A Systematic Review of Virtual Reality Therapeutics for Acute Pain Management



      The purpose of this systematic review is to examine the delivery and clinical efficacy of virtual reality (VR) therapeutics for acute pain management in adults and identify practical considerations of VR deployment, as well as current gaps in the literature.


      A systematic review.

      Data sources

      A search of PubMed, CINAHL, PsychINFO, Embase, Compendex, and Inspec was completed using Medical Subject Headings (MeSH) and keyword search terms related to acute pain and VR.

      Review/Analysis methods

      A systematic review of all pertinent articles published between January 1, 2000, and August 1, 2020, was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines.


      Twenty-three articles met final inclusion criteria and were included in this review. Studies utilized VR in a variety of settings for wound care, procedure-induced pain, physical or occupational therapy, dental treatment or generalized acute pain. A likely mechanism by which VR promoted analgesia in these studies is distraction. Of the reviewed studies, 19 (83%) reported decreases in pain intensity while using VR compared with no VR use or with a non-VR group.


      This systematic review found VR to be an effective tool for acute pain management. Findings from this review also underscore the importance of addressing the patient's sense of presence and levels of immersion, interaction, and interest when deploying VR. Future VR studies should consider incorporation of anxiety, presence, and VR side effect measures in addition to acute pain metrics.


