This paper is in the following e-collection/theme issue:

Perioperative Pediatric Care (33) Clinical Integration of XR and Spatial Computing (61) Pediatrics (297) Games in Pediatrics (58) Perioperative Pediatric Care (33) Clinical Integration of XR and Spatial Computing (61) Pediatrics (297) Anxiety and Stress Disorders (1366) Games in Pediatrics (58) Perioperative Pediatric Care (33) Clinical Integration of XR and Spatial Computing (61) Pediatrics (297) Anxiety and Stress Disorders (1366) Games in Pediatrics (58) Pain in Children and Adolescents (59) Perioperative Pediatric Care (33) Postoperative Pain Management (41) Clinical Integration of XR and Spatial Computing (61)

Published on in Vol 9 (2026)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/80902, first published .
Virtual Reality for the Management of Postoperative Pain and Anxiety in Children and Adolescents Undergoing Nuss Repair of Pectus Excavatum: Randomized Controlled Trial

Virtual Reality for the Management of Postoperative Pain and Anxiety in Children and Adolescents Undergoing Nuss Repair of Pectus Excavatum: Randomized Controlled Trial

Virtual Reality for the Management of Postoperative Pain and Anxiety in Children and Adolescents Undergoing Nuss Repair of Pectus Excavatum: Randomized Controlled Trial

Authors of this article:

Charlotte M Walter1 Author Orcid Image ;   Dillon Froass2 Author Orcid Image ;   Nora Bell3 Author Orcid Image ;   Lauren Haack4 Author Orcid Image ;   Chloe Boehmer1 Author Orcid Image ;   Claudia Bruguera Torres1 Author Orcid Image ;   Rachel Spivak1 Author Orcid Image ;   Max Chou5 Author Orcid Image ;   Kristie Geisler1 Author Orcid Image ;   Keith O'Conor6 Author Orcid Image ;   Sara E Williams7 Author Orcid Image ;   Lili Ding1 Author Orcid Image ;   Christopher D King1 Author Orcid Image ;   Vanessa A Olbrecht8, 9 Author Orcid Image
Article Authors Cited by Tweetations (3) Metrics

    1Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, United States

    2The Ohio State University Wexner Medical Center, Columbus, OH, United States

    3Department of Pediatrics, Vanderbilt University, Nashville, TN, United States

    4Department of Surgery, Wayne State University, Detroit, MI, United States

    5Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, OH, United States

    6Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States

    7Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA, United States

    8Department of Anesthesiology, Nemours Children’s Hospital, Wilmington, DE, United States

    9Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, United States

    Corresponding Author:

    Charlotte M Walter, MD


    Background: Virtual reality (VR) is a novel technology with implications for pain and sensory processing. VR may serve as a novel, scalable method to deliver clinically validated therapy for pain management as an alternative or adjunct to opioids for acute pain. Given that psychological factors and pain perception are both components of postoperative pain, it may also be beneficial to incorporate modalities that decrease anxiety, such as active relaxation and guided meditation with VR. Unfortunately, these therapies are not widely available due to multiple barriers. VR has the potential to deliver pain-reducing, psychologically based therapy to children, thereby enhancing multimodal analgesia and potentially decreasing opioid use. This study investigates the role of VR in reducing pain and anxiety after surgery. Given the substantial risks associated with opioid use, particularly in younger populations, alternative pain management strategies are crucial.

    Objective: The primary aim of this study was to evaluate the efficacy of VR as a nonpharmacological intervention for managing postoperative pain intensity, pain unpleasantness, anxiety, and opioid use in children and adolescents undergoing Nuss repair of pectus excavatum.

    Methods: A single-center, prospective, randomized, controlled trial was conducted at a tertiary care children’s hospital and research center. Ninety children and adolescents (8-18 y) undergoing the Nuss procedure were randomized to guided relaxation or mindfulness VR (n=30) and distraction-based gaming VR (n=30), combined to form the VR group (n=60), and a control group using a passive 360° video (n=30). Patients received a 10-minute session on postoperative days 1 and 2. Pain intensity, pain unpleasantness, and anxiety were evaluated before and 0-, 15-, and 30-minute post-session. In-hospital pain scores, anxiety scores, and opioid use were collected.

    Results: Children and adolescents who participated in VR reported a significantly greater decrease in pain intensity from baseline (0.41, SE 0.23) compared with those in the 360° video group at 30 minutes (P=.04) before multiplicity adjustment but not after multiplicity adjustment. There were no significant differences in pain scores or opioid use between the VR and control groups on postoperative day 1 or 2, nor were there changes in pain unpleasantness or anxiety at any time after the intervention.

    Conclusions: Daily, 10-minute VR sessions provided some trends toward transient analgesic and anxiolytic effects, albeit none that were statistically significant. VR did not significantly decrease overall pain scores or opioid usage, possibly due to the limited intervention duration and high standardized opioid use. Future studies should investigate extended and more frequent VR sessions and the integration of VR with other therapeutic modalities.

    Trial Registration: ClinicalTrials.gov NCT04351776; https://clinicaltrials.gov/study/NCT04351776

    JMIR Perioper Med 2026;9:e80902

    doi:10.2196/80902

    Keywords

    analgesia; anxiety; distraction-based virtual reality; pediatric anesthesia; prospective studies; child; human; virtual reality; pediatric pain medicine; acute postoperative pain 


    Background

    Multimodal pain management techniques for acute postoperative pain are commonly studied and utilized [1]; opioids continue to be the cornerstone of postoperative pain management. Opioid misuse continues to be a major public health issue in the United States, with children and adolescents particularly vulnerable, as many are initially exposed to opioids prescribed for pain management [2-4]. Furthermore, the risk of future opioid overdose significantly increases with the quantity of pills prescribed; adolescents receiving 30 or more pills have a 35% higher rate of overdose than those prescribed 18 or fewer pills [5]. The prescription of opioid analgesics is a well-documented pathway to misuse, opioid use disorder, and overdose [6].

    The Nuss procedure, performed to repair pectus excavatum, is associated with severe postoperative pain [7]. Effective management of postoperative pain after this surgery is crucial, as alleviating pain can enhance patient satisfaction and reduce complication rates [8]. Effective pain management techniques and regimens vary across pediatric institutions and have begun including intercostal nerve cryoablation [8,9]. Opioid use during recovery from the Nuss procedure is common, with one study finding that patients used opioids for a median of 8 days with an IQR of 6‐10 days [10]. Given the absence of standardized postoperative pain management protocols and the high usage of opioids following the Nuss procedure, it is essential to explore nonpharmacologic pain control adjuncts for these patients.

