The Use of Virtual Reality for

Pain Control: A Review

Nicole E. Mahrer, BA, and Jeffrey I. Gold, PhD

Corresponding author distraction, creating what investigators have termed VR

Jeffrey I. Gold, PhD analgesia [4•,5••]. Simpler, empirically supported forms
Department of Anesthesiology Critical Care Medicine, Comfort, of distraction include imagery, relaxation, and positive
Pain Management, and Palliative Care Program, Childrens Hospital
Los Angeles, 4650 Sunset Boulevard, MS #12, Los Angeles, CA
thinking [6–8]. More technology-specific distracters, such
90027-6062, USA. as TV and video games, have also been explored as means
E-mail: jgold@chla.usc.edu to reduce pain and distress associated with medical proce-
Current Pain and Headache Reports 2009, 13:100–109 dures [9]. VR distraction is unique in that it is immersive
Current Medicine Group LLC ISSN 1531-3433 and engaging, integrating many sensory experiences, and
Copyright © 2009 by Current Medicine Group LLC thus capturing a greater degree of attention. This becomes
possible through the use of interactive virtual environments
(VEs) with head-tracking systems, visually stimulating
Virtual reality (VR) is a relatively new technology scenery, and audio and tactile feedback (Table 1).
that enables individuals to immerse themselves in a VR enables users to become active participants in a
virtual world. This multisensory technology has been “virtual world.” Participants enter the virtual world
used in a variety of fields, and most recently has been through a combination of a head-mounted display (HMD),
applied clinically as a method of distraction for pain headphones with sound/music and noise reduction, and a
management during medical procedures. Investiga- joystick, rumble pad, or other device for manipulation/
tors have posited that VR creates a nonpharmacologic navigation of the VE (Fig. 1). In advanced models, head-
form of analgesia by changing the activity of the tracking systems are built into the HMD, enabling the VR
body’s intricate pain modulation system. However, system to track the motion of the user’s head and present
the efficacy of VR has not been proven and the exact the 360° illusion of being completely surrounded by the
mechanisms behind VR’s action remain unknown. virtual world. This combination of visual, auditory, and
This article presents a comprehensive review of the tactile stimuli helps immerse the user in the VE, creating
literature to date exploring the clinical and experi- a sense of presence.
mental applications of VR for pain control. The Several theories have been proposed to explain why dis-
review details specific research methodologies and traction may inhibit or decrease perception of pain. In 1965,
popular virtual environments. Limitations of the Melzack and Wall [10] proposed the Gate Control Theory.
research, recommendations for improvement of This theory posits that central nervous system activities (eg,
future studies, and clinical experiences with VR are attention, emotion, memory) play a role in sensory percep-
also discussed. tion. When pain signals travel through the body, they must
pass through “nerve gates” before the body can determine the
level of awareness. In other words, the level of attention paid
Introduction to the pain, the emotion associated with the pain, and past
Over the past two decades, the use of virtual reality (VR) experience with the pain all play a role in how that pain is
for medical and psychiatric purposes has been gaining individually interpreted. McCaul and Malott [11] expanded
attention. What initially began as a form of entertain- on this theory in 1984, describing the human being’s limited
ment has expanded its application into a variety of areas, capacity for attention. They stated that an individual must
including surgical training and treatment of psychiatric attend to a painful stimulus in order for it to be perceived as
disorders (eg, attention deficit hyperactivity disorder, painful. Therefore, if an individual is distracted, the percep-
phobias, post-traumatic stress disorder) [1–3]. In the tion of pain will be decreased. Wickens [12] proposed the
past 10 years, VR has also been introduced into medical Multiple Resources Theory, which states that resources in
settings as a means to attenuate pain perception during different sensory systems function independently. Thus, it is
painful medical procedures. In this context, VR has been better to use multisensory distractions. This lends support to
investigated and clinically applied as an advanced form of multimodal VR technology.
Table 1. Commonly used virtual environments from clinical and experimental studies
Virtual environment Description Study
Virtual reality
SpiderWorld (modified version of KitchenWorld; User controls a spider in a 3-D virtual kitchen environment. User can Hoffman et al. [14,21]
Division Ltd., San Mateo, CA) “pick up” objects, “eat” candy bars, and “touch” other spiders. User is
also able to kill the spider.
SnowWorld (www.vrpain.com) 3-D virtual canyon with snow and ice. Users aim with their gaze, and Hoffman et al. [14–16,22,28],
throw snowballs at snowmen and igloos using the spacebar or mouse Wright et al. [20], van Twillert et al. [25],
of a computer. Sharar et al. [26••]
Virtual Gorilla program [40] User takes on the persona of a gorilla and interacts with other gorillas in Gershon et al. [18,31]
the habitat. A joystick is used to maneuver through the environment.
Bush Soul (Rebecca Allen, 1997) Expansive, otherworldly planet surface in which the user can navigate Gold et al. [33]
and explore.
Street Luge (Fifth Dimension Technologies, Irvine, CA) User races down a hill while lying on a skateboard. Game is fast-paced Gold et al. [34]
with tactile feedback via a rumble pad.
Augmented reality
Hospital Harry (Australasian CRC for Interaction User operates the system by inserting plastic figures into the camera Mott et al. [27]
Design, Brisbane, Queensland, Australia) unit. This creates an animated character named “Hospital Harry.”
User can manipulate the character using the plastic figure. Auditory
narration prompts user to perform tasks with the figure.
Adapted video/computer game
Quake (Activision, Eden Prairie, MN) Video game presented via HMD. Users are on a track and use a pointer Das et al. [23]
to shoot monsters. A head-tracking system allows for interaction with
the environment.
Magic Carpet® (Electronic Arts, Redwood City, CA), CD-ROM games appropriate for patients 10–17 years old that is viewed Schneider and Workman [29]
Sherlock Holmes Mystery® (Frogwares, Dublin, using VR equipment (eg, VR HMD).
Ireland), and Seventh Guest® (Virgin Interactive,
London, England)
Escape (VIRTUAL i-O, Portland, OR) Video presented via VR glasses with earphones. Video includes 3-D Wint et al. [30]
scenes of skiing down the Swiss Alps and drag racing.
Free Dive (Breakaway Games Ltd., Hunt Valley, MD) Underwater 360°, 3-D VE presented via HMD. User scuba dives with Dahlquist et al. [38]
The Use of Virtual Reality for Pain Control: A Review