      3D (Three-Dimensional), AP (Acute Pain), BSARS (Burn-Specific Anxiety Rating Scale), DVD (Digital Video Disk), GRS (Graphic Rating Scale), FOV (Field of View), NRS (Numeric Rating Scale), MeSH (Medical Subject Headings), PC (Personal Computer), PCA (Patient Controlled Analgesia), PICO (Patient, Intervention, Comparison, Outcomes), PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses), PROMIS (Patient-Reported Outcome Management System), SF-MPQ (Short-Form McGill Pain Questionnaire), SOC (Standard of Care), VAS (Visual Analog Scale), VR (Virtual Reality)
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        • Alho H.
        • Dematteis M.
        • Lembo D.
        • Maremmani I.
        • Roncero C.
        • Somaini L.
        Opioid-related deaths in Europe: Strategies for a comprehensive approach to address a major public health concern.
        International Journal of Drug Policy. 2020; 76102616
        • Alshatrat S.M.
        • Alotaibi R.
        • Sirois M.
        • Malkawi Z.
        The use of immersive virtual reality for pain control during periodontal scaling and root planing procedures in dental hygiene clinic.
        International Journal of Dental Hygiene. 2019; 17: 71-76
        • Angell M.
        The quality of mercy.
        New England Journal of Medicine. 1982; 306: 98-99
        • Basak T.
        • Duman S.
        • Demirtas A.
        Distraction-based relief of pain associated with peripheral intravenous catheterisation in adults: A randomised controlled trial.
        Journal of Clinical Nursing. 2020; 29: 770-777
        • Benyamin R.
        • Trescot A.M.
        • Datta S.
        • Buenaventura R.
        • Adlaka R.
        • Sehgal N.
        • Vallejo R.
        Opioid complications and side effects.
        Pain Physician. 2008; 11: S105-S120
        • Boylan P.
        • Kirwan G.H.
        • Rooney B.
        Self-reported discomfort when using commercially targeted virtual reality equipment in discomfort distraction.
        Virtual Reality. 2018; 22: 309-314
        • Brady R.R.W.
        • Chitnis S.
        • Stewart R.W.
        • Graham C.
        • Yalamarthi S.
        • Morris K.
        NHS connecting for health: Healthcare professionals, mobile technology, and infection control.
        Telemedicine Journal and E-Health. 2012; 18: 289-291
        • Brennan F.
        • Carr D.B.
        • Cousins M.
        Pain management: A fundamental human right.
        Anesthesia & Analgesia. 2007; 105: 205-221
        • Brummett C.M.
        • Waljee J.F.
        • Goesling J.
        • Moser S.
        • Lin P.
        • Englesbe M.J.
        • Bohnert A.S.B.
        • Kheterpal S.
        • Nallamothu B.K.
        New persistent opioid use after minor and major surgical procedures in US adults.
        JAMA Surgery. 2017; 152 (-e170504)e170504
        • Carrougher G.J.
        • Hoffman H.G.
        • Nakamura D.
        • Lezotte D.
        • Soltani M.
        • Leahy L.
        • Engrav L.H.
        • Patterson D.R.
        The effect of virtual reality on pain and range of motion in adults with burn injuries.
        Journal of Burn Care & Research. 2009; 30: 785-791
        • Chan E.
        • Foster S.
        • Sambell R.
        • Leong P.
        Clinical efficacy of virtual reality for acute procedural pain management: A systematic review and meta-analysis.
        PloS One. 2018; 13e0200987
        • Chou R.
        • Gordon D.B.
        • de Leon-Casasola O.A.
        • Rosenberg J.M.
        • Bickler S.
        • Brennan T.
        • Carter T.
        • Cassidy C.L.
        • Chittenden E.H.
        • Degenhardt E.
        • Griffith S.
        • Manworren R.
        • McCarberg B.
        • Montgomery R.
        • Murphy J.
        • Perkal M.F.
        • Suresh S.
        • Sluka K.
        • Strassels S.
        • Wu C.L.
        Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council.
        Journal of Pain. 2016; 17: 131-157
        • Cobb S.V.G.
        • Nichols S.
        • Ramsey A.
        • Wilson J.R.
        Virtual Reality-Induced Symptoms and Effects (VRISE).
        Presence: Teleoperators and Virtual Environments. 1999; 8: 169-186
        • Cohen A.M.
        • Hersh W.R.
        • Peterson K.
        • Yen P.Y.
        Reducing workload in systematic review preparation using automated citation classification.
        Journal of the American Medical Informatics Association. 2006; 13: 206-219
        • Cowen R.
        • Stasiowska M.K.
        • Laycock H.
        • Bantel C.
        Assessing pain objectively: The use of physiological markers.
        Anaesthesia. 2015; 70: 828-847
        • Czub M.
        • Piskorz J.
        Body movement reduces pain intensity in virtual realitybased analgesia.