    Virtual reality (VR) technology provides an immersive, multisensory, and 3D environment that enables individuals to experience a modified reality, creating a sense of “presence” for each individual [11]. There is a clear need for alternative pain management methods, including nonpharmacologic techniques. VR has been shown to be effective in reducing perioperative and postoperative anxiety in pediatric patients. Studies show significant reductions in anxiety in pediatric patients immediately after distraction-based gaming virtual reality (VR-D) sessions, with some effects lasting for at least 15 minutes post-intervention [12,13]. Two approaches—VR-D and guided relaxation–based virtual reality (VR-GR)—are being researched for their effectiveness in reducing pain and anxiety following surgery.

    VR-D immerses patients in engaging experiences that help divert attention from pain or anxiety, providing effective short-term relief. Integration of these techniques is challenging in the perioperative space, with limited providers and resources and high costs limiting its feasibility. VR can be used anywhere, anytime, with access to a headset.

    Gate control theory suggests that distraction can be a valuable tool for pain management, as attentional load is fixed, and distraction toward a pleasant experience means less attention to pain [14,15]. It has been associated with immediate and short-term reductions in postoperative pain intensity and unpleasantness. VR-D techniques have been shown to decrease acute pain in children and adults [16-18]. Single sessions of VR-D have been shown to reduce postoperative pain for up to 30 minutes in some cases, regardless of baseline pain catastrophizing levels, suggesting broad applicability across pediatric populations experiencing postoperative pain [19]. The use of VR-D has also demonstrated pain reduction comparable to opioid use in burn injury patients during wound cleaning [20]. While VR-D is particularly effective for short-term pain management, additional strategies like guided relaxation may be needed for longer-lasting pain relief [21].

    VR-GR seeks to provide more sustained pain relief by combining distraction with mind-body techniques, such as guided relaxation or mindfulness within the VR environment. Psychological factors—including calmness, fear, anxiety, and depression—affect the subjective experience of pain [22]. Resilience has been negatively associated with pain unpleasantness, potentially serving as a protective factor in patients with higher baseline anxiety [22,23]. Incorporating active relaxation and guided meditation techniques may significantly contribute to pain reduction. This combination of settling the mind to increase resilience and distraction from acute pain may play a significant role in acute pain reduction [21]. VR-GR may further improve anxiety reduction, especially in children with higher anxiety sensitivity [12,24]. Although VR-GR may offer additional benefits for sustained pain relief compared to distraction alone, its effects were also primarily transient [21]. Using VR to perform guided relaxation could expand the benefits of these nonpharmacological pain management techniques to more children, including those having surgery.

    Overall, VR is a promising nonpharmacologic tool for managing postoperative pain and anxiety in children and adolescents. It can potentially enhance the perioperative experience, reduce reliance on pharmacological interventions, and increase patient and family satisfaction. However, randomized controlled trials are needed to establish standardized protocols and explore VR integration with other therapies, such as biofeedback, for more durable outcomes [13,21,25].

    Aim

    In this prospective, randomized, controlled clinical trial, we compare the short-term efficacy of immersive VR in decreasing acute postoperative pain (primary outcome), anxiety, and opioid consumption following pectus excavatum repair. We hypothesize that the use of VR will be more effective at reducing pain, anxiety, and opioid use as compared to the control group in this patient population.


    The original protocol for this study has been published [26].

    Study Design and Setting

    This single-center, randomized, unblinded clinical trial was conducted at Cincinnati Children’s Hospital Medical Center (CCHMC), a 670-bed tertiary care academic children’s hospital. The recruitment began on July 10, 2020, and the study was completed on July 30, 2023. The COVID-19 pandemic delayed study completion. We recruited children and adolescents undergoing Nuss repair of pectus excavatum to investigate the role of VR in the management of postoperative pain and anxiety.

    Ethical Considerations

    This study complies with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) statement [27] and the Consolidated Standard of Reporting Trials (CONSORT) statement [28]. The CCHMC Institutional Review Board approved this study (IRB 2019‐1090) on November 26, 2019, and it was conducted per the rules and regulations for ethical research. This study was registered at ClinicalTrials.gov on April 3, 2020 (NCT04351776). Written informed parental consent and patient assent (children >11 years) were obtained from all participants before enrollment into this study. Patients received a small stipend for participation. All identifying patient information was kept private and confidential.

    Patients and Recruitment

    Patients

    This study recruited 90 patients (30 patients per group), ages 8 to 18 years, undergoing Nuss repair of pectus excavatum surgery. Informed parental consent and patient assent were obtained before enrollment into this study.

    The inclusion criteria were as follows: patients were (1) between the ages of 8 and 18 years, (2) able to read, understand, and speak English, (3) presenting for Nuss repair of pectus excavatum, and (4) followed by the acute pain service following surgery.

    The exclusion criteria were as follows: patients with (1) a history of developmental delay, uncontrolled psychiatric conditions, or neurological conditions, (2) a history of seizures, epilepsy, vertigo, or significant motion sickness/nausea/vomiting, or (3) any condition that would preclude the application of the VR headset, such as craniofacial abnormalities.

    Recruitment

    Approximately 150 Nuss repair surgeries are performed at CCHMC each year. Therefore, our recruitment target of 90 patients was well within achievable limits. During the study, patients who underwent Nuss repair were recruited continuously until we met the targeted enrollment. The operating room schedule and surgical patient list were reviewed for potentially eligible patients, who were approached for recruitment before surgery. If patients wished to participate, consent (and assent for patients >11 years of age) was obtained, and eligibility criteria were verified. We recruited about 2 patients per week. Recruiting stopped during the COVID-19 pandemic, when elective surgeries were not performed, delaying study completion.

    Randomization

    Potential patients were identified using the operating room schedule and the pectus surgery list provided by the surgery team. Eligible participants were randomized (1:1:1) into three groups: active distraction-based guided relaxation virtual reality (VR-DGR, n=30) and active VR-D (n=30)—collectively the VR group (n=60)—and a control group—passive 360° video (360-V) without instructions, sound, guided relaxation, or active patient involvement (n=30).

    VR Technology

    All participants used a Starlight Xperience VR all-in-one device and software developed specifically for hospital settings. This technology is a customized version of the Lenovo Mirage Solo with a Daydream VR headset. It is easy to disinfect to comply with hospital infection safety protocols. Importantly, an integrated headphone device provides audio content, and the patients use head movements and a handheld controller for interaction and navigation. It is commercially available (not Food and Drug Administration–regulated) and was supplied by the Starlight Children’s Foundation.