turtles and fish while searching for treasure chests. Speakers simulate
I

the sounds of breathing through scuba equipment.

3-D—three dimensional; HMD—head-mounted display; VE—virtual environment; VR—virtual reality.
Mahrer and Gold
I
101
102
I Psychiatric Management of Pain

are discussed below. Studies are organized fi rst accord-

ing to study methodology (case study, RCT) and second,
by type of medical procedure (Table 2). Additionally,
CRISP-identified studies are presented to highlight the
current trends in VR and pain management research.
The review concludes with a discussion of limitations,
future directions, and a brief description of the authors
experience with VR technology and pediatric response.

Case Studies
Hoffman et al. [14] presented the fi rst evidence support-
ing the use of VR for pain management. This case study
employed a crossover design comparing VR with a video
Figure 1. A 12-year-old boy playing Street Luge virtual reality game game (Nintendo 64) in two male adolescent patients
with head-mounted display, head tracking, and rumble pad. with burns (ages 16 and 17 years) who were experiencing
pain during their burn care. Investigators found declines
In a recent review of VR pain attenuation, Gold et al. in pain ratings comprised of pain intensity, anxiety, and
[5••] hypothesized that VR may change the activity of the time spent thinking about pain in both patients during
body’s intricate pain modulation system by acting directly the VR condition.
and indirectly on signaling pathways of the pain matrix Hoffman et al. also investigated the use of VR in
through attention, emotion, memory, and other senses two patients (ages 51 and 56 years) with dental pain [15]
(eg, touch, auditory, visual), thereby producing analgesia. and the use of a water-friendly VR system in a 40-year-
One possible modulation pathway was suggested in a study old male undergoing burn care [16]. Both studies found
conducted by Bantick et al. [13], which tested the effect decreased pain ratings in the VR condition compared
of distraction on pain perception using functional MRI with standard of care.
(fMRI). During the distraction task (an adapted Stroop In a study by Steele et al. [17], a 16 year old with cere-
task), subjective reports of pain intensity decreased, and bral palsy participated in a crossover design comparing
fMRI showed an overall decrease in activation in the pain VR with standard of care during physiotherapy. The VR
matrix and an increase in activity in the anterior cingulate distraction consisted of a game in which the user could
cortex and orbitofrontal regions of the brain. VR, arguably interact with the virtual world, aim a virtual gun, and
a more powerful distracter, could potentially utilize these shoot creatures with a hand-held trigger. The patient
or other brain regions to attenuate perception of pain. reported 41.2% lower pain scores in the VR condition
The exploration of VR use for pain control has only versus standard of care as measured by a standardized
recently begun. Studies have been conducted using the self-report pain intensity scale.
technology during a variety of medical procedures, Gershon et al. [18] examined VR to alleviate pain and
but not all studies were scientifi cally rigorous in their anxiety during port access in an 8-year-old boy diagnosed
design or methodology. A careful review of the litera- with acute lymphomatic leukemia. The study compared
ture is necessary to delineate single case studies from three treatment conditions: 1) no distraction, 2) VR dis-
randomized controlled trials (RCTs) in order to address traction via computer, and 3) VR distraction via HMD.
the validity, reliability, and generalizability of VR for Investigators computed an average of pain intensity and
meeting acute, chronic, or other pain management needs anxiety ratings reported by the patient, parent, and nurse
in children/adolescents and adults. to create a pain score for each condition. Results revealed
a lower pain score and less behavioral distress during the
VR HMD condition. The boy’s rating of his own anxiety
Method in the VR HMD condition, however, was higher than in
For the purposes of this review, literature searches of the VR computer condition. Investigators theorized that
web-based scientific databases were conducted using this increase in anxiety was the result of the boy’s inabil-
PubMed, Medline, and the Computer Retrieval of ity to see the procedure. More recent investigations have
Information on Scientific Projects (CRISP; hosted by yielded mixed results on the role of visual occlusion in the
the National Institutes of Health [NIH]) to identify effectiveness of VR.
published manuscripts and current NIH-funded studies Patterson et al. [19] used hypnosis presented via VR
examining VR for pain control. Search terms included as a means to manage pain and anxiety in a patient with
VR and/or pain, analgesia, pain management, and dis- severe burn wounds. Pain intensity and anxiety levels
traction. Case studies and RCTs with children and adults dropped 40% following the VR hypnosis intervention;
 The Use of Virtual Reality for Pain Control: A Review
I Mahrer and Gold
I 103

