Virtual reality as a distraction technique in pediatric patients undergoing orthopedic procedures: A systematic review and meta-analysis of randomized controlled trials

Abstract

Introduction:

Pain and anxiety are common in pediatric orthopedic procedures such as cast or pin removal, often leading to distress and physiological stress responses. Virtual reality (VR) offers immersive distraction and has shown promise in pediatric procedural care; however, evidence in orthopedic procedures remains limited. This meta-analysis aimed to evaluate the effectiveness of VR compared with standard care in reducing pain, anxiety, and heart rate in children undergoing orthopedic procedures.

Methods:

A systematic search was conducted in PubMed, Scopus, and Cochrane Library from inception to 20 October 2025 for randomized controlled trials (RCTs) comparing VR distraction and standard care in pediatric patients undergoing orthopedic procedures. Outcomes of interest included pain, anxiety, and heart rate. Statistical analysis was performed with R 4.3.1. Standardized mean differences (SMD) using the Inverse-Variance method and the random-effects method.

Results:

A total of four RCTs were included in the final meta-analysis, comprising 624 patients, of whom 315 (50%) were distracted with VR during clinical orthopedic procedures (mean age 9.84 years, mean 40% females). In the pooled analysis, VR distraction significantly reduced anxiety (SMD = −0.55, 95% confidence intervals (CI) [−0.76, −0.34]; p < 0.01; I² = 0%), pain (SMD = −0.43; 95% CI [−0.68, −0.19]; p < 0.01; I² = 44%), and heart rate (SMD = −0.34; 95% CI [−0.60, −0.07]; p = 0.01; I² = 53%).

Conclusion:

In this meta-analysis of four RCTs including 624 pediatric patients, VR distraction reduced procedural anxiety and, in pooled analyses, was associated with modest but statistically significant reductions in pain and heart rate compared with standard care during predominantly cast-related orthopedic clinic procedures. The integration of this child-friendly, nonpharmacological approach provides enhanced procedural comfort and effective anxiety management.

Introduction

Pain and anxiety are one the most common challenges encountered in pediatric orthopedic procedures during interventions such as cast removal, pin removal, and fracture reduction. ¹ These procedures, while typically short on duration, can lead to significant psychological stress, fear, and sympathetic activation in children, often leading to increased heart rate, crying, resistance to care, and long-term procedural anxiety. ² Conventional approaches for managing distress in such settings typically rely on reassurance, parental presence, or distraction through toys or videos, yet these methods are often insufficient to fully mitigate children’s fear and discomfort.^1,2 Alongside virtual reality (VR), other child-centered nonpharmacological strategies have been developed to reduce procedural distress. Hospital clown therapy is one of the most extensively studied of these approaches: randomized and controlled studies from Italy, China and Spain, as well as a recent meta-analysis, show that clown interventions can reduce children’s preoperative and procedural anxiety, pain, crying time and stress markers, and can also lower anxiety levels in parents and caregivers across a variety of surgical and medical settings.^3–7

In recent years, VR has emerged as a novel, nonpharmacological tool for procedural pain and anxiety management. VR provides immersive, multisensory distraction by engaging visual, auditory, and sometimes tactile stimuli, effectively diverting the patient’s attention away from the clinical environment.^1,2,8 The technology has demonstrated promising results across various pediatric medical procedures—including venepuncture, dental procedures, and burn changes—where reductions in pain, anxiety, and physiological stress markers have been consistently reported. ⁹ However, its application within pediatric orthopedic procedures remains relatively limited and underexplored.

Current evidence in pediatric orthopedics is fragmented and inconsistent. Individual randomized controlled trials (RCTs) have reported varying degrees of benefit of VR in reducing anxiety and pain during procedures such as cast removal or fracture reduction. ² Some studies suggest substantial reductions in emotional distress and sympathetic response (e.g., heart rate), whereas others have found only modest or nonsignificant effects.^2,9,10 Furthermore, differences in outcome assessment tools, VR devices, and procedural settings have made it challenging to draw robust conclusions regarding the true efficacy of VR in this specific clinical field. To date, no comprehensive meta-analysis has synthesized the available RCT evidence assessing the effect of VR on pain, anxiety, and physiological responses in pediatric orthopedic procedures. Therefore, this study aims to systematically review and quantitatively analyze data from RCTs comparing VR to standard care in children undergoing orthopedic procedures such as cast removal, pin removal, and fracture reduction.