    VR-DGR and 360-V participants used the Mindful Aurora application, developed by the Stanford University Childhood Anxiety Reduction through Innovation and Technology program, to deliver relaxation/mindfulness content, which presents a relaxing nature scene with prompts instructing patients to actively slow and pace their breathing in conjunction with the movement of objects in the VR environment. 360°-V participants experienced the same relaxing nature scene without guided relaxation prompts; the 360°-V group also did not receive any audio and thus did not experience an immersive environment.

    VR-D participants had the option to choose and play one of the three games: Space Pups, in which the participant controls a puppy in space and collects treats to music; Pebbles the Penguin, in which the participant controls a penguin sliding down a mountain to collect pebbles; or Wonderglade, in which the participant can play five different mini-carnival games (Figure 1).  

    ‎
    Figure 1. Scenes from the Mindful Aurora application used in distraction-based guided relaxation virtual reality (VR-DGR) and 360° video (360-V) (A and B), and scenes from Space Pups (C) and Pebbles the Penguin (D) used in distraction-based gaming virtual reality (VR-D).

    Procedure

    Consent and assent were obtained before the visit. Patient characteristics, demographics, weight, and pain scores were collected preoperatively. All patients enrolled in this study received standard postoperative care via the CCHMC Pectus Surgery Pain Management Protocol, which standardizes all medications received by all pectus patients. This includes non-opioid pain medication such as pregabalin, acetaminophen, ketorolac, methocarbamol, and diazepam. All participants received the same non-opioid medications. Before the first session, patients completed the Childhood Anxiety Sensitivity Index to establish baseline anxiety levels and the Pain Catastrophizing Scale (PCS) for children. Patients were visited daily for one 10-minute session. Every effort was made to ensure the consistent timing of the visits for all patients. Sessions were completed beginning on postoperative day (POD) 1, then daily until the day of discharge, or until POD 3.

    Patients were trained to use the technology before the first VR session. All participants received a device tutorial that taught them how to use the device and introduced them to the VR software. Patients received a script about VR-GR, VR-D, or 360-V, depending on the group to which they are assigned. During each session, patients completed a 10-minute session of either VR-GR, VR-D, or 360-V, per assigned group. Patients were asked to rate their pain intensity, pain unpleasantness, and anxiety via Numerical Rating Scale (NRS), before, immediately after, and 15 and 30 minutes after each session. Pain and anxiety scores and opioid use/day were recorded in REDCap (Research Electronic Data Capture).

    Data Collection

    The primary outcome measure was pain intensity (NRS), measured before, immediately after, and 15 and 30 minutes following each session on POD1 and POD2. Secondary outcomes included opioid use on POD0, POD1, and POD2 and pain area under the curve (AUC) on POD1 and POD2, pain unpleasantness, and anxiety scores before and 0, 15, and 30 minutes after each session on POD1 and POD2 to establish change from baseline.

    For each eligible participant, data were collected from their patient history/interview and the electronic medical record in a standardized case report form in the REDCap system. Inpatient opioid use was identified from the patient’s electronic medical record based on documentation in the medication administration record and transferred to REDCap. All opioid quantities were translated to morphine milligram equivalents (MME) and summed to determine total morphine equivalents per 24-hour period (midnight-to-midnight) during the patients’ inpatient stay. Measures used in the study are summarized in Table 1.

    Table 1. Scales and questionnaires used in the study.
    Scales and questionnairesDefinition
    Pain intensity and pain unpleasantness
    Numerical Rating Scale (NRS) [29]The NRS is the most common validated self-report measure of pain intensity and pain unpleasantness. It involves verbally asking for an estimate of pain intensity using numbers from 0 (no pain) to 10 (maximal pain). Pain was described as being like listening to music; pain intensity is the volume, and pain unpleasantness is how much the music is disliked [30]. It requires no equipment to administer or score.
    Pain intensity across all postoperative daysArea under the time-pain score (NRS) curve using the trapezoidal rule (pain AUCa) measured pain intensity across all postoperative days 1 and 2.
    Anxiety
    Pain Catastrophizing Scale for Children (PCS-C) [31]A validated 13-item questionnaire (each rated on a 5-point scale, 0-4) designed to measure pain catastrophizing in children of age 8‐17 years. It is adapted from the adult version and assesses three key aspects of pain-related negative thinking: rumination, magnification, and helplessness.
    Child Anxiety Sensitivity Index (CASI) [32]A validated 18-item survey that measures perceived anxiety symptoms. Participants respond to each item on a 3-point scale (eg, “none,” “some,” and “a lot”). The total score is calculated by summing the responses, with higher scores indicating greater anxiety sensitivity. The total scores range from 18 to 54. CASI has been used in VRb studies in adolescents of age 10‐21 years [33].
    Numerical Rating Scale-Anxiety (NRS-A) [34]A validated self-report numeric 0‐10 anxiety scale that is easy to administer to children. The NRS-A is easy to administer and can be used quickly to assess anxiety levels.
    Opioid use
    NIH morphine milligram equivalents (MME) per day [35,36]Standardizes a metric for quantifying and comparing doses of different opioids. However, MMEs serve as a common metric for comparing different opioids.

    aAUC: area under the curve.

    bVR: virtual reality.

    Statistical Analysis

    Sample Size Calculation

    Sample size was based on the feasibility of conducting this clinical study and unpublished preliminary data that assessed the impact of a single VR-D session on pain intensity in children and adolescents after surgery, with a goal of 80% power to detect differences in mean changes of 1 between VR and 360-V (given pilot data which showed average change in pain intensity of −1 [SD 1.2] and correlation of 0.88). Assuming similar results in the passive control group, a sample size of 30 per group will have 80% power to detect differences in mean changes of 1 between VR-GR and the two control groups. Significance (α) is .025 to control for 2 comparisons.

    The VR-DGR and VR-D groups were combined into a single VR group for data analysis because both groups utilized active, distraction-based, immersive VR experiences. VR-DGR did not provide participants with feedback on their respiratory or heart rates. Consequently, it functioned as a distraction-based technique and did not significantly differ from the VR-D experience. Therefore, we combined the two groups, as both were fundamentally distraction-based.

    A sample size of 60 for the treatment group and 30 for the control group will have 80% power to detect differences in mean changes of 1 between VR and control.

