordance with hygiene protocols, a disposable VR headset sanitary cover was used for each patient and discarded after procedure. The immersive VR environment featured nature-themed videos, including forest walks, aerial and landscape scenes of snow-covered environments, and tropical beaches. The total duration of the combined videos was 1 h, 46 min, and 51 s, compiled from two separate recordings. For surgeries exceeding this duration, the videos were replayed as needed (Fig. 1). The accompanying audio included calming nature sounds such as wind, birdsong, and ocean waves. Patients were instructed to wear the VR headset continuously throughout the surgical procedure.

Fig. 1.

Examples of VR environment A: Tropical beach B: Nature and lake C: Mountain landscape D: Snow-covered forest

Preoperative period

Patient data, including age, gender, height, weight, educational status, occupation, marital status, comorbidities, and a history of elective or emergency surgery were recorded. We administered the STAI, specifically the STAI-1 and STAI-2 questionnaires, to assess preoperative state anxiety, and the QoR-15 questionnaire, to assess post-surgical recovery, further supplemented the study data. The STAI-2 questionnaire was administered preoperatively, solely for homogeneity assessment. In both groups, 0.02 mg/kg of midazolam was administered intravenously prior to peripheral nerve block in the preoperative unit. Patients in VR group were given VR glasses and headphones.

In the preoperative unit, ECG, non-invasive blood pressure (mmHg), heart rate (beats/min), and peripheral oxygen saturation (SpO2) (%) were monitored via pulse oximetry. A brachial plexus block (infraclavicular or axillary) was performed by the same anesthesiologist, tailored to the surgery type and position, for all patients undergoing upper extremity surgery (elbow and below) in the supine position. Patients remained in the supine position during follow-up.

The peripheral nerve block was administered using a FUJIFILM SONOSITE M-TURBO ultrasonography device, a 50 mm Vygon Echoplex + 22Gx50mm needle, and 20 mL of local anesthetic (10 mL 2% lidocaine + 10 mL 0.5% bupivacaine). Block efficacy was assessed via pinprick test and Modified Bromage scale. VR group patients with complete motor and sensory block were transferred to the operating room wearing VR headset, while control group patients were transferred in a standard way.

Intraoperative period

Routine monitoring in accordance with the American Society of Anesthesiologists (ASA) standards was performed. Hemodynamic parameters, including heart rate, non-invasive blood pressure and SpO₂, were monitored continuously and recorded at 5-minute intervals in both groups. Rescue intraoperative sedation, if clinically required, was administered with propofol in 10–20 mg incremental boluses at the anesthesiologist’s discretion in cases of patient discomfort, anxiety, or movement. The need for any rescue sedation was documented and subsequently included in the sensitivity analysis. In the VR group, the start and end times of VR exposure, any side effects (e.g., nausea, vomiting, dizziness), and surgical start and end times were recorded. Patients in the VR group remained immersed in the virtual environment throughout the procedure. A research staff member was present during the procedure to support patients; at any time, patients could report discomfort, anxiety, or a desire to discontinue VR [4]. The VR glasses and headset were removed at the completion of surgery.

Postoperative period

Patients were monitored in the postoperative recovery unit for at least one hour. At the 1-hour mark, Numeric Rating Scale (NRS) pain scores were recorded, and the operating surgeon evaluated procedural satisfaction using a structured form assessing patient cooperation, comfort, and overall procedural ease. Patients with an Aldrete score of 9 or higher were discharged to the ward with routine analgesia (1 g paracetamol, 3 times daily). Dexketoprofen was given as rescue analgesia for NRS scores of 4–10 (moderate-to-severe pain). At the 4th postoperative hour, ward visits assessed STAI-1 anxiety scores, NRS scores, and patient satisfaction using a structured form. NRS scores at the 12th and 24th postoperative hours, along with satisfaction scores and the QoR-15 recovery questionnaire, were administered and recorded. Postoperative anxiety was evaluated at 4 h, corresponding to the early recovery period when patients were fully awake and able to provide reliable self-assessment following regional anesthesia [11]. All postoperative assessments, including the STAI scores, NRS for pain, patient satisfaction, and additional analgesic requirements, were conducted in person during the standardized 24-hour postoperative hospitalization period prior to discharge. In accordance with our institutional routine protocol, all patients were observed in the hospital for a minimum of 24 h postoperatively.