however, similar decreases were noted in the audio-only design to compare VR versus standard of care in eight
intervention as well. children (mean age, 6.54 years) during routine dressing
Wright et al. [20] explored the use of VR in a changes. Results showed no significant differences in
67-year-old man receiving transurethral microwave pain intensity, as measured by a standardized pain scale,
thermotherapy. The study compared standard of care to between the two conditions. Nurses, however, using a
standard of care with VR. The patient reported less pain standardized measure, observed decreases in the children’s
intensity and anxiety in the VR condition, as measured by behavioral distress during the VR intervention.
a visual analogue scale (VAS). In another study, van Twillert et al. [25] compared
the within-patient effects of VR with alternate forms
of distraction (eg, TV, music) and standard of care dur-
Randomized Control Trials ing dressing changes in 19 participants with burns (age
Burn care 8–65 years). Pain intensity was measured using a visual
A variety of VR technologies have been used to investigate analogue thermometer, an adapted version of the VAS for
VR use for the pain control during burn care. Hoffman patients with burns. Results demonstrated that the VR
et al. [21] explored the use of VR to alleviate pain dur- and alternate distraction conditions were significantly dif-
ing physical therapy in adult patients with burns. Twelve ferent from the standard of care (P < 0.01), but not from
patients (age 19–47 years), while receiving physical therapy each other. Enthusiasm for the VR game did not predict
to increase their range of motion, spent 3 minutes with its success, and younger participants were more willing
standard analgesia and 3 minutes with VR plus analgesia. to participate. Measures of anxiety were not significantly
Following each condition, patients were asked to rate their different in any of the conditions, and participants noted
pain intensity, anxiety, and time spent thinking about pain minimal simulator sickness.
on a VAS. Results showed that pain ratings were signifi- Sharar et al. [26••] published an article combining
cantly lower in the VR plus analgesia condition (P < 0.008). data from three studies. It examined the efficacy of VR in
Ten of the patients also demonstrated a greater range of reducing pain associated with postburn physical therapy in
limb motion when immersed in VR. 88 patients (age 6–65 years). Of the 88 patients, 66 (75%)
The same investigators examined the use of VR for were children between 6 and 18 years old. Standard anal-
pain control during three consecutive physical therapy gesic care was compared with VR plus standard of care
treatments in seven patients (age 9–32 years) with deep during postburn physical therapy, and pain ratings were
burns over 6% to 60% of their bodies [22]. Pain intensity taken using a graphic rating scale (GRS). Investigators
and affective pain were measured using a VAS following found significant reductions in reported pain intensity,
each treatment. A mean of these five ratings was calcu- unpleasantness, and time spent thinking about pain in the
lated to create an average pain score. Range of motion VR condition (P < 0.01). The study found no age, sex, or
was measured following each treatment. Results revealed ethnicity differences.
significant pain reduction during the fi rst three physical Mott et al. [27] tested the efficacy of augmented
therapy sessions with VR (P < 0.001) and pain reduction reality (AR), an alternate form of VR. Rather than
remained constant with repeated use. Additionally, range immersing the player into an imaginary environment,
of limb motion was greater following the VR condition in AR technology overlays images onto the physical world.
all but one of the physical therapy sessions. Although AR does not employ an HMD, it contains simi-
The first RCT examining VR use exclusively for chil- lar multimodal characteristics of sight, touch, and sound.
dren with burns examined seven children (age 5–18 years) The study examined 42 children (age 3–14 years), and
[23]. In this within-subjects design, children switched compared AR with cognitive behavioral therapy (CBT)
between treatments with an analgesic and analgesic treat- techniques (eg, distraction, breathing, positive reinforce-
ment with VR during wound debridement. Results showed ment) during dressing changes. Both conditions were
that VR coupled with an analgesic was significantly coupled with an analgesia. Pain scores, measured using
more effective in reducing pain according to a validated age-appropriate standardized pain intensity scales, were
self-report pain intensity scale (P < 0.01). Three children significantly lower in the AR group compared with the
(43%) self-reported equal pain intensity in both conditions; CBT group for patients with dressing times greater than
however, parent reports and nurse reports indicated that, 30 minutes (P = 0.01). The authors noted the limitations
behaviorally, these children were exhibiting less distress in of the AR equipment as being heavy, not waterproof, and
the VR condition. limited to an older appeal group.
Chan et al. [24] examined the use of a VR prototype in Hoffman et al. [28] used a water-friendly VR system
providing relief to children with burns. The VR prototype in wound debridement for 11 patients (age 9–40 years).
consisted of graphic animation presented via eyeglasses, The investigation found that, according to GRS ratings,
which the children controlled using a computer mouse. VR lowered ratings of worst pain and pain unpleasant-
This descriptive exploratory study used a within-subjects ness, and increased ratings of fun (P < 0.05), but only in
 104