    Data Analysis

    All statistical analyses were performed using SAS 9.4 (SAS Institute). Patient demographics were described using mean (SD) or median (IQR) for continuous variables, depending on data distribution, and frequency (percentage) for categorical variables and compared between groups using t tests, Wilcoxon rank-sum tests, chi-square tests, or Fisher exact tests, as appropriate. Pain AUCs on POD1 and POD2 were calculated as the area under the time-pain score curve using the trapezoidal rule. MMEs, a metric for quantifying and comparing doses of different opioids, were derived for POD0, POD1, and POD2. Change from baseline on pain intensity, pain unpleasantness, and anxiety immediately after and 15 and 30 minutes following each session was calculated as the postinterval value minus the baseline (before session) value on POD 1 and POD2. Mixed effects models for repeated measures were used for pain AUC, MME, and change from baseline on pain intensity, pain unpleasantness, and anxiety outcomes. All mixed effects models included the intervention group and POD as fixed effects and the participant as a random effect. Models for the change from baseline outcomes also included baseline value, time (0-, 15-, and 30-min post-intervention), and group and time interaction as fixed effects. Missing data in the outcomes were examined for pattern and assumed missing at random and handled using full information maximum likelihood (FIML) for mixed effects models. Sidak adjustment for multiplicity was used for change from baseline in pain intensity between intervention groups at 3 time points (immediately after and 15 and 30 minutes following each session).


    Participants

    Ninety patients were enrolled in the study (60 in VR and 30 in 360-V; Figure 2 ). The participants comprised 73 male and 17 female patients and had an American Society of Anesthesiologists (ASA) Physical Status Classification System score of 1‐3, with a mean age of 15.5 (SD 1.4) years. The 2 groups had no differences demographically except for a difference in PCS scores (VR: median 18, IQR 15‐23; VR-360: median 24, IQR 16‐28; P=.04). Patients were primarily male, adolescent, and Caucasian. This is consistent with the demographics of patients with pectus excavatum [37], and these are the patients most likely to undergo the Nuss procedure [38] (Table 2). All patients had at least 1 observation on all repeated-measured outcomes (pain AUC, MME, pain intensity, pain unpleasantness, and anxiety), and all available data were included in the mixed effects models for the outcomes.

    ‎
    Figure 2. CONSORT (Consolidated Standards of Reporting Trials) 2010 flow diagram. VR: virtual reality.
    Table 2. Patient characteristics.
    CharacteristicVRa360° videoOverallP value (test)
    Age (y), mean (SD)15.6 (1.4)15.1 (1.5)15.5 (1.4).10
    ASAb physical status, n (%).34
    I3 (5)4 (13.3)7 (7.8)
    II44 (73.3)21 (70.0)65 (72.2)
    III13 (21.7)5 (16.7)18 (20.0)
    Race, n (%).55
    Caucasian57 (95)30 (100)87 (96.7)
    African American0 (0)0 (0)0 (0)
    Asian0 (0)0 (0)0 (0)
    Other3 (5)0 (0)3 (3.3)
    Ethnicity, n (%).25
    Hispanic3 (5)0 (0)3 (3.3)
    Non-Hispanic56 (93.3)28 (93.3)94 (93.3)
    Unknown1 (1.7)2 (6.7)3 (3.3)
    Sex, n (%).70
    Male48 (80)25 (83.3)73 (81.1)
    Female12 (20)5 (16.7)17 (18.9)
    Weight (kg), mean (SD)58.9 (9.8)56.3 (10)58.1 (9.9).24
    CASIc score, mean (SD)29.3 (5)30.9 (4.8)29.8 (5).14
    Pain Catastrophizing Scale (PCS), median (IQR)18 (15-23)24 (16-28)19 (15-26).04

    aVR: virtual reality.

    bASA: American Society of Anesthesiologists.

    cCASI: Child Anxiety Sensitivity Index.

    Changes From Baseline (VR vs Control)

    Pain Intensity

    Patients who participated in VR reported significantly decreased pain intensity from baseline (0.41 more decrease in pain intensity with SE 0.23) compared with those in the 360-V group at 30 minutes (P=.04) before multiplicity adjustment but not after multiplicity adjustment. There was no significant difference from baseline in reported pain intensity between VR vs 360-V immediately following the session (P=.08) or after 15 minutes (P=.56; Figure 3).

    ‎
    Figure 3. Changes in baseline in pain intensity, pain unpleasantness, and anxiety in time points following 360° video (360-V) and virtual reality (VR) in a mixed effect model with standard error bars.
    Pain Unpleasantness

    There was no significant difference in the reported pain unpleasantness between patients who participated in VR versus 360-V immediately following the VR session (P=.64), after 15 minutes (P=.20), or after 30 minutes (P=.57; Figure 3).

    Anxiety

    There were no significant differences in reported anxiety from baseline between patients who participated in the VR versus 360-V immediately following the session (P=.13), after 15 minutes (P=.12), or after 30 minutes (P=.40; Figure 3).

    Inpatient Pain and Opioid Use

    There were no significant differences in mean AUC pain scores between VR and 360-V (P=.60). There were also no significant differences in inpatient opioid use (MME/kg/day) between VR and 360-V (P=.26; Table 3).

    Table 3. Inpatient pain and opioid use.
    CharacteristicVRa, mean (SD)360-Vb, mean (SD)P valuec
    Inpatient pain (AUCd).60
    PODe1110.0 (34.3)107.9 (31.8)
    POD295.9 (32.5)90.6 (36.0)
    Inpatient opioid use (MMEf/kg/day).26
    POD00.18 (0.29)0.18 (0.24)
    POD10.58 (0.22)0.64 (0.28)
    POD20.50 (0.17)0.51 (0.20)

    aVR: virtual reality.

    b360-V: 360° video.

    cP value from mixed effects models.

    dAUC: area under the curve.

    ePOD: postoperative day.

    fMME: morphine milligram equivalents.


    Principal Results

    In our study, we found that active, immersive VR experiences had some trends to transient effects on both acute pain and anxiety compared to a nonimmersive 360-V control; however, these effects did not meet statistical significance. Patients who participated in VR reported a significantly greater decrease in pain intensity from baseline (0.41 with SE 0.23) compared with those in the 360-V group at 30 minutes (P=.04) before multiplicity adjustment but not after multiplicity adjustment. The trends in reduction in pain and anxiety were small; these trends did not achieve clinical significance either. Current literature indicates that a reduction of at least 2 points on the NRS for pain intensity or a 30% reduction in pain is considered clinically significant [39]. We did not see effects on overall AUC pain scores or opioid use. In this research, the VR-GR experience was likely distraction-based, as we could not document or assess feedback on patients’ ability to perform the guided relaxation techniques correctly. In spite of not reaching statistical significance, these trends are not an absence of evidence of the effectiveness of VR to reduce postoperative pain and anxiety. We had relatively similar treatment conditions in small samples with attrition. The trends point us in the direction of future work.

