Feasibility of Mobile Phone-Based Virtual Reality as a Non-pharmacologic Acute Procedural Pain Management Intervention in an Inpatient Burn Center.

Feasibility of Mobile Phone-Based Virtual Reality as a Non-pharmacologic Acute Procedural Pain Management Intervention in an Inpatient Burn Center - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice J Clin Psychol Med Settings . 2026 Apr 6;33(2):381–392. doi: 10.1007/s10880-026-10146-z Feasibility of Mobile Phone-Based Virtual Reality as a Non-pharmacologic Acute Procedural Pain Management Intervention in an Inpatient Burn Center Mariel Emrich 1, 2, ✉ , Andrew A McAleavey 1 , Katarzyna Wyka 1, 3 , Andrew Greenway 4 , Abraham P Houng 5 , Philip H Chang 4 , Constance Zhou 6 , JoAnn Difede 1 Author information Article notes Copyright and License information 1 Department of Psychiatry, Weill Cornell Medicine, New York, USA 2 Department of Psychological Sciences, University of Connecticut, Storrs, USA 3 Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, USA 4 Department of Surgery, Trauma, Burns, and Acute and Critical Care Division, Weill Cornell Medicine, New York, USA 5 The Burn Center at Cooperman Barnabas Medical Center, Rutgers New Jersey Medical School, Livingston, USA 6 Weill Cornell/Rockefeller/Sloan Kettering Tri-Institutional MD-PhD Program, New York, USA ✉ Corresponding author. Accepted 2026 Mar 25; Issue date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13226390  PMID: 41942793 Abstract Burn patients often experience severe procedural pain throughout hospitalization, and poorly controlled pain is a significant predictor of long-term psychological adjustment post-injury. Virtual Reality (VR) presents a promising adjunctive approach to pharmacological analgesics by redirecting patients’ attention away from painful stimuli using immersive, multidimensional environments. Recent technological advances have made VR more affordable, portable, and hands-free permitting the head-mounted display to be easily transported with minimal set up, particularly conducive to hospital environments. This proof-of-concept randomized pilot trial compared VR-enhanced distraction to treatment as usual (TAU) during painful procedures (e.g., wound dressing changes) in hospitalized burn patients. Of 51 patients approached, 15 adults enrolled and 100% completed the study. VR was rated as highly enjoyable ( M = 77.5/100) and moderately immersive ( M = 63.3/100) with minimal side effects. Descriptively, VR participants demonstrated smaller increases in peri-procedural pain and anxiety relative to TAU and reported reduced cognitive pain during the procedure (i.e., time thinking about pain; M = 33.3 vs. 94.0). Within six hours post-procedure, fewer VR participants required pharmacologic analgesia compared to TAU participants (50.0% vs. 71.4%). Preliminary data indicate that portable VR appears to be a highly feasible and acceptable adjunct to traditional pharmacologic interventions for acute procedural pain in an inpatient burn center. Clinicaltrials.gov: NCT04685486 . Keywords: Acute pain management, Burn patients, Procedural pain, Virtual reality, Non-pharmacologic interventions Introduction Hospitalized burn patients undergo extremely painful procedures, including wound dressing changes, staple removals, and physical therapy, which can compound the nociceptive and neuropathic pain from the injury itself (Griggs et al., 2017 ). Pain severity during hospitalization is one of the most robust predictors of psychological adjustment in the years following discharge, above and beyond burn size or length of hospitalization (Patterson et al., 2006 ). Opioid analgesics to manage pain not only pose significant risks of adverse side effects, dependence, and hyperalgesia (Holtman & Jellish, 2012 ; Paul et al., 2021 ), but also can have limited efficacy (Emery & Eitan, 2020 ; Emery et al., 2017 ). In fact, studies have found that many burn patients continue to report unrelieved moderate to excruciating pain during wound care even with opioids (Mendoza et al., 2016 ; Perry et al., 1981 ). Thus, the need for non-pharmacologic interventions to manage acute procedural pain in burn patients is critical. Virtual reality (VR) is a promising adjunctive tool for pain reduction by leveraging immersive, multisensory environments to redirect patient’s attention away from painful stimuli (Dreesmann et al., 2022 ; Hoffman et al., 2000 ; Smith et al., 2020 ). VR includes two key features: immersion (i.e., sensory input delivered by the VR system) and presence (i.e., subjective sense of being in the virtual world) that differentiate it from other distraction tasks such as