Outcome measures

The primary outcome of this study was the postoperative STAI-1 score. The Spielberger’s STAI, a 40-item questionnaire that includes a state scale evaluating momentary emotional status and a trait scale assessing general emotional disposition [12]. Secondary outcomes included pre–post change in STAI-1, recovery quality, hemodynamics, sedation requirements, postoperative pain, analgesic use, and satisfaction.

Recovery quality was evaluated using the QoR-15, a patient-reported measure of postoperative recovery adapted from the QoR-40 by Myles et al. This simplified, one-page questionnaire includes 15 items assessing physical comfort, independence, emotional state, psychological support, and pain [13–15].

Postoperative pain was assessed using a NRS (0–10), at 1, 4, 12, and 24 h after surgery, where 0 indicated no pain and 10 the most severe pain. Scores of 1–3 were considered mild, 4–6 moderate, and 7–10 severe pain. This widely used, accessible tool is standard in clinical practice [16, 17].

A set of structured questions based on a 0–10 NRS was used to assess satisfaction and perioperative anxiety. Patients rated their satisfaction with regional anesthesia, preoperative anxiety, intraoperative anxiety, and overall satisfaction at 24 h, where 0 represented “not at all” and 10 represented “extremely high. Similarly, surgeons provided 0–10 NRS ratings to evaluate patient compliance, comfort with VR compared to general anesthesia, and comfort with VR compared to regional anesthesia alone. This NRS-based structured evaluation has been previously used in perioperative research as a simple and reliable approach to quantify subjective perceptions of anxiety, comfort, and satisfaction.

All assessment instruments were administered in their validated Turkish versions. The STAI and QoR-15 have been psychometrically validated in Turkish populations, and the NRS was delivered verbally in Turkish [18, 19]. All evaluations were performed by an investigator who was blinded to group allocation and was not involved in intraoperative care.

Intraoperative hemodynamic parameters were recorded regularly, alongside all side effects (e.g., nausea, vomiting, dizziness, headache, hypotension, bradycardia, desaturation, apnea) and rescue sedative use.

Statistical analysis

We conducted statistical analyses using IBM SPSS Statistics 21.0 (IBM Corp., 2012, Armonk, NY) and MS Excel 2007, setting significance at p < 0.05. The power analysis was conducted using G*Power 3.1.9.7, assuming an effect size of d = 0.68 and a two-tailed α = 0.05 with 80% power. In the preliminary study (n = 20), the postoperative STAI-1 score (mean ± SD) was 22.80 ± 3.16 in the VR group and 26.10 ± 6.11 in the control group. Accordingly, using α-error = 0.05 at 80% power, the number of patients required per group was determined as 36 (total n = 72). Anticipating a 20% exclusion rate, we set the sample size at 86 (43 per group).

We assessed the normality of continuous variables graphically and with the Shapiro-Wilks test. We reported descriptive statistics as mean ± standard deviation and median (minimum–maximum). We compared STAI-1, STAI-2, SAP, DAP, HR, NRS, and QoR-15 values between VR and Control groups using the Independent Sample t-test for normally distributed parameters and the Mann-Whitney U test for non-normal parameters. We evaluated parameter changes across measurement times (preoperative, intraoperative 0 min, 60 min, end of operation, postoperative 1st, 4th, 12th, 24th hours) with repeated measures ANOVA for normal distributions and Friedman’s test for non-normal distributions, applying Bonferroni correction for pairwise comparisons.

We used the paired sample t-test to assess STAI-1 differences (preoperative vs. postoperative) and the Wilcoxon signed-rank test to evaluate QoR-15 differences (preoperative vs. postoperative). We compared categorical variables between VR and Control groups using cross-tabulations, reporting number (n), percentage (%), and chi-square (χ²) test statistics. The correlation between VR exposure time and the change in STAI-1 scores was analyzed using Spearman’s rank correlation coefficient. A sensitivity analysis was conducted by excluding patients who received rescue intraoperative sedation to confirm that the anxiolytic effect of VR was independent of sedative exposure.

We calculated the MCID for postoperative STAI-1, STAI-1 difference, and intraoperative concern using Cohen’s d (0.20 = small, 0.50 = medium, 0.80 = large effect size; Fischer, 2017). We derived Cohen’s d by dividing the mean difference between groups by the averaged standard deviation of both groups.