    Demographically, our two groups showed no significant differences except for a difference in PCS scores (VR: median 18, IQR 15‐23; VR-360: median 24, IQR 16‐28; P=.04). However, this result, while statistically significant, may not be clinically significant, as only PCS scores above 30 are clinically relevant, and neither group’s median score exceeded 30 [40].

    Although we noted some trends toward reduction in acute pain and anxiety from immersive VR following Nuss repair of pectus excavatum, these effects did not result in a significant change in AUC pain scores or inpatient opioid usage between the two groups. Several factors may account for the lack of significance. At our institution, the standard postoperative pain management protocol for following pectus surgery involves the scheduled administration of opioids, meaning all patients receive a standardized, weight-based dosage of opioids during their hospital stay, regardless of their actual pain level, with variations only in as-needed doses [10]. Consequently, opioid consumption may not accurately represent the patients’ pain levels and opioid requirements. Home medication use might better reflect patients’ pain and opioid needs. This study limited VR experiences to hospitalized patients. Extending its use past hospital discharge may have yielded different results. Future studies should investigate the integration of VR therapy into postoperative pain management both during and after hospitalization.

    Limitations

    Although this study was a prospective, randomized clinical trial, which can provide the best clinical evidence and support for VR, it has several limitations due to both study design and factors outside the control of the research team. Our patient population was somewhat homogeneous, as most individuals undergoing pectus excavatum repair are adolescent white males [38]. Therefore, our findings may not be generalizable to a broader population. Additionally, our control group may have been too similar to our intervention group. While the 360-V group did not receive audio instructions for guided relaxation, they still used a VR headset and experienced some level of distraction and immersion. Hence, the difference between the two groups may not have been substantial enough to detect a meaningful difference. This lack of significant differences in the treatment groups may account for the lack of statistical differences between the two groups when comparing pain and anxiety. Future research will use nonimmersive, non-headset control and retrospectively compare historical data to better assess the impact of VR on these outcomes.

    Reporting bias may have also played a role, as study participants may have felt inclined to report decreased pain and/or anxiety after treatment due to their perception of receiving an intervention, regardless of actual changes. The self-reported 1 to 10 rating scale is limited and has been shown to have a moderate correlation with clinical indicators of pain; thus, we cannot rely exclusively on this measure for pain evaluation [41]. Future studies should consider additional outcome measures.

    The limited use of the intervention (10 min per d) makes it unlikely to produce meaningful changes in the severe postoperative pain often experienced by these patients. This suggests a need for further investigation of VR for pain relief, potentially incorporating VR interventions more systematically throughout the perioperative period. This could include preoperative VR exposure, repeated interventions multiple times per day, for additional consecutive days following surgery. We accounted for our attrition in our statistical analysis. However, the attrition with small groups to start likely was one reason for our inability to find statistically significant differences in results between the two groups.

    Comparison With Prior Work

    Controlling pain after surgery is important; uncontrolled postoperative pain can lead to increased morbidity, decreased function, prolonged recovery, and higher costs [42]. Severe acute postoperative pain can also lead to chronic postoperative pain, with rates of chronic postsurgical pain reported to be about 20% in pediatric populations [43]. Furthermore, opioid use after surgery also has risks, including persistent opioid use postoperatively; one study found a rate of 4.8% of persistent opioid use in postoperative adolescents as compared to a 0.1% rate of persistent opioid use in their nonsurgical matched cohorts [44].

    Our study’s results align with prior research suggesting that VR-D may play a role in transiently reducing acute pain and that relaxation via guided imagery can promote reductions in both pain and anxiety [20,45]. Research consistently shows that VR is effective in lowering procedural pain, anxiety, and fear in pediatric patients, particularly during needle-related and other painful interventions [46-55]. A few studies have also demonstrated the feasibility of using VR to alleviate acute postoperative pain [21,56]. In adults, a meta-analysis found that patients receiving perioperative VR had lower pain scores than those receiving usual care (mean deviation −0.64, 95% CI −1.05 to −0.22; P<.02). Additionally, patients receiving VR postoperatively experienced a significant reduction in pain scores (mean deviation −0.50, 95% CI −0.76 to −0.24; P=.002) [57]. One pediatric study indicated that a single preoperative VR experience reduced the need for rescue analgesics in the recovery unit for painful procedures [58].

    Relaxation-guided imagery has been shown to reduce both pain and anxiety in children undergoing minor surgery [59]. VR-GR has also demonstrated effectiveness in reducing pain and anxiety in children during medical procedures. These effects were immediate but transient, with some studies reporting reductions lasting up to 30 minutes after a session [21,60,61]. Additionally, a small (n=51) single-center, prospective study evaluated a single VR-GR session for acute postoperative pain and anxiety in children and adolescents. This study showed similar transient reductions in pain intensity and anxiety [21].

    Using guided relaxation, our study aimed to harness the benefits of using mind-body techniques to manage postoperative pain. However, there are several potential reasons for the lack of clinically significant lasting effects on acute pain and anxiety in this population or opioid consumption. First, our study did not include a non-headset control group. Previous studies assessing the effects of VR on opioid use compared VR experiences to standard care without VR [55,62,63]. In our study, every patient utilized a VR headset and had some level of an immersive experience, even with 360-V (a nonimmersive option). As a result, all patients, including the control group, likely experienced some distraction.

    Moreover, the effectiveness of the VR sessions may have been limited by the short duration of each session and the low number of sessions. Ten minutes per day may be an inadequate time to achieve lasting pain relief of severe acute pain, especially as compared to other therapeutic and/or pharmacologic interventions that are administered more frequently. Future studies should investigate the optimal timing and length of intervention for maximal benefit of VR.

    While our results indicated that active, immersive VR experiences had some trends toward effects on both acute pain and anxiety compared to the nonimmersive 360-V control, these effects were not clinically significant. The study may not have produced clear positive results due to experimental factors such as the similarity of the VR and control treatments, the short duration of treatments, and the protocol-driven high use of opioids that were not adequately considered in the study design. Nevertheless, the findings provide a valuable framework for designing future VR studies. We can learn from our null results to design future VR studies with a control treatment that does not use a VR headset and use a population that only receives opioids on an as-needed basis. Longer treatment duration and less subject attrition could also lead to more significant results.