Table 2. Clinical investigations examining virtual reality for pain control

I

Study Study type Patients, n Age range, m (SD) Conditions Primary findings in VR condition
Burn care
Hoffman et al. [14] Case study 2 16–17 VR*/video game* Decreased pain, anxiety, and time spent thinking
about pain
Hoffman et al. [21] RCT 12 19–47 VR*/standard analgesia Decreased pain, anxiety, and time spent thinking
about pain
Hoffman et al. [22] RCT 7 9–32 Repeated VR*/No VR* Pain ratings and degree of VR immersion
remained constant
Hoffman et al. [16] Case study 1 40 VR (water-friendly)/no VR Decreased pain ratings
Psychiatric Management of Pain

Patterson et al. [19] Case study 1 VR hypnosis/audio only Pain levels dropped in both conditions
Das et al. [23] RCT 7 5–18 VR*/analgesia Reduced pain scores in four subjects
Chan et al. [24] Exploratory 8 6.54 (2.27) VR*/standard of care Nurses observed less behavioral distress
van Twillert et al. [25] RCT 19 8–65 VR*/TV*/standard of care Lower pain scores than standard of care only
Sharar et al. [26••] RCT 88 6–65 VR*/analgesia Reduced pain intensity, unpleasantness, and time
thinking about pain
Mott et al. [27] RCT 42 3–14 AR*/CBT* Lower pain scores
Hoffman et al. [28] RCT 11 9–40 VR (water-friendly)*/no VR* Lower pain ratings and unpleasantness in subjects
who were immersed in VR
Cancer pain
Schneider and Workman [29] Pilot study 11 10–17 VR*/standard of care Children preferred VR to previous treatments
Wint et al. [30] Pilot study 30 10–19 VR*/standard of care No significant differences
Gershon et al. [18] Case study 1 8 VR*/computer/no distraction Lower pain score and less behavioral distress;
higher anxiety
Gershon et al. [31] RCT 59 7–19 VR*/distraction/standard of care Lower physiologic arousal and nurse-reported
pain ratings
Schneider et al. [32] RCT 20 18–55 VR*/standard of care Decreased symptom distress and perceived
treatment time
Routine procedures
Gold et al. [33] RCT 100 8–12 VR via HMD/VR via computer/cartoon/ Lower frequency of moderate to severe pain
no distraction intensity in VR via HMD
Gold et al. [34] RCT 20 8–12 VR*/topical anesthetic No change in pain intensity pre- and post-IV;
higher satisfaction ratings
*With analgesia.
AR—augmented reality; CBT—cognitive behavioral therapy; HMD—head-mounted display; IV—intravenous; RCT—randomized controlled trial; M—mean; SD—standard deviation; VR—vir-
tual reality.
Table 2. Clinical investigations examining virtual reality for pain control (Continued)

Study Study type Patients, n Age range, m (SD) Conditions Primary findings in VR condition
Miscellaneous medical treatments
Hoffman et al. [15] Case study 2 51–56 VR/movie/control Lower pain ratings
Steele et al. [17] Case study 1 16 VR/standard of care Lower pain scores
Wright et al. [20] Case study 1 67 VR*/local anesthesia Reduced pain and anxiety ratings
*With analgesia.
AR—augmented reality; CBT—cognitive behavioral therapy; HMD—head-mounted display; IV—intravenous; RCT—randomized controlled trial; M—mean; SD—standard deviation; VR—vir-
tual reality.
The Use of Virtual Reality for Pain Control: A Review
I
Mahrer and Gold
I
105
106
I Psychiatric Management of Pain