listening to music or watching television (Berkman & Akan, 2019 ; Slater & Wilbur, 1997 ). Previous studies have shown that VR reduces pain during medical and surgical procedures (Albazee et al., 2025 ; Alseneid et al., 2025 ; Dreesmann et al., 2022 ; Keny et al., 2025 ; Smith et al., 2020 ; Teh et al., 2024 ; Uçgun & Çitak, 2025 ). VR has also been shown to reduce procedural anxiety (Arthur et al., 2025 ), which both co-occurs with and exacerbates acute pain (Schupp et al., 2005 ). In burn settings, VR distraction for pain management was first introduced in the 1990s (Hoffman et al., 2000 , 2003 ), and has been found to successfully reduce procedural pain and anxiety (Dewi et al., 2024 ; Lan et al., 2023 ; Lou et al., 2024 ; Mazaheri et al., 2023 ; Morris et al., 2009 ; Norouzkhani et al., 2022 ; Senol Celik et al., 2024 ). The analgesic effects of VR have also been demonstrated by neuroimaging studies showing reduced brain activation in regions associated with acute pain (Dreesmann et al., 2022 ; Hoffman et al., 2006a , 2006b ). VR environments have varied from passive nature scenes (Ramage & Davis, 2025 ) to more interactive games such as SnowWorld (Carrougher et al., 2009 ; Hoffman et al., 2004a , 2004b , 2008 ; Maani et al., 2011 ; McSherry et al., 2018 ), with higher interactivity in the environments generally associated with greater pain reduction (Armstrong et al., 2023 ; Xiang et al., 2021 ). Historically, implementing VR in burn care has been challenging due to logistical barriers such as the use of expensive, heavy, computer-tethered headsets that are not conducive to hospital settings (Hitching et al., 2023 ). Traditional VR systems also require hand-held controllers, which can create accessibility barriers for patients with upper extremity burns (Phelan et al., 2021 ). Recent technological advancements have increased the portability, affordability, and accessibility of VR systems, allowing equipment to be easily transported and utilized with minimal setup, and without the use of hand-held controllers. Despite these developments, further empirical research is needed to evaluate the feasibility and preliminary clinical effects of applying cost-effective, portable, interactive, hands-free VR systems in inpatient medical settings (Hoffman et al., 2019 ). The primary objective of the current study was to determine the feasibility and acceptability of VR for non-pharmacologic acute pain management, as well as identify any barriers to recruitment and implementation within a multidisciplinary inpatient hospital setting. Secondary objectives included examining changes in pain, analgesic use, and anxiety peri-procedure across study arms. Methods This proof-of-concept randomized pilot trial compared VR-enhanced distraction to treatment as usual (TAU) during painful procedures (e.g., wound dressing changes, staple removal, and physical therapy) in hospitalized burn patients. The multidisciplinary study team consisted of individuals from the psychiatry department (e.g., principal investigator, research coordinator, clinical psychologist, and medical students) and burn center team (e.g., surgeons, nurses, and residents). The majority of the data was collected between April, 2019 and March, 2020 before pausing during the COVID-19 pandemic and resuming periodically between July, 2021 and March, 2023 (last four participants). Data collection was ultimately stopped due to reduced personnel and operational resources after the pandemic. This study was approved by the Weill Cornell Medicine Institutional Review Board (#1610017629) and registered on clinicaltrials.gov ( NCT04685486 ). Although the trial was originally designed to evaluate clinical efficacy of the VR intervention compared to TAU, the sample size was smaller than anticipated and limited inferential testing. Thus, this manuscript focuses on feasibility, acceptability, and preliminary changes in pain, analgesic use, and anxiety for this pilot investigation. Participants and Recruitment Participants were recruited from the inpatient unit at the William Randolph Hearst Burn Center at NewYork-Presbyterian Hospital, a 20-bed facility that treats approximately 700 patients annually. Target enrollment was 50 patients (25 per group). Inclusion criteria were: (a) 8 years or older, (b) burn injury being treated at the William Randolph Hearst Burn Center at NewYork-Presbyterian Hospital, (c) awake, alert, ambulatory, (d) burns comprising less than 15% total body surface area (TBSA), (e) no requirement for conscious sedation such as ketamine for procedure, and (f) ability to provide informed consent in English. Exclusion criteria were: (a) diagnosis