By pooling available evidence, our meta-analysis aims to (1) clarify the overall effectiveness of VR in reducing anxiety, pain, and heart rate in pediatric orthopedic patients; (2) identify methodological and knowledge gaps in the literature; and (3) provide recommendations for future research aimed at optimizing VR integration into pediatric orthopedic practice. This meta-analysis contributes new insights into an emerging, child-friendly approach for during procedure comfort and anxiety management.

Methods

Eligibility criteria

This systematic review and meta-analysis followed the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement.^11,12 This meta-analysis did not require Institutional Review Board approval because it used data from previously published and publicly available articles. Restrictions were applied to only English-language, peer-reviewed articles. Gray literature was excluded. Studies that met all the following criteria were included in the meta-analysis: (1) RCTs; (2) studies with with pediatric patients (≤18 years) undergoing clinical orthopedic procedures, including cast removal, pin removal, or fracture reduction; (3) studies using VR or VR-based distraction (immersive or non-immersive systems) during the orthopedic procedure; (4) studies with a control group receiving standard of care, defined as usual clinical practice, routine care, or no distraction during the procedure; (5) studies that report at least one of the following outcomes: pain, anxiety, heart rate assessed using validated measurement tools. Studies were excluded if they didn’t meet our inclusion criteria or they were) non-RCT study designs (gray literature, conference abstracts, dissertations, case reports/series, and reviews). This systematic review and meta-analysis were registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the ID “CRD420251177282.”

Search strategy and data extraction

We systematically searched PubMed, Scopus, Web of Science and Cochrane Central from inception to 20 October 2025 with the following search strategy: ((“Child”[Mesh] OR “Infant”[Mesh] OR “Adolescent”[Mesh] OR pediatric* OR child* OR children OR adolescent* OR infant*) AND (“Orthopedic Procedures”[Mesh] OR “Orthopedics”[Mesh] OR “Fractures, Bone”[Mesh] OR “Fracture Fixation”[Mesh] OR “Casts, Surgical”[Mesh] OR “cast removal” OR “cast saw” OR “plaster removal” OR “pin removal” OR “fracture reduction”) AND (“Virtual Reality”[Mesh] OR “virtual reality” OR “virtual reality distraction” OR VR) AND (“standard care” OR “standard of care” OR “routine care” OR “usual care” OR SOC OR placebo OR control OR “control group”) AND (RCT[pt] OR controlled clinical trial[pt] OR “Randomized Controlled Trials as Topic”[Mesh] OR random* OR placebo* OR trial)). In addition, backward snowballing of references of the included studies was conducted to capture relevant studies beyond the database scope. Two authors independently extracted the data using predefined search criteria, quality assessment methods, and Rayyan software. ¹³ Any disagreements between these authors were resolved through consensus.

Endpoints and subgroup analyses

The meta-analysis included pain, anxiety, and heart rate endpoints. In addition, we conducted a subgroup analysis for each endpoint based on the risk of bias assessment and the country in which the study was conducted.

Quality assessment

The risk of bias (ROB 2) was assessed using the Cochrane Collaboration’s tool for assessing the risk of bias in randomized studies of interventions. ¹⁴ The ROB 2 tool categorizes the risk of bias as low, some concerns, or high. Two authors independently performed the assessments, resolving disagreements through consensus. Publication bias was evaluated using contour-enhanced funnel plots with the trim-and-fill method, which allows for a better interpretation of asymmetry related to statistical significance thresholds, in line with the recommendations by Nakagawa et al. ¹⁵ Additional methods, such as p-curve or p-uniform analysis, were not feasible due to the absence of reported exact p-values or test statistics in all included studies. Following the Cochrane guidelines, the Egger test was not performed because fewer than 10 studies were included in the meta-analysis. ¹¹