patients who reported being present in the VR game. The reported a lower frequency of moderate to severe levels of
five patients who did not report feeling immersed in the pain intensity compared with children in the other three
game did not show significant reductions in pain ratings. conditions (P < 0.05). Other analyses revealed no differ-
ences in pain intensity and state anxiety among the four
Cancer pain conditions. State anxiety was negatively associated with
VR has also been used to treat pain associated with cancer VR presence.
treatment. Pilot studies have been conducted examining Gold et al. [34] also examined 20 children (age 8–12
the feasibility of VR in reducing pain during cancer treat- years) requiring intravenous (IV) placement for contrast
ment in children. Schneider and Workman [29] asked 11 for an MRI/CT scan. Children were randomly assigned
children (age 10–17 years) receiving chemotherapy to recall to VR presented via HMD plus a topical anesthetic or
previous treatments and compare their experience with the topical anesthetic alone. Children in the VR condi-
VR to previous experiences with standard of care using an tion reported no significant change in pain intensity
investigator-developed questionnaire. Eighty-two percent between pre- and post-IV placement, whereas children
stated that the chemotherapy with the VR distraction was in the control condition demonstrated a fourfold pain
better than previous treatments. All children reported that increase (P < 0.01), as measured by a standardized pain
they would like to use VR in future treatments. intensity scale. Caregivers preferred the VR condition in
Wint et al. [30] examined the efficacy of VR glasses in terms of child cooperation and pain reduction. The VR
reducing pain experienced during lumbar puncture. The condition also received higher satisfaction ratings from
pilot study used a between-groups design with 30 ado- the children, their caregivers, and the nurse performing
lescent patients with cancer (age 10–19 years). Seventeen the procedure. Additionally, children reported no simu-
patients were placed in the VR condition and 13 in stan- lator sickness and a high level of presence.
dard of care. Pain intensity scores, using a self-report VAS,
were not statistically different between the two groups.
Investigators reported a trend toward lower scores in the Current National Institutes of Health Studies
VR group, but the trend was not significant. Two NIH-funded studies are currently investigating
Gershon et al. [31] conducted a larger study looking VR for pain control. Lynnda Dahlquist (University of
at 59 children and adolescents (age 7–19 years) receiving Maryland, Baltimore College) is examining differences
port access associated with cancer treatment. The study between interactive VR, active VR, and passive VR. One
compared three conditions: 1) VR distraction via HMD, aim of the study is to assess a younger sample of chil-
2) VR distraction via computer, and 3) standard of care. dren (age 6–8 years). Additionally, the investigator aims
Results showed VR HMD distraction to be significantly to pilot the use of VR distraction for patients receiving
better than standard of care, according to measures of care in the division of Hematology-Oncology. David
physiologic arousal (ie, pulse) and nurse-reported VAS Patterson (University of Washington) is exploring the
pain ratings (P < 0.05). No other differences were found. combination of VR and hypnosis. Patterson will test this
In 2004, Schneider et al. [32] published a crossover- novel combination during dressing changes in patients
designed study examining the effect of VR on pain in with burns and in college students receiving thermally
women receiving chemotherapy treatment for breast induced pain. He will compare high and low VR technol-
cancer. Patients chose one scenario (deep-sea diving, ogy delivered through a water-friendly system. Patterson
walking through a museum, or solving a mystery), will also examine the relationship between hypnotic sug-
which was projected onto a headset with corresponding gestibility and the effectiveness of VR.
sounds. Significant fi ndings included decreased symptom
distress (P < 0.05) and perceived time playing the VR
game/receiving treatment (P < 0.001), termed the time- Experimental Virtual Reality in
elapse compression effect. Healthy Populations
Recently, VR research has expanded to examine experimen-
Routine medical procedures tally induced pain in healthy populations. In these studies,
VR use has also been investigated with routine pediatric the investigators induce pain and monitor the effects of VR
medical procedures. Gold et al. [33] examined 100 chil- on pain perception and pain tolerance. This enables inves-
dren (age 8–12 years) receiving routine outpatient blood tigators to test the direct effects of VR on pain inhibition
draw. Children were randomly assigned to one of four while eliminating other confounding variables, such as
conditions: 1) no distraction, 2) cartoon distraction, 3) disease pathology, medications, or the hospital environ-
VR via computer, or 4) VR via HMD. Visual occlusion ment. Tse et al. [35] tested the effects of visual stimulation
was controlled across all four conditions by creating a pass on pain threshold and pain tolerance in a between-groups
wall through which the children had to place their arm study of 72 university student volunteers. In the experi-
for the blood draw. Children in the VR HMD condition mental condition, visual stimulation of natural scenery
 The Use of Virtual Reality for Pain Control: A Review
I Mahrer and Gold
I 107