    Conclusions

    This study found that daily, 10-minute VR sessions had trends toward transiently reducing pain and anxiety compared to a 360-V experience in participants following Nuss repair of pectus excavatum. These results were not clinically significant. Due to the limited duration of the intervention and the standardized, scheduled, high utilization of opioids in this population, VR was not sufficient in significantly decreasing opioid use and overall AUC pain scores. Despite these conclusions, exploring guided relaxation VR as an adjunct to, rather than a replacement for, postoperative pharmacologic analgesics may prove valuable. Increasing the length and frequency of VR experiences per day, along with a policy of not automatically administering opioids unless requested, may help decrease opioid usage and AUC pain scores. A systematic integration of VR into perioperative care is likely necessary to impact the pain trajectory and opioid usage in postoperative patients. Furthermore, improving the VR experience to incorporate true guided relaxation would likely enhance effectiveness compared to a purely distraction-based approach. Future studies are needed to further explore the use of this therapy in postoperative pain management.

    Acknowledgments

    The authors gratefully acknowledge Maria E Ashton, MS, RPh, MBA, medical writer, Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, for providing writing assistance, editing, and proofreading.

    The authors gratefully acknowledge Luke Wilson and the Stanford CHARIOT program for the development and use of the Mindful Aurora application.

    Funding

    Support was provided by the Department of Anesthesiology at Cincinnati Children’s Hospital Medical Center and a Research Innovation/Pilot Award from Cincinnati Children’s Hospital Medical Center.

    Conflicts of Interest

    None declared.

    Checklist 1

    CONSORT-eHEALTH checklist (V 1.6.1).