        International Journal of Human-Computer Interaction. 2018; 34: 1045-1051
        • Dascal J.
        • Reid M.
        • IsHak W.W.
        • Spiegel B.
        • Recacho J.
        • Rosen B.
        • Danovitch I.
        Virtual reality and medical inpatients: A systematic review of randomized, controlled trials.
        Innovations in Clinical Neuroscience. 2017; 14: 14-21
        • Ding J.
        • He Y.
        • Chen L.
        • Zhu B.
        • Cai Q.
        • Chen K.
        • Liu G.
        Virtual reality distraction decreases pain during daily dressing changes following haemorrhoid surgery.
        Journal of International Medical Research. 2019; 47: 4380-4388
        • Fedorowicz Z.
        • Nasser M.
        • Sequeira-Byron P.
        • de Souza R.F.
        • Carter B.
        • Heft M.
        Irrigants for non-surgical root canal treatment in mature permanent teeth.
        Cochrane Database of Systematic Reviews. 2012; CD008948
        • Ford C.G.
        • Manegold E.M.
        • Randall C.L.
        • Aballay A.M.
        • Duncan C.L.
        Assessing the feasibility of implementing low-cost virtual reality therapy during routine burn care.
        Burns. 2018; 44: 886-895
        • Furman E.
        • Jasinevicius T.R.
        • Bissada N.F.
        • Victoroff K.Z.
        • Skillicorn R.
        • Buchner M.
        Virtual reality distraction for pain control during periodontal scaling and root planing procedures.
        Journal of the American Dental Association. 2009; 140: 1508-1516
        • Glennon C.
        • McElroy S.F.
        • Connelly L.M.
        • Mische Lawson L.
        • Bretches A.M.
        • Gard A.R.
        • Newcomer L.R.
        Use of virtual reality to distract from pain and anxiety.
        Oncology Nursing Forum. 2018; 45: 545-552
        • Gold J.I.
        • Belmont K.A.
        • Thomas D.A.
        The neurobiology of virtual reality pain attenuation.
        CyberPsychology & Behavior. 2007; 10: 536-544
        • Gomes T.
        • Tadrous M.
        • Mamdani M.M.
        • Paterson J.M.
        • Juurlink D.N.
        The burden of opioid-related mortality in the United States.
        JAMA Network Open. 2018; 1e180217
        • Guo C.
        • Deng H.
        • Yang J.
        Effect of virtual reality distraction on pain among patients with hand injury undergoing dressing change.
        Journal of Clinical Nursing. 2015; 24: 115-120
        • Gutierrez-Maldonado J.
        • Gutierrez-Martinez O.
        • Cabas-Hoyos K.
        Interactive and passive virtual reality distraction: Effects on presence and pain intensity.
        Annual Review of CyberTherapy and Telemedicine. 2011; 9: 54-57
        • Gutierrez-Martinez O.
        • Guiterrez-Maldonado J.
        • Cabas-Hoyos K.
        • Loreto D.
        The illusion of presence influences VR distraction: Effects on cold-pressor pain.
        Annual Review of CyberTherapy and Telemedicine. 2010; 8: 123-126
        • Gutierrez-Martínez O.
        • Gutiérrez-Maldonado J.
        • Loreto-Quijada D.
        Control over the virtual environment influences the presence and efficacy of a virtual reality intervention on pain.
        Studies in Health Technology and Informatics. 2011; 167: 111-115
        • Higgins J.P.T.
        • Altman D.G.
        • Gøtzsche P.C.
        • Jüni P.
        • Moher D.
        • Oxman A.D.
        • Savović J.
        • Schulz K.F.
        • Weeks L.
        • Sterne J.A.C.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
        • Hoffman H.G.
        • Patterson D.R.
        • Carrougher G.J.
        Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: A controlled study.
        Clinical Journal of Pain. 2000; 16: 244-250
        • Hoffman H.G.
        • Seibel E.J.
        • Richards T.L.
        • Furness T.A.I.
        • Patterson D.R.
        • Sharar S.R.
        Virtual reality helmet display quality influences the magnitude of virtual reality analgesia.
        Journal of Pain. 2006; 7: 843-850
        • Hoffman H.G.
        • Sharar S.R.
        • Coda B.
        • Everett J.J.
        • Ciol M.
        • Richards T.
        • Patterson D.R.
        Manipulating presence influences the magnitude of virtual reality analgesia.
        Pain. 2004; 111: 162-168
        • Howard M.C.
        Virtual reality interventions for personal development: A meta-analysis of hardware and software.
        Human–Computer Interaction. 2019; 34: 205-239
        • Hudson B.F.
        • Ogden J.
        • Whiteley M.S.
        Randomized controlled trial to compare the effect of simple distraction interventions on pain and anxiety experienced during conscious surgery.
        European Journal of Pain. 2015; 19: 1447-1455
        • JahaniShoorab N.