without sound was presented via eyeglasses. In the control Another concern, raised early in the research, was the
condition, participants were presented with a static blank possibility that VR may be effective primarily due to its
screen. Pain was administered with a modified tourniquet. ability to impede the patient’s view of the painful proce-
Results showed an increase in pain threshold and toler- dure [14]. In a study by Gershon et al. [18], the participant
ance during the experimental condition. Another study reported increased levels of anxiety while immersed in
using experimentally induced ischemic tourniquet pain an HMD. The investigators hypothesized that this effect
tested the effects of VR in 20 healthy adults. Magora et al. may be due to the child’s inability to view the procedure
[36] found that the VR condition increased pain tolerance and fear of the unknown. However, in 2005, Gold et al.
(P < 0.001). Additionally, participants self-reported lower [33] designed a study controlling for visual occlusion of
affective distress and pain unpleasantness when immersed the medical procedure across all conditions and demon-
in VR (P < 0.001). strated that VR HMD remained superior. As this is the
Hoffman et al. [37] administered experimental only study conducted with this strict methodology, future
pain using a blood pressure cuff to 22 college students studies should incorporate similar rigor to evaluate the
during VR and non-VR conditions. Results showed influence of visual occlusion versus VR analgesia during
signifi cant differences, with VR distraction decreasing medical procedures. Additionally, future studies would
pain intensity by an average of 52%, across male and benefit from assessing coping styles of the participants (ie,
female students. Dahlquist et al. [38] used cold pres- “attenders” [those who like to watch the procedure] vs
sor pain with 41 children (age 6–14 years) to assess “distracters” [those who like to look away]) in an attempt
whether the use of an HMD enhanced the effects of a to examine the impact of coping style on the efficacy of
video game for children and adolescents. The authors VR for procedural pain.
found that the HMD resulted in additional benefi t for There is also worry regarding the cost/benefit of VR.
the older children (ie, increasing pain tolerance), but VR is an expensive mode of distraction when less expen-
had no effect for the younger children. sive, more easily accessible modes (eg, TV, music, bubbles,
toys) have been proven to be effective. Practically speak-
ing, although costs associated with VR have significantly
Scientific Concerns declined, the cost/benefit analysis as compared with other
Although VR research is showing initial promise in its modes of distraction is still undecided. Recently, inves-
ability to decrease pain perception and other negative tigators have hypothesized that VR attenuates pain and
aspects of painful medical and experimental procedures, creates analgesia at a level beyond that of simple distrac-
results should be interpreted cautiously in light of some tion. To address this concern, it is necessary to explore
basic scientific limitations. In general, sample sizes con- the neurobiologic mechanisms behind the effect of VR.
tinue to be small, thus reducing generalizability of the Researchers have begun to examine the neural correlates
fi ndings. Additionally, although VR has been tested in associated with VR pain distraction through the use of
specified populations, the methodology used to test the fMRI and experimentally induced pain [4•].
technology has been highly variable. Investigators have Clinicians/investigators should also be careful in
used a variety of VEs, pain measures, and study designs. their choice of VE, as not all VEs are created equally. A
Results from one population cannot be generalized truly immersive VE provides the 360° illusion of being
to another population unless similar methodology is immersed in the virtual world, often with head tracking
applied. Future studies should use consistent and experi- to allow for more complete interaction. Additionally, the
mentally rigorous methodologies and recruit a greater game should involve other sensory modalities, such as
number of participants to increase the power and gener- auditory stimulation and tactile feedback. Many investi-
alizability of results. gators have used an HMD to deliver video or computer
There are additional concerns regarding the measure- games to the user, without the fully immersive elements
ment of pain and other health outcomes collected during (Table 1). These do not qualify as immersive VR. Inves-
VR investigations. Although some research teams have tigations have also revealed differential effects due to
used standardized measures, many researchers have quality of the VR system. Hoffman et al. [39] conducted a
relied on unstandardized, investigator-developed ques- between-groups study testing the pain-attenuating effects
tionnaires. Additionally, self-report measures have been of high-tech VR versus low-tech VR in healthy volunteers.
the primary mode of data collection in lieu of integrated The study found that participants in the high-tech VR
multirater and multimodal pain assessment. Investigative condition reported a higher level of presence and greater
teams should combine standardized subjective self-report pain reduction compared with the low-tech VR group.
questionnaires with behavioral, observational, and physi- Continued investigation of immersive and interactive VR
ologic indices in order to better evaluate the relationships and the identification of neural correlates associated with
between VR interventions and associated health outcomes VR analgesia will serve to further explain the use of VR
(eg, pain, anxiety, distress). for pain management.
108
I Psychiatric Management of Pain