Results

Study population

We evaluated 100 patients for eligibility in this study and included 86, randomly assigning 43 to the VR group and 43 to the control group. After randomization, 4 patients dropped out from VR group: 2 removed the VR glasses, and 2 refused the postoperative questionnaire. In control group, 3 withdrew: 1 required general anesthesia, and 2 declined the postoperative questionnaire. (Fig. 2) We followed the study protocol fully, losing no data. Table 1 presents the patients’ demographic characteristics, VR follow-up duration, and side effect status in VR Group. Values for comorbidity, age, gender, BMI, marital status, occupation, education, anesthesia history, rescue sedatives, ASA, case, and surgical duration showed no significant differences (p > 0.05) (Table 1). Two patients in the VR group experienced mild nausea, which was successfully managed with 4 mg intravenous ondansetron, allowing them to remain in the study. Apart from these cases, no VR-related adverse effects such as dizziness, headache, hypotension, bradycardia, desaturation, or apnea were observed. The mean VR duration was 91.8 ± 47.0 min. Subsequent analysis revealed no significant differences in hemodynamic variables between groups at any time point (p > 0.05) (Fig. 3).

Fig. 2.

Consort flow diagram

Table 1.

Demographic characteristics and VR-specific parameters of the study population

	All Patients (n = 79)	VR (n = 39)	Control (n = 40)	P value
	Mean ± SD Median (Min-Max)	Mean ± SD Median (Min-Max)	Mean ± SD Median (Min-Max)
Age (year)	43.5 ± 15.2	44.3 ± 14.9	42.8 ± 15.6	0.829
	44.0 (18–70)	46.0 (18–70)	42.5 (18–70)
Gender, n (%)
Male	39 (49.4)	19 (48.7)	20 (50.0)	0.909
Female	40 (50.6)	20 (51.3)	20 (50.0)
	169.0 (150–192)	169.0 (150–192)	168.5 (150–190)
BMI (kg/m2)	27.2 ± 5.0	27.5 ± 4.2	26.9 ± 5.7	0.622
	27.4 (17.7–44.3)	27.1 (19.5–34.9)	27.8 (17.7–44.3)
Comorbidities, n (%)
No	37 (46.8)	17 (43.6)	20 (50.0)	0.573
Yes	42 (53.2)	22 (56.4)	20 (50.0)
Marital Status, n (%)
Married	53 (67.1)	25 (64.1)	28 (70.0)	0.577
Single	26 (32.9)	14 (35.9)	12 (30.0)
Occupation, n (%)
Retired	9 (11.4)	5 (12.8)	4 (10.0)	0.731
Housewife	22 (27.8)	8 (20.5)	14 (35.0)
Laborer	15 (19.0)	8 (20.5)	7 (17.5)
Public Employee	15 (19.0)	8 (20.5)	7 (17.5)
Student	4 (5.1)	3 (7.7)	1 (2.5)
Teacher	1 (1.3)	0 (0.0)	1 (2.5)
Self-employed	11 (13.9)	6 (15.4)	5 (12.5)
Military personal	2 (2.5)	1 (2.6)	1 (2.5)
Educational Status, n (%)
Primary school	2 (2.5)	1 (2.6)	1 (2.5)	0.933
Middle school	5 (6.3)	2 (5.2)	3 (7.5)
High school	35 (44.3)	16 (41.0)	19 (47.5)
Vocational school	23 (29.2)	13 (33.3)	10 (25.0)
University	14 (17.7)	7 (17.9)	7 (17.5)
Anesthesia History, n (%)
No	35 (44.3)	20 (51.3)	15 (37.5)	0.328
Elective	38 (48.1)	15 (38.4)	23 (57.5)
Emergency	2 (2.5)	1 (2.6)	1 (2.5)
Both Elective and Emergency	4 (5.1)	3 (7.7)	1 (2.5)
Rescue Sedative, n (%)
Yes	8 (10.1)	3 (7.7)	5 (12.5)	0.370
No	71 (89.9)	36 (92.3)	35 (87.5)
ASA score, n (%)
I	25 (31.7)	16 (41.0)	9 (22.5)	0.066
II	52 (65.8)	23 (59.0)	29 (72.5)
III	2 (2.5)	0 (0.0)	2 (5.0)
Surgery type, n (%)
OR-IF	42 (53.2)	22 (56.4)	20 (50.0)	0.812
CTR	10 (12.6)	5 (12.8)	5 (12.5)
Other	27 (34.2)	12 (30.8)	15 (37.5)
Duration of surgery	77.5 ± 42.3	72.3 ± 42.5	82.5 ± 41.9	0.263
	75.0 (15–180)	65.0 (15–163)	85.0 (20–180)
Duration of VR exposure (min), Mean ± SD	-	91.8 ± 47.0	-	-
Nausea during VR, n (%)	-	2 (5.1)	-	-

Data are shown as mean ± SD, median (min–max), or n (%) as appropriate

VR-specific values were reported only for the VR group without comparison

OR-IF Open Reduction, internal fixation, CTR Carpal tunnel release

Fig. 3.