    PDF File, 1122 KB
    1. Yaster M, McNaull PP, Davis PJ. The opioid epidemic in pediatrics: a 2020 update. Curr Opin Anaesthesiol. Jun 2020;33(3):327-334. [CrossRef] [Medline]
    2. Drug overdose deaths: facts and figures. National Institute on Drug Abuse (NIDA). URL: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates [Accessed 2026-02-16]
    3. Hudgins JD, Porter JJ, Monuteaux MC, Bourgeois FT. Trends in opioid prescribing for adolescents and young adults in ambulatory care settings. Pediatrics. Jun 2019;143(6):e20181578. [CrossRef] [Medline]
    4. Johnston LD, O’Malley PM, et al. Monitoring the future" national survey results on drug use, 1975–2017: 2017 overview, key findings on adolescent drug use. Institute for Social Research, University of Michigan; 2017. URL: https://monitoringthefuture.org/wp-content/uploads/2022/08/mtf-overview2017.pdf [Accessed 2026-02-16]
    5. Groenewald CB, Zhou C, Palermo TM, Van Cleve WC. Associations between opioid prescribing patterns and overdose among privately insured adolescents. Pediatrics. Nov 2019;144(5):e20184070. [CrossRef] [Medline]
    6. Battaglia M, Groenewald CB, Campbell F, et al. We need to talk: the urgent conversation on chronic pain, mental health, prescribing patterns and the opioid crisis. J Psychopharmacol. May 2023;37(5):437-448. [CrossRef] [Medline]
    7. Breglio AM, Fitzgerald TN, Moore CB, Einhorn LM. Evaluation of analgesic practice changes following the Nuss procedure in pediatric patients. J Surg Res. Nov 2023;291:289-295. [CrossRef] [Medline]
    8. Densmore JC, Peterson DB, Stahovic LL, et al. Initial surgical and pain management outcomes after Nuss procedure. J Pediatr Surg. Sep 2010;45(9):1767-1771. [CrossRef] [Medline]
    9. Lai K, Notrica DM, McMahon LE, et al. Cryoablation in 350 Nuss procedures: evolution of hospital length of stay and opioid use. J Pediatr Surg. Aug 2023;58(8):1435-1439. [CrossRef] [Medline]
    10. Walter CM, Lee CS, Moore DL, et al. Retrospective study comparing outcomes of multimodal epidural and erector spinae catheter pain protocols after pectus surgery. J Pediatr Surg. Mar 2023;58(3):397-404. [CrossRef] [Medline]
    11. Tashjian VC, Mosadeghi S, Howard AR, et al. Virtual reality for management of pain in hospitalized patients: results of a controlled trial. JMIR Ment Health. Mar 29, 2017;4(1):e9. [CrossRef] [Medline]
    12. Simonetti V, Tomietto M, Comparcini D, Vankova N, Marcelli S, Cicolini G. Effectiveness of virtual reality in the management of paediatric anxiety during the peri‑operative period: a systematic review and meta-analysis. Int J Nurs Stud. Jan 2022;125:104115. [CrossRef] [Medline]
    13. Olbrecht VA, O’Conor KT, Williams SE, et al. Transient reductions in postoperative pain and anxiety with the use of virtual reality in children. Pain Med. Nov 26, 2021;22(11):2426-2435. [CrossRef] [Medline]
    14. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. Nov 19, 1965;150(3699):971-979. [CrossRef] [Medline]
    15. Smith KL, Wang Y, Colloca L. Impact of virtual reality technology on pain and anxiety in pediatric burn patients: a systematic review and meta-analysis. Front Virtual Real. Jan 2022;2:2022. [CrossRef] [Medline]
    16. Indovina P, Barone D, Gallo L, Chirico A, De Pietro G, Giordano A. Virtual reality as a distraction intervention to relieve pain and distress during medical procedures: a comprehensive literature review. Clin J Pain. Sep 2018;34(9):858-877. [CrossRef] [Medline]
    17. Ahmadpour N, Randall H, Choksi H, Gao A, Vaughan C, Poronnik P. Virtual reality interventions for acute and chronic pain management. Int J Biochem Cell Biol. Sep 2019;114:105568. [CrossRef] [Medline]
    18. Hadjiat Y, Marchand S. Virtual reality and the mediation of acute and chronic pain in adult and pediatric populations: research developments. Front Pain Res (Lausanne). 2022;3:840921. [CrossRef] [Medline]
    19. Sánchez-Caballero E, Ortega-Donaire L, Sanz-Martos S. Immersive virtual reality for pain and anxiety management associated with medical procedures in children and adolescents: a systematic review. Children (Basel). Aug 13, 2024;11(8):975. [CrossRef] [Medline]
    20. Hoffman HG, Rodriguez RA, Gonzalez M, et al. Immersive virtual reality as an adjunctive non‑opioid analgesic for pre‑dominantly Latin American children with large severe burn wounds during burn wound cleaning in the intensive care unit: a pilot study. Front Hum Neurosci. 2019;13(262):262. [CrossRef] [Medline]
    21. Olbrecht VA, O’Conor KT, Williams SE, et al. Guided relaxation–based virtual reality for acute postoperative pain and anxiety in a pediatric population: pilot observational study. J Med Internet Res. Jul 12, 2021;23(7):e26328. [CrossRef] [Medline]
    22. Hemington KS, Cheng JC, Bosma RL, Rogachov A, Kim JA, Davis KD. Beyond negative pain‑related psychological factors: resilience is related to lower pain affect in healthy adults. J Pain. Sep 2017;18(9):1117-1128. [CrossRef] [Medline]
    23. Agoston AM, Sieberg CB. Nonpharmacologic treatment of pain. Semin Pediatr Neurol. Aug 2016;23(3):220-223. [CrossRef] [Medline]
    24. Turgut A, Özcan İlçe A, Öztürk H. The effect of immersive virtual reality application on anxiety, pain, and parental satisfaction in the perioperative process of children: a randomized controlled trial. Pain Manag Nurs. Dec 2024;25(6):584-590. [CrossRef] [Medline]
    25. Orgil Z, Johnson L, Karthic A, et al. Feasibility and acceptability of perioperative application of biofeedback-based virtual reality versus active control for pain and anxiety in children and adolescents undergoing surgery: protocol for a pilot randomised controlled trial. BMJ Open. Jan 25, 2023;13(1):e071274. [CrossRef] [Medline]
    26. Olbrecht VA, Williams SE, O’Conor KT, et al. Guided relaxation-based virtual reality versus distraction-based virtual reality or passive control for postoperative pain management in children and adolescents undergoing Nuss repair of pectus excavatum: protocol for a prospective, randomised, controlled trial (FOREVR Peds trial). BMJ Open. Dec 30, 2020;10(12):e040295. [CrossRef] [Medline]
    27. Chan AW, Tetzlaff JM, Gøtzsche PC, et al. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ. Jan 8, 2013;346:e7586. [CrossRef] [Medline]
    28. Hopewell S, Chan AW, Collins GS, et al. CONSORT 2025 statement: updated guideline for reporting randomized trials. JAMA. Jun 10, 2025;333(22):1998-2005. [CrossRef] [Medline]
    29. Tsze DS, von Baeyer CL, Pahalyants V, Dayan PS. Validity and reliability of the verbal numerical rating scale for children aged 4 to 17 years with acute pain. Ann Emerg Med. Jun 2018;71(6):691-702. [CrossRef] [Medline]
    30. Price TJ, Ray PR. Recent advances toward understanding the mysteries of the acute to chronic pain transition. Curr Opin Physiol. Oct 2019;11:42-50. [CrossRef] [Medline]
    31. Pielech M, Ryan M, Logan D, Kaczynski K, White MT, Simons LE. Pain catastrophizing in children with chronic pain and their parents: proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure. Pain. Nov 2014;155(11):2360-2367. [CrossRef] [Medline]
    32. Silverman WK, Fleisig W, Rabian B, Peterson RA. Childhood anxiety sensitivity index. J Clin Child Psychol. Jun 1991;20(2):162-168. [CrossRef]
    33. Gold JI, Mahrer NE. Is virtual reality ready for prime time in the medical space? A randomized control trial of pediatric virtual reality for acute procedural pain management. J Pediatr Psychol. Apr 1, 2018;43(3):266-275. [CrossRef] [Medline]
    34. Proczkowska M, Ericsson E. Validity of the modified‑distraction‑short‑scale and verbal‑numeric‑anxiety‑fear‑rating‑scale for children in a preoperative setting. Paediatr Anaesth. Feb 2024;34(2):121-129. [CrossRef] [Medline]
    35. Adams MCB, Sward KA, Perkins ML, Hurley RW. Standardizing research methods for opioid dose comparison: the NIH HEAL morphine milligram equivalent calculator. Pain. Feb 3, 2025;166(8):1729-1737. [CrossRef] [Medline]
    36. Morphine milligram equivalent (MME) calculator: frequently asked questions (FAQs) for HEAL researchers. National Institutes of Health; 2025. URL: https://www.nih.gov/sites/default/files/2026-01/MME%20Calculator%20FAQ_508.pdf [Accessed 2026-02-16]
    37. Pitt JB, Zeineddin S, Carter M, et al. Demographics of anterior chest wall deformity patients: a tertiary children's hospital experience. J Surg Res. Jan 2024;293:451-457. [CrossRef] [Medline]
    38. Mack SJ, Till BM, Huang C, et al. National trends in pectus excavatum repair: patient age, facility volume, and outcomes. J Thorac Dis. Apr 2022;14(4):952-961. [CrossRef] [Medline]
    39. Rowbotham MC. What is a “clinically meaningful” reduction in pain? Pain. Nov 2001;94(2):131-132. [CrossRef] [Medline]
    40. Sullivan MJ. The pain catastrophizing scale: user manual. McGill University; 2009. URL: https://drsandler.in/PCSmanual.pdf [Accessed 2026-02-16]
    41. Nugent SM, Lovejoy TI, Shull S, Dobscha SK, Morasco BJ. Associations of pain numeric rating scale scores collected during usual care with research administered patient reported pain outcomes. Pain Med. Oct 8, 2021;22(10):2235-2241. [CrossRef] [Medline]
    42. Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017;10:2287-2298. [CrossRef] [Medline]
    43. Rabbitts JA, Fisher E, Rosenbloom BN, Palermo TM. Prevalence and predictors of chronic postsurgical pain in children: a systematic review and meta-analysis. J Pain. Jun 2017;18(6):605-614. [CrossRef] [Medline]
    44. Harbaugh CM, Lee JS, Hu HM, et al. Persistent opioid use among pediatric patients after surgery. Pediatrics. Jan 2018;141(1):e20172439. [CrossRef] [Medline]
    45. Chen SF, Wang HH, Yang HY, Chung UL. Effect of relaxation with guided imagery on the physical and psychological symptoms of breast cancer patients undergoing chemotherapy. Iran Red Crescent Med J. Nov 2015;17(11):e31277. [CrossRef] [Medline]
    46. Dumoulin S, Bouchard S, Ellis J, et al. A randomized controlled trial on the use of virtual reality for needle-related procedures in children and adolescents in the emergency department. Games Health J. Aug 2019;8(4):285-293. [CrossRef] [Medline]
    47. Iannicelli AM, Vito D, Dodaro CA, et al. Does virtual reality reduce pain in pediatric patients? A systematic review. Ital J Pediatr. Dec 30, 2019;45(1):171. [CrossRef] [Medline]
    48. Eijlers R, Utens EMWJ, Staals LM, et al. Systematic review and meta-analysis of virtual reality in pediatrics: effects on pain and anxiety. Anesth Analg. Nov 2019;129(5):1344-1353. [CrossRef] [Medline]
    49. Czech O, Wrzeciono A, Rutkowska A, Guzik A, Kiper P, Rutkowski S. Virtual reality interventions for needle-related procedural pain, fear and anxiety-a systematic review and meta-analysis. J Clin Med. Jul 23, 2021;10(15):3248. [CrossRef] [Medline]
    50. Walther-Larsen S, Petersen T, Friis SM, Aagaard G, Drivenes B, Opstrup P. Immersive virtual reality for pediatric procedural pain: a randomized clinical trial. Hosp Pediatr. Jul 2019;9(7):501-507. [CrossRef] [Medline]
    51. Jenabi E, Bashirian S, Salehi AM, Rafiee M, Bashirian M. Virtual reality for pain reduction during intravenous injection in pediatrics: a systematic review and meta-analysis of controlled clinical trials. Clin Exp Pediatr. Dec 2023;66(12):533-537. [CrossRef] [Medline]
    52. Addab S, Hamdy R, Thorstad K, Le May S, Tsimicalis A. Use of virtual reality in managing paediatric procedural pain and anxiety: an integrative literature review. J Clin Nurs. Nov 2022;31(21-22):3032-3059. [CrossRef] [Medline]
    53. Alshatrat SM, Sabarini JM, Hammouri HM, Al-Bakri IA, Al-Omari WM. Effect of immersive virtual reality on pain in different dental procedures in children: a pilot study. Int J Paediatr Dent. Mar 2022;32(2):264-272. [CrossRef] [Medline]
    54. Gao Y, Xu Y, Liu N, Fan L. Effectiveness of virtual reality intervention on reducing the pain, anxiety and fear of needle-related procedures in paediatric patients: a systematic review and meta-analysis. J Adv Nurs. Jan 2023;79(1):15-30. [CrossRef] [Medline]
    55. Camacho-Cruz J, Palacios-Ariza MA, Orrego-Celestino L, et al. Effectiveness of non-immersive virtual reality in the management of procedure-related pain in preschool children: a randomized clinical trial. Eur J Pediatr. Sep 2023;182(9):4103-4112. [CrossRef] [Medline]
    56. Mosso JL, Rizzo S, Wiederhold B, et al. Cybertherapy--new applications for discomfort reductions. Surgical care unit of heart, neonatology care unit, transplant kidney care unit, delivery room-cesarean surgery and ambulatory surgery, 27 case reports. Stud Health Technol Inform. 2007;125:334-336. [Medline]
    57. Ding L, Hua H, Zhu H, et al. Effects of virtual reality on relieving postoperative pain in surgical patients: a systematic review and meta-analysis. Int J Surg. Oct 2020;82:87-94. [CrossRef] [Medline]
    58. Eijlers R, Dierckx B, Staals LM, et al. Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: a randomised controlled trial. Eur J Anaesthesiol. Oct 2019;36(10):728-737. [CrossRef] [Medline]
    59. Vagnoli L, Bettini A, Amore E, De Masi S, Messeri A. Relaxation-guided imagery reduces perioperative anxiety and pain in children: a randomized study. Eur J Pediatr. Jun 2019;178(6):913-921. [CrossRef] [Medline]
    60. Bernaerts S, Bonroy B, Daems J, et al. Virtual reality for distraction and relaxation in a pediatric hospital setting: an interventional study with a mixed-methods design. Front Digit Health. 2022;4:866119. [CrossRef] [Medline]
    61. Hoag JA, Karst JS, Bingen KM, Palou-Torres A, Yan K. Distracting through procedural pain and distress using virtual reality and guided imagery in pediatric, adolescent, and young adult patients: randomized controlled trial. J Med Internet Res. Apr 18, 2022;24(4):e30260. [CrossRef] [Medline]
    62. Xiang H, Shen J, Wheeler KK, et al. Efficacy of smartphone active and passive virtual reality distraction vs standard care on burn pain among pediatric patients: a randomized clinical trial. JAMA Netw Open. Jun 1, 2021;4(6):e2112082. [CrossRef] [Medline]
    63. Gold JI, SooHoo M, Laikin AM, Lane AS, Klein MJ. Effect of an immersive virtual reality intervention on pain and anxiety associated with peripheral intravenous catheter placement in the pediatric setting: a randomized clinical trial. JAMA Netw Open. Aug 2, 2021;4(8):e2122569. [CrossRef] [Medline]