of a cognitive disorder, psychotic disorder, or bipolar I disorder as determined by previous diagnosis, (b) current opioid abuse, and (c) current evidence or history of significant endocrine, cardiac, neurologic, respiratory, metabolic, genitourinary, or gastrointestinal impairment. Patients with head/facial burns were allowed to participate if they received clearance from the medical team and wore proper bandaging of open wounds while wearing the headset. Of note, the study was initially designed to include adult patients only; inclusion criteria were subsequently broadened to include patients 8 years or older to increase the recruitment pool. However, no children were ultimately approached, screened, or enrolled. Recruitment initially relied on a referral process from the burn team. To increase enrollment, we adopted a more hands-on recruitment approach in which the research coordinator from the psychiatry department reviewed electronic medical records (EMR; located in Allscripts before transitioning to Epic) to identify potential candidates and attended weekly multidisciplinary burn rounds. Following clearance from medical team, participants were recruited at bedside by a research coordinator to complete informed consent. All patients were offered an opportunity to briefly try the VR equipment if they wished before agreeing to participate in the study. Participant compensation was not provided. Study Procedures After consent, participants completed baseline questionnaires (see Measures), administered the day before the painful procedure when possible. Immediately before the procedure, participants were randomly assigned to VR or TAU using blocked randomization. Randomization lists were generated by a biostatistician on a website ( www.sealedenvenlope.com ) with a fixed block size of 6. No stratification was used. Randomization conditions were revealed to participants by the research coordinator, who then completed pre-procedure visual analog scales (VAS) of pain and anxiety. The research coordinator accompanied the patient to the painful procedure which was typically in the burn center hydrotherapy room. Patients randomized to VR were given the headset to wear during the procedure. Halfway through, all participants were asked to rate their pain. Immediately post- procedure, participants completed VAS of pain and anxiety, as well as different facets of pain during the procedure including cognitive, affective and sensory components. Lastly, the research coordinator followed up with participants two hours post-procedure to complete VAS of pain and anxiety. Questionnaires were administered by the research coordinator on an iPad via HIPAA-compliant REDCap. Intervention Conditions Participants randomized to VR were given a portable Samsung Gear VR headset playing an interactive game called Bear Blast, developed by AppliedVR, delivered via a Samsung Galaxy S7 device connected to the headset. This environment was specifically selected for this population because it is an interactive game, an important component of effective pain management (Armstrong et al., 2023 ), while requiring only minimal head movement and no hand controllers, which is particularly critical for burn patients. Participants controlled the direction of a continuously firing cannon by head movement and eye gaze to target objects in a cartoon environment (see Image 1 ). Participants in the VR group received the VR intervention in addition to standard of care during the procedure, while the TAU group received only standard of care. Standard of care includes receiving the medical procedure with pain medications as needed throughout the procedure. Medical staff occasionally play music in the background or talk to the patients during the procedures. However, there are no other formal distraction methods consistently used with patients. Image 1. Open in a new tab Bear Blast VR environment (AppliedVR) Safety Precautions and Equipment Cleaning Protocols Prior to study onset, the study team worked with NewYork-Presbyterian/Weill Cornell Medicine Infection Prevention and Control to ensure proper cleaning of the headsets due to the risks associated with open wounds in an inpatient burn center setting. The headset had a disposable liner that is discarded and replaced between each user and silicone straps were utilized rather than Velcro straps for easier cleaning. Sani-Wipes were utilized to clean the headset and phone. Patients wore a bouffant cap underneath the headset. Additionally, patients with head/facial burns were required to have bandaging of open wounds while wearing the headset. Measures Baseline Measures Demographics and Burn