Clinical Experiences with Virtual Reality References and Recommended Reading

Hospitalized patients with an acute or a chronic medi- Papers of particular interest, published recently,
cal condition often undergo numerous painful routine have been highlighted as:
(ie, blood draw, IV placement) and sometimes invasive • Of importance
(ie, lumbar puncture, wound care, line placement) medi- •• Of major importance
cal procedures. As analgesics or other pharmacologic
interventions are not always indicated, VR is beginning 1. Gershon J, Anderson P, Graap K, et al.: Virtual reality
exposure therapy in the treatment of anxiety disorders.
to emerge as a fi rst-line or adjunctive/complementary Sci Rev Ment Health Pract 2000, 1:76–81.
intervention for painful procedures. In addition to the 2. Zimand E, Anderson P, Gershon J, et al.: Virtual reality
well-documented pain associated with these procedures, therapy: innovative treatment for anxiety disorders. Prim
Psychiatry 2002, 9:51–54.
patients also report fear, anxiety, and, to some degree, 3. Rothbaum BO, Hodges L, Kooper R: Virtual reality
post-traumatic stress reactions (eg, nightmares, fear of exposure therapy. J Psychother Pract Res 1997, 6:219–226.
the hospital) associated with exposure to painful medical 4.• Hoffman HG, Richards TL, Bills AR, et al.: Using fMRI to
procedures. In these authors’ opinions, VR is promising as study the neural correlates of virtual reality analgesia. CNS
Spectr 2006, 11:45–51.
an adjunctive/complementary or fi rst-line intervention to Demonstrates the direction of the field with a study combining VR,
manage pain and distress associated with painful medical pain, and fMRI.
procedures. In addition to the positive outcomes previ- 5.•• Gold JI, Belmont KA, Thomas DA: The neurobiology of
virtual reality pain attenuation. Cyberpsychol Behav 2007,
ously described, preliminary investigations demonstrate 10:536–544.
that participants enjoy the VR experience and report min- A recent review theorizing possible mechanisms of VR’s pain-
imal ill effects (ie, simulator sickness or nausea). During attenuating effects.
6. Blount RL, Bachanas PJ, Powers SW, et al.: Training
investigations conducted by the senior author, children children to cope and parents to coach them during routine
and their caregivers have relayed that: “It [VR] made the immunizations: effects on child, parent, and staff behaviors.
medical test easier,” “I would do it again,” “The child Behav Ther 1992, 23:689–705.
was more cooperative,” and “It was fun.” Additionally, 7. Jay S, Elliott CH, Fitzgibbons I, et al.: A comparative study
of cognitive behavior therapy versus general anesthesia for
health care providers have commented that VR helped the painful medical procedures in children. Pain 1995, 62:3–9.
child be less nervous, more calm, and more cooperative, 8. Cohen LL, Blount RL, Panopoulos G: Nurse coaching and
thus making the procedure easier. Nurses have stated that cartoon distraction: an effective and practical intervention
to reduce child, parent, and nurse distress during immuniza-
procedures with VR require fewer needle sticks/attempts, tions. J Pediatr Psychol 1997, 22:355–370.
and health care providers have reported that they prefer 9. Cassidy KL, Reid GJ, McGrath PJ, et al.: Watch needle,
the VR condition to standard of care alone. watch TV: autovisual distraction in preschool immunization.
Am Acad Pain Med 2002, 3:108–118.
10. Melzack R, Wall PD: Pain mechanisms: a new theory.
Science 1965, 150:971–979.
Conclusions 11. McCaul KD, Malott JM: Distraction and coping with pain.
VR use for pain control is in its infancy. Investigations Psychol Bull 1984, 95:516–533.
12. Wickens CD: Multiple resources and mental workload.
have demonstrated initial promise with specific popula- Hum Factors 2008, 50:449–455.
tions and acute medical procedures. As VR technology 13. Bantick SJ, Wise RG, Ploghaus A, et al.: Imaging how
decreases in cost and increases in availability, new VEs attention modulates pain in humans using functional MRI.
and integrated VR technology will enable clinicians and Brain 2002, 125:310–319.
14. Hoffman HG, Doctor JN, Peterson DR, et al.: Virtual reality
researchers to further investigate the usability of VR. as an adjunctive pain control during burn wound care in
Future studies in VR require greater scientific rigor, adolescent patients. Pain 2000, 85:305–309.
increased sample sizes, sound methodology, and increased 15. Hoffman HG, Garcia-Palacios A, Patterson DR, et al.: The
effectiveness of virtual reality for dental pain control: a case
attention to individual user characteristics. VR’s promise study. Cyberpsychol Behav 2001, 4:527–535.
in acute medical procedures may also contribute to the 16. Hoffman HG, Patterson DR, Magula J, et al.: Water-friendly
understanding and management of chronic pain. VR is virtual reality pain control during wound care. J Clin
emerging as both a viable fi rst-line intervention and as Psychol 2004, 60:189–195.
17. Steele E, Grimmer K, Thomas B, et al.: Virtual reality
an adjunctive therapy to pharmacologic agents. As VR as a pediatric pain modulation technique: a case study.
researchers gain a better understanding of the neurobio- Cyberpsychol Behav 2003, 6:633–638.
logic mechanisms associated with VR analgesia, VR may 18. Gershon J, Zimand E, Lemos R, et al.: Use of virtual reality
as a distracter for painful procedures in a patient with
shift from a simple form of immersive distraction to a pediatric cancer: a case study. Cyberpsychol Behav 2003,
powerful nonpharmacologic agent. 6:657–662.
19. Patterson DR, Tininenko JR, Schmidt AE, Sharar SR:
Virtual reality hypnosis: a case report. Int J Clin Exp Hypn
2004, 52:27–38.
Disclosures 20. Wright JL, Hoffman HG, Sweet RM: Virtual reality as an
No potential confl icts of interest relevant to this article adjunctive pain control during transurethral microwave
were reported. thermotherapy. Urology 2005, 66:1320.
 The Use of Virtual Reality for Pain Control: A Review
I Mahrer and Gold
I 109