Distribution of hemodynamic values: Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and heart rate (HR) trends over time in the VR and control groups. Values are plotted at 5-minute intervals. Solid lines represent the VR group, and dotted lines represent the control group. Circle markers indicate SAP, squares indicate DAP, and triangles indicate HR

Anxiety and pain

Preoperative STAI-1 and STAI-2 scores were similar between the VR and control groups (STAI-1: 32.9 ± 10.7 vs. 34.7 ± 11.3, p > 0.05), indicating comparable baseline anxiety levels. Postoperative STAI-1 scores were significantly lower in the VR group than in the control group (23.8 ± 3.8 vs. 26.5 ± 6.7, p = 0.032). (Table 2) An MCID analysis yielded a threshold of 2.6 points, and the observed between-group difference exceeded this value by 102.1%. The reduction in STAI-1 from pre- to postoperative assessment was also greater in the VR group than in the control group (ΔSTAI-1: −6.5 ± 6.3 vs. − 3.2 ± 6.3, p = 0.021). The Δ value represents the within-group pre- to postoperative difference. Given an MCID of 3.2 points, the observed between-group difference of 3.3 points exceeded this threshold by 106.0%. When patients who received rescue intraoperative sedation were excluded, the reduction in STAI-1 scores remained significantly greater in the VR group compared to the control group (− 6.89 ± 6.46 vs. −3.54 ± 5.42, p = 0.021). Within the VR group, exposure time (median 90 min, range 25–185) showed a weak-to-moderate negative correlation with the change in STAI-1 scores (Spearman ρ = −0.32, p = 0.05), indicating greater anxiety reduction with longer VR use. Postoperative NRS values at 1, 4, 12, and 24 h showed no significant differences between groups (p > 0.05), nor did the use of rescue analgesia (p > 0.05). (Table 2)

Table 2.

Comparison of anxiety levels, pain scores, and rescue analgesia requirement between VR and control groups

	VR (n = 39)	Control (n = 40)
	Mean ± SD	Mean ± SD	P value
Preoperative STAI-2	32.9 ± 10.7	34.7 ± 11.3	0.517
Preoperative STAI-1	30.3 ± 7.8	29.7 ± 6.7	0.689
Postoperative STAI-1	23.8 ± 3.8	26.5 ± 6.7	0.032
Changes in STAI-1 score*	-6.5 ± 6.3	-3.2 ± 6.3	0.021
NRS Pain Score, Median (Min–Max)
Postoperative 1st hour	0.0 (0–0)	0.0 (0–4)	0.160
Postoperative 4th hour	0.0 (0–6)	0.5 (0–4)	0.087
Postoperative 12th hour	3.0 (0–10)	5.0 (0–10)	0.066
Postoperative 24th hour	2.0 (0–8)	2.0 (0–10)	0.814
Rescue Analgesia Required, n (%)	6 (15.4)	10 (25.0)	0.288

STAI scores are presented as mean ± standard deviation. Pain scores measured with the Numerical Rating Scale (NRS) are presented as median (minimum–maximum). Rescue analgesia requirement is presented as number and percentage (n, %) Statistically significant p values (p < 0.05) are highlighted in bold

*“Changes in STAI-1” represents the within-group pre- to postoperative difference; p-values refer to between-group comparisons

Recovery and satisfaction

We found no significant difference in preoperative and postoperative QoR-15 values between the VR and control groups (137.3 ± 11.9 vs. 137.4 ± 12.0, p = 0.980). However, intraoperative anxiety levels, as assessed by the 0–10 numerical rating scale, were significantly lower in the VR group than in the control group (1.0 ± 1.9 vs. 2.8 ± 3.4, p = 0.018). (Table 3) Other patient and surgeon rated parameters evaluated using the 0–10 numerical rating scales showed no significant differences between the groups. (Table 3). For intraoperative anxiety, the MCID was calculated as 1.3 points, and the observed between-group difference exceeded this threshold by 138.9%.