        • Ebrahimzadeh Zagami S.
        • Nahvi A.
        • Mazluom S.R.
        • Golmakani N.
        • Talebi M.
        • Pabarja F.
        The effect of virtual reality on pain in primiparity women during episiotomy repair: A randomized clinical trial.
        Iranian Journal of Medical Sciences. 2015; 40: 219-224
        • Jin C.
        • Feng Y.
        • Akbulut Y.
        • Shan Z.
        Virtual reality intervention in postoperative rehabilitation after total knee arthroplasty: A prospective and randomized controlled clinical trial.
        International Journal of Clinical and Experimental Medicine. 2018; 11: 6119-6124
        • Kahneman D.
        Attention and effort.
        American Journal of Psychology. 1973; 88: 339-340
        • Karaman D.
        • Erol F.
        • Yilmaz D.
        • Dikmen Y.
        Investigation of the effect of the virtual reality application on experimental pain severity in healthy.
        Revista da Associacao Medica Brasileira (1992). 2019; 65: 446-451
        • Konstantatos A.H.
        • Angliss M.
        • Costello V.
        • Cleland H.
        • Stafrace S.
        Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine in patients having burns dressings changes.
        Burns. 2009; 35: 491-499
        • Korving H.
        • Sterkenburg P.S.
        • Barakova E.I.
        • Feijs L.M.G.
        Physiological measures of acute and chronic pain within different subject groups: A systematic review.
        Pain Research and Management. 2020; 2020924465
        • Levac D.E.
        • Galvin J.
        When Is Virtual Reality “Therapy”?.
        Archives of Physical Medicine and Rehabilitation. 2013; 94: 795-798
        • Maani C.V.
        • Hoffman H.G.
        • Morrow M.
        • Maiers A.
        • Gaylord K.
        • McGhee L.L.
        • DeSocio P.A.
        Virtual reality pain control during burn wound debridement of combat-related burn injuries using robot-like arm mounted vr goggles.
        Journal of Trauma. 2011; 71: S125-S130
        • Mallari B.
        • Spaeth E.K.
        • Goh H.
        • Boyd B.S.
        Virtual reality as an analgesic for acute and chronic pain in adults: A systematic review and meta-analysis.
        Journal of Pain Research. 2019; 12: 2053-2085
        • Meissner W.
        • Coluzzi F.
        • Fletcher D.
        • Huygen F.
        • Morlion B.
        • Neugebauer E.
        • Pergolizzi J.
        Improving the management of post-operative acute pain: Priorities for change.
        Current Medical Research and Opinion. 2015; 31: 2131-2143
        • Melzack R.
        • Katz J.
        Pain in the 21st century: The neuromatrix and beyond.
        in: Young G. Nicholson K. Kane A.W. Psychological Knowledge in Court: PTSD, Pain, and TBI. Springer US, New York2006: 129-148
        • Melzack R.
        • Wall P.D.
        Pain mechanisms: A new theory.
        Science. 1965; 150: 971-979
        • Miller A.C.
        • Hickman L.C.
        • Lemasters G.K.
        A distraction technique for control of burn pain.
        Journal of Burn Care & Rehabilitation. 1992; 13: 576-580
        • Mitra S.
        • Carlyle D.
        • Kodumudi G.
        • Kodumudi V.
        • Vadivelu N.
        New advances in acute postoperative pain management.
        Current Pain and Headache Reports. 2018; 22: 35
        • Moher D.
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        Annals of Internal Medicine. 2009; 151 (W64): 264-269
        • Moher D.
        • Shamseer L.
        • Clarke M.
        • Ghersi D.
        • Liberati A.
        • Petticrew M.
        • Shekelle P.
        • Stewart L.A.
        • Group PRISMA-P
        Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.
        Systematic Reviews. 2015; 4: 1
        • Morris L.D.
        • Louw Q.A.
        • Crous L.C.
        Feasibility and potential effect of a low-cost virtual reality system on reducing pain and anxiety in adult burn injury patients during physiotherapy in a developing country.
        Burns. 2010; 36: 659-664
        • Mosso Vázquez J.L.
        • Lara D.M.
        • Lara J.L.M.
        • Miller I.
        • Wiederhold M.D.
        • Wiederhold B.K
        Pain distraction during ambulatory surgery: Virtual reality and mobile devices.
        Cyberpsychology, Behavior, and Social Networking. 2019; 22: 15-21
        • Ouzzani M.
        • Hammady H.
        • Fedorowicz Z.
        • Elmagarmid A.
        Rayyan—A web and mobile app for systematic reviews.
        Systematic Reviews. 2016; 5: 210
        • Pandya P.G.
        • Kim T.E.
        • Howard S.K.
        • Stary E.
        • Leng J.C.
        • Hunter O.O.
        • Mariano E.R.
        Virtual reality distraction decreases routine intravenous sedation and procedure-related pain during preoperative adductor canal catheter insertion: A retrospective study.