Statistical analysis

Standardized mean differences (SMD) with 95% confidence intervals (CI) with the Generic Inverse-Variance method were computed to compare effects for continuous endpoints using the restricted maximum-likelihood estimator random-effects method.^16,17 Heterogeneity was assessed using the I² statistic and the Cochran Q test. Two-sided p-values < 0.05 were regarded as statistically significant. Subgroup analyses were performed based on the risk of bias assessment and the country in which the study was conducted to minimize the risk of selection bias. Leave-one-out (LOO) sensitivity analyses were also conducted to assess the robustness of the findings. A Baujat plot was generated to identify studies contributing most to heterogeneity and their influence on the overall meta-analytic results. This diagnostic tool visually represents the balance between a study’s contribution to heterogeneity (x-axis) and its weight in the meta-analysis (y-axis), aiding in the interpretation of outlier or highly influential studies. Statistical analysis was performed using R software version 4.3.1 with the packages “metafor” and “meta.” ¹⁸

Results

Study selection and baseline characteristics

The search strategy yielded a total of 64 results. After removing duplicate records and unrelated articles or abstracts, the remaining 6 studies were fully reviewed to determine whether they met the inclusion and exclusion criteria (Figure 1). Four studies were included, with 624 patients.^1,2,8,9 Of these, 315 patients (50%) underwent VR during clinical orthopedic procedures. The mean age of the population was 9.84 ± Standard deviation years. The females accounted for a mean of 40%. Population characteristics are presented in Table 1.

Figure 1.

PRISMA flow diagram and study selection.

Table 1.

Baseline characteristics of the included studies.

Study	Study design	Country	No. patients	VR	SC	Age*	Female, %
Georgiadis 2025	RCT	USA	184	92	92	VR: 7.91 SC: 7.77	VR: 50 SC: 50
Desai 2024	RCT	USA	95	48	47	VR: 10.1 SC: 10.6	VR: 25 SC: 36
Poppelaars 2024	RCT	Netherlands	255	130	125	VR: 10.5 SC: 10.7	VR: 50 SC: 44
Jivraj 2020	RCT	Canada	90	45	45	VR: 10.2 SC: 10.3	VR: 33 SC: 33

^*Mean age. VR: Virtual reality; RCT: Randomized controlled trial; SC: Standard care.

Pooled analyses of all included studies

Anxiety

VR distraction significantly reduced anxiety during cast removal compared to standard care (SMD = −0.55; 95% CI [−0.76, −0.34]; p < 0.01; I² = 0%) (Figure 2). A LOO analysis was performed to test the robustness of our results. The overall effect size remained consistent across all iterations, and the result remained significant in all cases (SMD = −0.55; 95% CI [−0.76, −0.34]; p < 0.01; I² = 0%) (Figure S1). This suggests that no single study has a disproportional influence on the overall outcome. The Baujat plot identified in the study by Georgiadis et al. as potentially influential, contributing substantially to the overall heterogeneity (Figure S2). According to the GRADE assessment, the certainty of evidence for this outcome was rated as high (Supplemental Table 1).

Figure 2.

Forest plot illustrating the effect of VR distraction versus standard care on reducing anxiety during cast removal.

The pooled results show a significant reduction in anxiety for the VR group. VR: Virtual reality.

Pain

A significantly greater reduction in pain during cast removal was observed in patients distracted with VR compared to standard care (SMD = −0.43; 95% CI [−0.68, −0.19]; p < 0.01; I² = 44%) (Figure 3). A LOO analysis was performed to test the robustness of our results. The overall effect size remained consistent across all iterations, and the result remained significant in all cases (SMD = −0.43; 95% CI [−0.68, −0.19]; p < 0.01; I² = 44%) (Figure S3). This suggests that no single study has a disproportional influence on the overall outcome. The Baujat plot identified in the study by Georgiadis et al. as potentially influential, contributing substantially to the overall heterogeneity (Figure S4). According to the GRADE assessment, the certainty of evidence for this outcome was rated as moderate (Supplemental Table 1).