21. Hoffman HG, Patterson DR, Carrougher CJ: Use of virtual 31. Gershon J, Zimand E, Pickering M, et al.: A pilot and fea-
reality for adjunctive treatment of adult burn pain during sibility study of virtual reality as a distraction for children
physical therapy. Clin J Pain 2000, 16:244–250. with cancer. J Am Acad Child Adolesc Psychiatry 2004,
22. Hoffman HG, Patterson DR, Carrougher CJ, Sharar SR: 43:1243–1249.
Effectiveness of virtual reality-based pain control with 32. Schneider SM, Prince-Paul M, Allen MJ, et al.: Virtual
multiple treatments. Clin J Pain 2001, 17:229–235. reality as a distraction intervention for women receiving
23. Das DA, Grimmer KA, Sparon AL, et al.: The efficacy chemotherapy. Oncol Nurs Forum 2004, 31:81–88.
of playing a virtual reality game in modulating pain for 33. Gold JI, Reger G, Rizzo AA, et al.: Virtual reality in
children with acute burn injuries: a randomized controlled outpatient phlebotomy: evaluating pediatric pain distraction
trial. BMC Pediatr 2005, 5:1–10. during blood draw. Presented at the 10th Annual Poster
24. Chan EA, Chung JW, Wong TK, et al.: Application of a Session of the Saban Research Institute. Los Angeles:
virtual reality prototype for pain relief of pediatric burn in Children’s Hospital Los Angeles; 2005.
Taiwan. J Clin Nurs 2007, 16:786–793. 34. Gold J, Kim S, Kant A, et al.: Effectiveness of virtual
25. van Twillert B, Bremer M, Faber AW: Computer-generated reality for pediatric pain distraction during IV placement.
virtual reality to control pain and anxiety in pediatric and Cyberpsychol Behav 2005, 9:207–212.
adult burn patients during wound dressing changes. J Burn 35. Tse MM, Ng JK, Chung JW, Wong TK: The application of
Care Res 2007, 28:694–702. eyeglass displays in changing the perception of pain. Stud
26.•• Sharar SR, Carrougher GJ, Nakamura D, et al.: Factors Health Technol Inform 2002, 85:532–535.
influencing the efficacy of virtual reality distraction 36. Magora F, Cohen S, Shochina M, Dayan E: Virtual reality
analgesia during postburn physical therapy: preliminary immersion method of distraction to control experimental
results from 3 ongoing studies. Arch Phys Med Rehabil ischemic pain. Isr Med Assoc J 2006, 8:261–265.
2007, 88:43–49. 37. Hoffman HG, Garcia-Palacios A, Kapa V, et al.: Immersive
The largest RCT of VR and pain management in the literature to date. virtual reality for reducing experimental ischemic pain. Int
27. Mott J, Bucolo S, Cuttle L, et al.: The efficacy of an J Hum Comput Interact 2003, 15:469–486.
augmented virtual reality system to alleviate pain in 38. Dahlquist LM, Weiss KE, Dillinger Clendaniel L, et al.:
children undergoing burns dressing changes: a randomised Effects of videogame distraction using a virtual reality type
controlled trial. Burns 2008, 34:803–808. head-mounted display helmet on cold pressor pain in children.
28. Hoffman HG, Patterson DR, Seibel E, et al.: Virtual J Pediatr Psychol 2008 Mar 26 (Epub ahead of print).
reality pain control during burn wound debridement in the 39. Hoffman HG, Sharar SR, Coda B, et al.: Manipulating
hydrotank. Clin J Pain 2008, 24:299–304. presence influences the magnitude of virtual reality
29. Schneider SM, Workman ML: Virtual reality as a distraction analgesia. Pain 2004, 111:162–168.
intervention for older children receiving chemotherapy. 40. Allison D, Bowman D, Wineman J, Hodges LF: The virtual
Pediatr Nurs 2000; 26:593–597. reality gorilla exhibit. IEEE Comput Graphics Applications
30. Wint S, Eshelman D, Steele J, Guzetta CE: Effects of 1997, 17:30–38.
distraction using virtual reality glasses during lumbar
punctures in adolescents with cancer. Oncol Nurs Forum
2002, 29:8–15.