        Korean Journal of Anesthesiology. 2017; 70: 439-445
        • Patterson DR
        • Weichman SA
        • Jensen M
        • Sharar SR.
        Hypnosis delivered through immersive virtual reality for burn pain: A clinical case series.
        International Journal of Clinical & Experimental Hypnosis. 2006; 54: 130-142
        • Pratt R.
        • Pellowe C.
        • Loveday H.
        • Robinson N.
        • Smith G.
        • Barret S.
        Standard principles for preventing hospital-acquired infections.
        J Hosp Infect. 2001; 47: S21-S37
        • Primack B.A.
        • Carroll M.V.
        • McNamara M.
        • Klem M.L.
        • King B.
        • Rich M.
        • Chan C.W.
        • Nayak S.
        Role of video games in improving health-related outcomes: A systematic review.
        American Journal of Preventive Medicine. 2012; 42: 630-638
        • Scapin S.
        • Echevarría-Guanilo M.E.
        • Boeira Fuculo Junior P.R.
        • Gonçalves N.
        • Rocha P.K.
        • Coimbra R.
        Virtual Reality in the treatment of burn patients: A systematic review.
        Burns. 2018; 44: 1403-1416
        • Sharar S.R.
        • Alamdari A.
        • Hoffer C.
        • Hoffman H.G.
        • Jensen M.P.
        • Patterson D.R.
        Circumplex model of affect: A measure of pleasure and arousal during virtual reality distraction analgesia.
        Games for Health. 2016; 5: 197-202
        • Sikka N.
        • Shu L.
        • Ritchie B.
        • Amdur R.L.
        • Pourmand A.
        Virtual reality-assisted pain, anxiety, and anger management in the emergency department.
        Telemedicine Journal and E-Health. 2019; 25: 1207-1215
        • Slater M.
        • Wilbur S.
        A framework for immersive virtual environments (FIVE): Speculations on the role of presence in virtual environments.
        Presence: Teleoperators and Virtual Environments. 1997; 6: 603-616
        • Spiegel B.
        • Fuller G.
        • Lopez M.
        • Dupuy T.
        • Noah B.
        • Howard A.
        • Albert M.
        • Tashjian V.
        • Lam R.
        • Ahn J.
        • Dailey F.
        • Rosen B.T.
        • Vrahas M.
        • Little M.
        • Garlich J.
        • Dzubur E.
        • IsHak W.
        • Danovitch I.
        Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial.
        PLoS ONE. 2019; 14e0219115
        • Stark L.W.
        How virtual reality works: Illusions of vision in “real” and virtual environments.
        Human Vision, Visual Processing, and Digital Display VI. 1995; 2411: 277-287
        • Tanja-Dijkstra K.
        • Pahl S.
        • White M.P.
        • Auvray M.
        • Stone R.J.
        • Andrade J.
        • May J.
        • Mills I.
        • Moles D.R.
        The soothing sea: A virtual coastal walk can reduce experienced and recollected pain.
        Environment and Behavior. 2018; 50: 599-625
        • Terkelsen A.J.
        • Andersen O.K.
        • Mølgaard H.
        • Hansen J.
        • Jensen T.S.
        Mental stress inhibits pain perception and heart rate variability but not a nociceptive withdrawal reflex.
        Acta Physiologica Scandinavica. 2004; 180: 405-414
        • Tse M.M.Y.
        • Ng J.K.F.
        • Chung J.W.Y.
        Visual Stimulation as Pain Relief for Hong Kong Chinese Patients with Leg Ulcers.
        CyberPsychology & Behavior. 2003; 6: 315-320
        • Walker M.R.
        • Kallingal G.J.S.
        • Musser J.E.
        • Folen R.
        • Stetz M.C.
        • Clark J.Y.
        Treatment efficacy of virtual reality distraction in the reduction of pain and anxiety during cystoscopy.
        Military Medicine. 2014; 179: 891-896
        • Wender R.
        • Hoffman H.G.
        • Hunner H.H.
        • Seibel E.J.
        • Patterson D.R.
        • Sharar S.R.
        Interactivity influences the magnitude of virtual reality analgesia.
        Journal of Cyber Therapy and Rehabilitation. 2009; 2: 27-33
        • Wright J.L.
        • Hoffman H.G.
        • Sweet R.M.
        Virtual reality as an adjunctive pain control during transurethral microwave thermotherapy.
        Urology. 2005; 66: 1320
        • Yumurtacı O.
        A theoretical framework for the evaluation of virtual reality technologies prior to use: A biological evolutionary approach based on a modified media naturalness theory.
        Turkish Online Journal of Design, Art and Communication. 2016; 6: 181-192
        • Zschaler S.
        [Increased pain through psychological therapy?: Combination of PCA morphine therapy with virtual reality by awake dressing change: paradoxical effects].
        Schmerz (Berlin, Germany). 2010; 24: 629-630