Figure 3.

Forest plot illustrating the effect of VR distraction versus standard care on pain reduction during cast removal.

The pooled results show a significant pain reduction for the VR group. VR: Virtual reality.

Heart rate

Patients distracted with VR significantly experienced a reduced heart rate compared to those with standard care only (SMD = −0.34; 95% CI [−0.60, −0.07]; p = 0.01; I² = 53%) (Figure 4). A LOO analysis was performed to test the robustness of our results. The overall effect size remained consistent across all iterations, and the result remained significant in all cases (SMD = −0.34; 95% CI [−0.60, −0.07]; p = 0.01; I² = 53%) (Figure S5). This suggests that no single study has a disproportional influence on the overall outcome. The Baujat plot identified the studies by Georgiadis et al. and Desai et al. as potentially influential, contributing substantially to the overall heterogeneity (Figure S6). According to the GRADE assessment, the certainty of evidence for this outcome was rated as moderate (Supplemental Table 1).

Figure 4.

Forest plot illustrating the effect of VR distraction versus standard care on reducing heart rate during cast removal.

The pooled results show a significant heart rate reduction for the VR group. VR: Virtual reality.

Subgroup analyses

Anxiety based on the ROB

No statistically significant differences between the subgroups were observed (MD −0.55; 95% CI [−0.76, −0.34]; p = 0.6078; I² = 0%; Figure S7).

Anxiety based on the country type

No statistically significant differences between the subgroups were observed (MD −0.55; 95% CI [−0.76, −0.34]; p = 0.2482; I² = 0%; Figure S8).

Pain based on the ROB

No statistically significant differences between the subgroups were observed (MD −0.43; 95% CI [−0.68, −0.19]; p = 0.0593; I² = 44%; Figure S9).

Pain based on the country type

No statistically significant differences between the subgroups were observed (MD −0.43; 95% CI [−0.68, −0.19]; p = 0.0593; I² = 44%; Figure S10).

Heart rate based on the ROB

No statistically significant differences between the subgroups were observed (MD −0.34; 95% CI [−0.60, −0.07]; p = 0.2041; I² = 53%) (Figure S11).

Heart rate based on the country type

No statistically significant differences between the subgroups were observed (MD −0.34; 95% CI [−0.60, −0.07]; p = 0.2041; I² = 53%) (Figure S12).

Quality assessment

Among the four included studies, three were assessed as having a low risk of bias, and one as having some concerns about risk of bias based on the Rob 2 tool. The detailed evaluation is presented in Figure 5. The most common sources of bias were related to bias due to deviations from intended interventions (D2), with one study judged to have some concerns in these domains. Publication bias was evaluated using contour-enhanced trim-and-fill funnel plot analyses, plotting individual study weights against point estimates. The funnel plots for the outcomes did show some asymmetry, but given the small number of included studies, visual interpretation is limited (Figures S13–S15).

Figure 5.

Rob 2 assessment summary for the included studies.

Among the four studies, three were assessed as having a low risk of bias and one as having some concerns about risk of bias. The most common source of bias was related to deviations from intended interventions (D2), where one study received a rating of “some concerns.”

Rob: Risk of bias.

Discussion

This systematic review and meta-analysis of 4 RCTs involving 624 pediatric patients provides comprehensive evidence that VR distraction significantly reduces anxiety, pain, and heart rate during orthopedic procedures such as cast removal compared with standard care. The findings underscore the potential of immersive technologies as a safe, nonpharmacological adjunct to improve patient experience in pediatric orthopedic practice.^1,2,8,9