Table 3.

Comparison of QoR-15 scores and satisfaction parameters

	VR (n = 39)		Control (n = 40)
	Mean ± SD	Median (Min-Max)	Mean ± SD	Median (Min-Max)	P value
QoR15 Preoperative	132.7 ± 15.1	136.0 (80–150)	133.3 ± 13.9	135 (84–150)	0.926
QoR15 Postoperative	137.3 ± 11.9	141 (106–150)	137.4 ± 12.0	141 (98–150)	0.980
Satisfaction with RA	8.9 ± 1.9	9 (2–10)	8.7 ± 2.1	10 (0–10)	0.949
Preoperative Anxiety	3.3 ± 3.7	2.0 (0–10)	3.4 ± 3.4	2.5 (0–10)	0.727
Intraoperative Anxiety	1.0 ±1.9	0.0 (0–7)	2.8 ± 3.4	0.5 (0–10)	0.018
24th hour Overall satisfaction	8.9 ± 1.6	10(5–10)	8.2 ± 2.0	8 (3–10)	0.099
Patient compliance during surgery (0–10)	9.4 ± 1.1	10 (6–10)	9.0 ± 2.0	10 (1–10)	0.391
Surgeon comfort: VR vs. General Anesthesia (0–10)	9.0 ± 1.5	10(5–10)	8.6 ± 1.8	10 (4–10)	0.370
Surgeon comfort: VR vs. RA Alone (0–10)	9.3 ± 1.0	10 (7–10)	9.1 ± 1.1	10 (6–10)	0.458

Data are presented as mean ± standard deviation and median (min–max) Statistically significant p values (p < 0.05) are highlighted in bold

QoR-15  Quality of Recovery-15, RA  Regional Anesthesia, NRS  Numerical Rating Scale, VR  Virtual Reality

Discussion

Previous studies have demonstrated the effectiveness of distraction techniques in reducing anxiety and sedation requirements in patients undergoing regional anesthesia, primarily by attenuating intraoperative anxiety levels. In our study, we evaluated the impact of immersive virtual reality on perioperative anxiety in patients undergoing upper extremity surgery under peripheral nerve block in the supine position. Consistent with prior findings, we observed a significant reduction in intraoperative anxiety levels in the VR group compared with the control group. However, no significant differences were observed between the groups in terms of pain scores. Likewise, while intraoperative anxiety was positively impacted by VR, there were no significant differences between groups in postoperative QoR-15 scores or in most domains of the patient and surgeon satisfaction questionnaires.

Researchers have identified multiple factors causing perioperative anxiety, including relocation, disrupted routines, physical limitations, and insufficient information about anesthesia and surgery. Patients awaiting peripheral nerve block surgery particularly worry about block efficacy and potential pain [20]. High anxiety correlates with postoperative complications, infections, insomnia, delayed healing, and prolonged discharge [9]. Distraction methods like VR have recently proven effective in reducing anxiety during burn treatment and colonoscopy [6]. Alaterre et al. demonstrated VR’s success in lowering anxiety in upper extremity surgery under peripheral nerve block [9]. Separately, Akelma et al. found that patients’ favorite music significantly reduced postoperative anxiety [1]. In our study, postoperative STAI-1 scores were significantly lower in the VR group compared to the control group, with a greater reduction also observed in the STAI-1 change scores. Notably, a trend toward greater anxiety reduction was observed with longer VR exposure, suggesting a potential dose–response relationship that should be explored in larger samples. These findings indicate statistically significant improvements in postoperative anxiety with the use of VR. Moreover, the clinical relevance of this reduction was supported by an MCID analysis, which identified a threshold of 2.6; the observed group difference exceeded this value by 102.1%, suggesting that the reduction in postoperative anxiety may be clinically meaningful.