    ‎
    360-V: 360° video
    AUC: area under the curve
    CCHMC : Cincinnati Children’s Hospital Medical Center
    CONSORT: Consolidated Standard of Reporting Trials
    MME: morphine milligram equivalents
    NRS: numerical rating scale
    PCS : Pain Catastrophizing Scale
    POD : postoperative day
    REDCap: Research Electronic Data Capture
    SPIRIT: Standard Protocol Items: Recommendations for Interventional Trials
    VR: virtual reality
    VR-D : distraction-based gaming virtual reality
    VR-DGR: distraction-based guided relaxation virtual reality
    VR-GR: guided relaxation–based virtual reality

    Edited by Nidhi Rohatgi; submitted 18.Jul.2025; peer-reviewed by Ilja Cornelisz, Jeffrey W Gander; final revised version received 20.Jan.2026; accepted 06.Feb.2026; published 10.Mar.2026.

    Copyright

    © Charlotte M Walter, Dillon Froass, Nora Bell, Lauren Haack, Chloe Boehmer, Claudia Bruguera Torres, Rachel Spivak, Max Chou, Kristie Geisler, Keith O'Conor, Sara E Williams, Lili Ding, Christopher D King, Vanessa A Olbrecht. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 10.Mar.2026.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Perioperative Medicine, is properly cited. The complete bibliographic information, a link to the original publication on http://periop.jmir.org, as well as this copyright and license information must be included.