The pooled analyses revealed that VR distraction significantly reduced procedural anxiety (SMD = −0.55; 95% CI [−0.76, −0.34]; p < 0.01; I² = 0%) and pain (SMD = −0.43; 95% CI [−0.68, −0.19]; p < 0.01; I² = 44%) compared to standard care. In addition, heart rate—a physiological marker of sympathetic activation—was significantly lower in the VR group (SMD = −0.34; 95% CI [−0.60, −0.07]; p = 0.01; I² = 53%). These consistent results across both subjective and objective outcomes confirm the efficacy of VR distraction for lowering procedural distress in children. Sensitivity and LOO analyses confirmed the robustness of the results, indicating that no single study disproportionately influenced the pooled estimates. Pain and anxiety are among the most common and distressing experiences for children undergoing orthopedic procedures. Cast or pin removal and fracture reduction often induce fear due to the associated noise, vibration, and unfamiliar sensations.^1,2,8 Traditional nonpharmacological methods—such as parental presence, storytelling, or music—can partially alleviate distress but often fail to maintain attention throughout the procedure. VR provides a unique advantage by offering immersive multisensory engagement, which effectively diverts cognitive resources away from pain perception and anxiety.^2,9 Previous systematic reviews and meta-analyses across pediatric medical and dental procedures have consistently shown that VR reduces pain and anxiety compared to standard care.^19,20 However, this is the first meta-analysis to focus specifically on orthopedic interventions, which are characterized by strong sensory stimulation and procedural discomfort. The results of this analysis expand the current evidence, demonstrating that VR remains effective even under high sensory load conditions.

The beneficial effects of VR on pain and anxiety can be explained through cognitive-attentional theories and neurophysiological mechanisms.^21–23 According to the gate control theory of pain, attention and emotion modulate the transmission of nociceptive signals at the spinal level. Immersive VR environments capture the child’s attention through visual, auditory, and sometimes kinesthetic input, thereby limiting the brain’s ability to process painful stimuli. ²¹ Neuroimaging studies have demonstrated that VR reduces activation in pain-related brain regions such as the anterior cingulate cortex, insula, and somatosensory cortex, while increasing activation in regions related to attention and emotion regulation. ²³ The significant reduction in heart rate observed in this meta-analysis supports these findings, reflecting reduced sympathetic arousal and enhanced parasympathetic tone during VR exposure. Together, these physiological and psychological mechanisms contribute to a measurable reduction in procedural distress.

The findings of this meta-analysis have several important clinical implications. First, VR represents a safe, child-friendly, and easily implementable tool that can enhance the quality of pediatric orthopedic care without the need for pharmacological interventions. It can be integrated into outpatient and emergency settings, requiring minimal setup and staff training. Second, the reduction in procedural pain and anxiety may improve patient cooperation and decrease procedural time. This can have cascading benefits, including enhanced procedural efficiency, improved staff satisfaction, and reduced resource utilization. Third, VR may reduce the need for pharmacologic sedation or analgesia, thus minimizing potential side effects, costs, and recovery time. ²⁴ Across the included trials, acceptability was generally high: approximately 90% of children reported that they would be willing to use VR again, whereas about 10% declined or were neutral, indicating high but not universal acceptability and underscoring the need to offer alternative distraction options for children who do not tolerate or prefer not to use VR.^8,9 This aligns with modern pediatric care principles emphasizing comfort, engagement, and emotional safety during clinical procedures.

Despite its potential benefits, VR is associated with several practical drawbacks that may limit its widespread implementation. First, there are direct and indirect costs related to hardware acquisition, software licensing, maintenance, and replacement of damaged equipment, which may be particularly challenging in resource-constrained settings. Second, successful integration into routine care requires training of nursing and medical staff, and when appropriate, a brief orientation of children and caregivers, to ensure correct use, troubleshooting, and minimal disruption of clinic workflow. Third, infection control considerations are critical because headsets and controllers need to be cleaned thoroughly between uses, and clinics must establish clear protocols for disinfection to minimize the risk of cross-contamination. An additional practical consideration is that many VR systems require some degree of hand use for headset adjustment or interaction with controllers. This may be less feasible during procedures on the upper extremity, particularly when the dominant arm is involved, and may be more straightforward during lower extremity procedures. In such cases, adaptations such as staff-assisted control or hands-free VR interfaces may be needed to maintain both comfort and procedural access to the limb. Finally, a small proportion of children may experience discomfort or cybersickness, or may simply dislike wearing a headset, which underscores that VR should be offered as one option within a broader menu of nonpharmacological distraction strategies rather than as a one size fits all solutions. Interestingly, Fabricant et al. ¹⁰ compared headset-based VR with simple tablet-based video distraction during in-office cast and pin removal and found no important differences in procedural pain or anxiety between groups. Together with the higher costs, implementation needs, and variable tolerance of VR, the authors concluded that routine use of VR in pediatric orthopedic outpatient practice may not be necessary. Considered alongside our findings, this suggests that VR is superior to standard care without structured distraction, but that simple low-cost distraction strategies can provide comparable benefits and should be viewed as valid alternatives rather than inferior options.