In our study, all patients received a standardized low pre-block dose of midazolam (0.02 mg/kg IV) to ensure baseline comfort, and rescue intraoperative propofol sedation was administered only when clinically indicated by the anesthesiologist— in cases of patient discomfort, anxiety, or involuntary movement. This approach maintained both safety and uniformity, with rescue sedation required in only a small proportion of patients (3 in the VR group and 5 in the control group). Although such mild pharmacological anxiolysis could have partially attenuated the measurable magnitude of VR’s effect, the VR group still exhibited a significantly greater reduction in postoperative anxiety compared to controls, indicating a robust anxiolytic benefit. Consistent with previous findings, Carella et al. reported that VR-assisted hypnosis during total knee arthroplasty under spinal anesthesia significantly reduced intraoperative midazolam requirements without altering recovery quality. In contrast, our study involved upper extremity procedures, which are typically shorter and less stimulating than knee arthroplasty, likely contributing to the overall lower need for sedative supplementation [21]. Despite this, VR still provided a meaningful anxiolytic benefit, suggesting that its effect was independent of pharmacological support. Future studies directly comparing VR with sedative agents under standardized conditions may further clarify its independent anxiolytic efficacy.

Research shows that anxiety and stress heighten pain perception and sensitivity by influencing brain regions like the amygdala, hippocampus, and prefrontal cortex. Distraction techniques, such as VR, modulate pain perception by shifting attention away from pain [22]. We found no significant difference in NRS pain scores between the VR and Control groups (p > 0.05). Although the VR group exhibited numerically lower postoperative NRS scores, the differences did not reach statistical significance. A possible explanation may lie in the nature of upper extremity surgeries under peripheral nerve block, where immediate postoperative pain is already well-managed. The profound analgesic effect of the block likely created a floor effect, reducing the capacity of adjunctive methods like VR to demonstrate further analgesic benefit. Additionally, the timing of VR exposure—limited to the intraoperative period—may not have been sufficient to impact pain scores hours later. Prior studies showing analgesic benefits from VR often involved painful or anxiety-inducing procedures with continuous VR exposure or interactive content. For instance, in burn patients, VR has typically been applied during the painful procedures themselves, providing real-time distraction, which may have contributed to its analgesic effect [23, 24]. Similarly, we observed no significant difference in rescue analgesic use. Smith et al.’s meta-analysis reported that VR reduced acute pain in 67% of inpatient studies [25], while Walker et al. found VR headset ineffective for pain during cystoscopy [26]. Unlike similar studies where VR lowered pain, our results differed. We hypothesize that the lack of significant analgesic effect in our study may be attributed to low baseline pain scores and the limited scope of VR application. Future prospective studies that prioritize NRS scores as a primary outcome and incorporate more interactive VR protocols, longer exposure durations, or postoperative implementation may yield clearer evidence of analgesic benefit.

Quality of recovery is a recognized clinical and research outcome measure. Recovery quality, a key clinical metric, includes physiological changes, adverse events, and emotional state [27]. In this study, we assessed recovery quality with the QoR-15 and found no significant differences between the VR and Control groups in preoperative and postoperative values (p > 0.05). In our study, all patients underwent minor upper extremity surgeries under regional anesthesia and were discharged after an uneventful recovery, with minimal disruption to daily functioning. This rapid return to baseline likely limited the sensitivity of QoR-15 in detecting differences. Moreover, QoR-15 encompasses multiple dimensions such as physical comfort, psychological support, physical independence, and emotional state [28]. While VR may positively influence the emotional aspects—particularly anxiety—it is unlikely to impact other domains such as nausea, fatigue, or mobility, especially when applied only during the intraoperative period. In this context, a ceiling effect may have occurred, in which patients in both groups already achieved near-maximal QoR-15 scores. Similarly, Huang et al. reported that VR headset did not affect recovery quality in orthopedic surgery patients under spinal anesthesia [29], suggesting VR does not directly enhance recovery. A more meaningful effect might emerge in patients undergoing major or painful surgeries with prolonged recovery periods, where emotional distress and physical limitations are more prominent. This may explain the lack of difference in quality of recovery between the two groups in our study.

Patient satisfaction, a vital perioperative outcome, reflects care quality. Poor experiences can increase the quality of patients’ postoperative recovery and their fear of pain [30]. We evaluated patient and surgeon satisfaction using structured 0–10 numerical rating scales at intraoperative and 24-hour postoperative time points, and found no significant differences between the groups. While this finding may initially appear to contradict the observed anxiolytic benefit of VR, it underscores the multifactorial nature of patient satisfaction. Satisfaction encompasses expectations, communication, staff behavior, and physical comfort—areas not directly targeted by a passive VR intervention. Moreover, overall satisfaction scores were already high in both groups, which may have limited the ability to detect additional improvements attributable to VR. This indicates VR reduces anxiety effectively but may not boost satisfaction. However, Tharion et al. found higher satisfaction scores in patients using a mobile phone-based head-mounted screen during arthroscopic knee surgery under spinal anesthesia [4]. In our study, the consistently high satisfaction scores in both groups may also be explained by the minor nature of the hand surgeries and the short hospitalization period, which likely contributed to overall comfort and positive recovery perception. These findings underscore the need for further research to pinpoint VR’s benefits and optimize its use.