The quality of evidence for the anxiety outcome was rated as high, while pain and heart rate outcomes were rated as moderate according to the GRADE assessment. The ROBINS II evaluation indicated that three studies had a low risk of bias, and one had “some concerns,” mainly related to deviations from intended interventions. Importantly, none of the studies exhibited a high risk of bias in randomization or outcome measurement. The consistency of findings across studies, along with the absence of major publication bias indicators, supports the reliability of the evidence. Subgroup analyses by risk of bias and country type revealed no significant differences; however, all four trials were conducted in high-income Northern European or North American centers, which limits the generalizability of these findings to other health-care systems and cultural contexts. However, the small number of included studies limits the power of subgroup analyses and the ability to detect small-study effects through funnel plot inspection. This meta-analysis possesses several notable strengths. It is the first quantitative synthesis focusing specifically on the application of VR during pediatric orthopedic procedures, thereby addressing a critical knowledge gap. The use of RCTs exclusively enhanced methodological rigor, and the application of advanced statistical methods—including LOO sensitivity analysis and Baujat plots—ensured the robustness of findings. Moreover, the integration of both psychological and physiological outcomes provides a greater understanding of VR’s impact.

However, several limitations should be considered. First, the number of eligible RCTs was small, limiting the ability to explore heterogeneity sources in greater detail. Second, the sample sizes within individual studies were modest, which may affect the precision of effect estimates. Third, variations in VR systems (e.g., content type, duration, headset specifications) and in the measurement tools for pain and anxiety may introduce some heterogeneity. Fourth, blinding participants and staff is difficult in VR interventions, potentially leading to performance bias. Nonetheless, the inclusion of objective outcomes such as heart rate mitigates this concern to some extent. Fifth, because all included RCTs were performed in Northern European or North American settings, caution is warranted when extrapolating these results to low- and middle-income countries or regions with different cultural backgrounds, resource availability, or patterns of pediatric orthopedic care. Future trials conducted in more diverse health-care systems are needed to confirm the generalizability of these findings. Finally, the included studies primarily assessed short-term outcomes during or immediately after the procedure. The long-term effects of VR on behavioral conditioning, procedural memory, or future procedural anxiety remain unexplored and warrant further investigation.

Future studies should aim to recruit larger and more diverse populations to confirm these findings and strengthen the evidence. Standardization of VR protocols—including exposure duration, content type, and intensity—would enhance comparability across studies. The use of validated and uniform outcome measures is also essential for improving data synthesis accuracy. Furthermore, cost-effectiveness analyses are needed to inform health policy and support the integration of VR into pediatric clinical workflows. Exploring personalized approaches—such as tailoring VR content to age, cultural background, or emotional state—could further enhance its efficacy. Finally, combining VR with other behavioral or cognitive interventions (e.g., biofeedback, relaxation training, or interactive storytelling) could provide synergistic benefits in managing pediatric procedural pain and anxiety.

Conclusion

This meta-analysis of 624 pediatric patients indicates that VR distraction consistently reduces procedural anxiety and demonstrates modest but statistically significant pooled reductions in pain and heart rate compared with standard care, mainly in the context of cast-related orthopedic clinic procedures. Further randomized studies with larger sample sizes and standardized assessment tools are warranted to confirm and extend these findings.