Preoperative and intraoperative anxiety levels were assessed by asking participants to rate their anxiety on a 0–10 numerical scale. Comparing the groups, we found significantly lower intraoperative anxiety scores in the VR group than in the control group (p = 0.018), supporting our hypothesis that VR effectively reduces anxiety, as confirmed by STAI questionnaire results.

Although we did not conduct a formal cost-effectiveness analysis, the VR equipment used—consisting of an off-the-shelf headset and standard audio system—represents a low-cost, reusable setup. Only disposable hygienic pads were replaced between patients, with negligible recurring cost. Considering this, VR may offer a cost-effective, easily implementable adjunct to enhance perioperative patient experience once initial acquisition costs are met.

This study has several limitations. First, a single standardized VR video was used for all participants, without accounting for individual sociocultural differences; the lack of interactivity or personalization may have limited engagement and attenuated the intervention’s effect on outcomes such as satisfaction and recovery. Future VR interventions could be improved through adaptive or preference-based designs that allow patients to select calming or culturally familiar environments and adjust visual and auditory elements according to personal comfort. Second, the inclusion of more complex surgical procedures and a larger sample size in future studies may yield broader insights into VR’s role in perioperative and postoperative recovery. Moreover, this was a single-centre study in patients undergoing upper extremity surgery under regional anaesthesia, which may limit the generalisability of our findings to other settings and surgical populations. In addition, our study was not powered to perform responder–non-responder subgroup analyses to explore potential predictors of VR benefit. Furthermore, anxiety and pain were assessed using self-report scales, which are inherently subject to reporting and response bias. Finally, extending VR use into the postoperative period and evaluating longer-term outcomes—such as anxiety recurrence, sleep quality, and functional recovery—could provide a more comprehensive understanding of its therapeutic potential.

Conclusions

With advancing technology, VR headsets are increasingly being integrated into clinical practice. In upper extremity surgeries performed under peripheral regional anesthesia, pharmacological sedatives are commonly used to manage perioperative anxiety. In this randomized trial, we evaluated VR as a non-pharmacological adjunct to regional anesthesia. Our findings indicate that VR use was associated with greater reductions in pre- to postoperative and intraoperative anxiety compared with standard care, with between-group differences exceeding prespecified MCID thresholds. Although no statistically significant differences were observed in recovery quality, pain intensity, or patient satisfaction, VR offers a pharmacology-free strategy for anxiety management that may be particularly attractive in settings where minimizing sedative exposure is desirable. These results support VR as a promising adjunct in perioperative care, but confirmation in larger, multicentre studies and more diverse surgical populations is warranted.

Abbreviations

ASA

American Society of Anesthesiologists

DBP

Diastolic Blood Pressure

fMRI

Functional magnetic resonance imaging

HR

Heart Rate

MAP

Mean Arterial Pressure

MCID

Minimum clinically important difference

PACU

Post-Anesthesia Care Unit

RA

Regional Anesthesia

SBP

Systolic Blood Pressure

SpO₂

Peripheral Oxygen Saturation

STAI

State-Trait Anxiety Inventory

QoR-15

Quality of Recovery-15

VR

Virtual Reality

Authors’ contributions

Surgical and Medical Practices: B.N., Concept: B.N., F.K.A., Design: B.N., F.K.A., Data Collection or Processing: M.K, Analysis or Interpretation: B.N., F.K.A., Literature Search: M.K., B.N., Writing: B.N., M.K., F.K.A.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This randomized controlled trial was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Clinical Research Ethics Committee of Health Sciences University Ankara Bilkent City Hospital (approval number: E2-23-4787, Chair: Prof. Dr. F.E. Canpolat) on August 23, 2023. Written informed consent was obtained from all participants prior to enrollment. The study was designed and reported in accordance with the CONSORT (Consolidated Standards of Reporting Trials) guidelines.

Consent for publication

Not applicable. The study does not include any individual person’s data in any form (including images, videos, or personal identifiers). The Ethics Committee waived the requirement for individual consent for publication.

Competing interests

The authors declare no competing interests.