Injury Characteristics . Age, gender, and race/ethnicity were self-reported. Burn injury characteristics (i.e., injury type, TBSA of burn, location of burn, and degree of burn) were obtained through the EMR. Baseline Pain and Anxiety . At baseline, participants were asked to complete visual analog scales (VAS) for current pain and anxiety. VAS ranged from 0 ( no pain/anxiety ) to 100 ( worst possible pain/anxiety ). VAS were utilized to minimize patient burden and have demonstrated sound psychometric properties (Abend et al., 2014 ; Hawker et al., 2011 ; Tamiya et al., 2002 ). Trait Anxiety . Trait anxiety was measured using the subscale of the State-Trait Anxiety Inventory (STAI-T) at baseline to characterize the sample. The STAI-T has demonstrated adequate test–retest reliability and concurrent validity with other measures (Spielberger, 1983 ). The STAI-T is comprised of 20 statements such as “I feel nervous and restless” with options from 1 ( not at all ) to 4 ( very much so ) to describe how they feel in general. Items were summed to create a total score. Cronbach’s alpha was .81 in this sample. Psychiatric Symptoms . To assess a broad range of psychiatric symptoms, screening questions were taken from the Structured Clinical Interview for DSM-IV (SCID-IV) screening module, spanning alcohol use (i.e., ≥ 5 drinks on one occasion), illicit drug use, non-medical use of prescription medications, panic attacks, agoraphobia, social anxiety, specific phobias, obsessions/compulsions, generalized anxiety, and disordered eating. These items assess lifetime endorsement of symptoms or behaviors (with the exception of generalized anxiety which assesses symptoms in the past 6 months) and were used to characterize the sample; full SCID-IV modules were not administered. The mood module of the Structured Clinical Interview for DSM-5 Disorders – Clinician Version (SCID-5-CV) was administered separately to assess for current and past major depressive episodes more comprehensively. Screening items for current hypomanic episodes, past manic/hypomanic episodes, and persistent depressive disorder were also administered. Peri-Procedure Measures Peri-Procedure Pain and Anxiety . Pain severity was assessed using a VAS ranging from 0 ( no pain ) to 100 ( worst possible pain ) obtained immediately before the procedure, halfway through the procedure, immediately post-procedure, and two hours post-procedure. The VAS was presented visually to participants before and after the procedure. During the procedure, pain ratings were obtained verbally using the same 0–100 anchors while participants remained immersed in the VR environment; the headset was not removed. Although traditional VAS administration involves marking a continuous line, verbal numeric ratings were used during the procedure to avoid disrupting immersion. Additionally, VAS measures of different facets of pain including cognitive (i.e., amount of time thinking about pain; 0 = none of the time ; 100 = most of the time ), affective (i.e., pain unpleasantness; 0 = not unpleasant ; 100 = most unpleasant ), and sensory (i.e., worst pain; 0 = no pain ; 100 = worst pain ) were obtained post-procedure (Hoffman et al., 2004a , 2004b ; Hoffman et al., 2006a , 2006b , 2020; Soltani et al., 2018 ). Cognitive, affective, and sensory components of pain have been demonstrated as distinct constructs that can differentially activate different brain regions (Rainville, 2002 ; Rainville et al., 1997 ). Of note, domain-specific pain questions were added in after our first four participants. VAS of current anxiety ranging from 0 ( no anxiety) to 100 ( worst possible anxiety ) were obtained immediately before the procedure, immediately post-procedure, and two hours post-procedure. VR Experience and Acceptability . Following the procedure, those in the VR condition were asked follow up questions adapted from prior studies (e.g., Hoffman et al., 2004a , 2004b ; Sharar et al., 2007 ). Immersion into the virtual environment was assessed with the question, “while experiencing VR, to what extent did you feel like you went into the virtual world?” with options ranging from 0 ( I did not feel like I went into the virtual world at all ) to 100 ( I went completely into the virtual world ). Degree of fun experienced was assessed with the question, “how much fun did you have during VR?” with options ranging from 0 ( no fun ) to 100 ( extremely fun ). Side effects of the VR were assessed with questions of “to what extent if at all did you feel nausea during VR?” and “to what extent if at all did you feel motion sickness during VR?” with options ranging from 0 ( none ) to 100 ( very much ). Lastly, a brief open-ended question was asked, “how was your experience with VR?” These questions were added after our first two participants. Pain Medications . The burn service follows a standardized analgesia protocol for pain management depending on the size of the burn injury. Analgesic medications are usually ordered PRN (as needed), and patients have the option to decline doses. Pain medication administration records from up to 6 h before the procedure and up to 6 h after the procedure were obtained by the study team from the patient’s EMR. Statistical Analyses Demographic and burn injury characteristics were reported using frequencies and percentages for categorical variables and means and standard deviations for continuous variables. For aim 1, feasibility and acceptability were evaluated descriptively using multiple indices including recruitment rate (percentage consented of those approached), intervention adherence (headset wear time and completion), outcome data completeness, self-reported ratings of immersion and fun, qualitative feedback, and adverse side effects. For aim 2, mean pain and anxiety symptoms were calculated for each timepoint by study arm. Within group effect sizes (Cohen’s d z ) were calculated by dividing the mean change score by the standard deviation of the change scores. Due to the small sample size, inferential statistics were not computed. Pain medications were coded into type (opioids vs. non-opioids) and delivery method (IV vs. oral) for descriptive analysis by study arm. Results Primary Aim: Feasibility and Acceptability After screening the EMR, the most common reasons for exclusion prior to approaching for recruitment included medical/psychiatric reasons (e.g., seizure disorder, psychosis, opioid abuse), < 8 years old, non-English language, imminent discharge, TBSA > 15%, and absence of burn injury (e.g., Stevens-Johnson Syndrome). In total, 51 patients were approached to participate and 15 consented, yielding a recruitment rate of 29.4%. Of the 36 who did not participate, 17 declined participation (citing reasons such as dizziness when using VR or wanting to watch what was happening during the procedure), 5 had complicating medical conditions (e.g., severe facial burns), 9 weren’t fluent in English, and 5 were discharged before signing consent. All enrolled participants completed the study and follow-up (100% completion; see Fig. 1 ). Fig. 1. Open in a new tab Consort diagram. Note. VR = virtual reality; TAU = treatment as usual Procedures lasted an average of 8.9 min (range = 3–19). Since the VR game lasted 15 min, the software required resetting for procedures exceeding that length. In these cases, the headset was briefly removed and then reapplied once the program was restarted. Appropriate positioning for VR use was occasionally challenging, particularly when procedures required patients to lie down for wound cleaning or stand during physical therapy; these challenges were mitigated by adjustments such as providing a pillow for head support or allowing patients to hold a handrail for stability. One VR participant removed the headset a few minutes before the procedure ended due to “overstimulation” during a period of heightened pain, while two others very briefly removed it for positioning adjustments or during a pause between dressing removal and wound care initiation. All other VR participants (62.5%) wore the headset for the full duration of the procedure. Participant Characteristics The analytic sample included 15 burn patients ranging from 18 to 63 years old ( M = 35.6; SD = 17.2), who were 60.0% men and 46.7% White. Participants were randomized to VR ( n = 8) or TAU ( n = 7). Groups were similar in trait anxiety ( M VR = 19.0, SD VR = 8.8; M TAU = 17.6, SD TAU = 9.5). A range of psychiatric symptoms were endorsed in both groups. Notably, alcohol use, drug use, and current or prior major depressive episodes were reported by 85.7%, 42.9%, and 42.9% of TAU participants, respectively, and by 37.5%, 12.5%, and 12.5%, VR participants respectively. Burn injuries ranged in location (e.g., legs, hands, torso, face), and severity (2nd-3rd degree), with TBSA ranging from 1 to 7% in VR ( M = 3.1%) and 1–9% in TAU ( M = 5.6%). The time from hospital admission to the study procedure ranged from 1 to 12 days and was comparable across groups ( M = 5.6 days in VR, M = 5.3 days in TAU). The most common medical procedures included dressing application/removal (87.5% of VR vs. 85.7% of TAU) and wound cleaning (75.0% of VR vs. 71.4% of TAU). Less common procedures included staple removal (28.6% of TAU vs. 0.0% of VR) and physical therapy (12.5% of VR vs. 0.0% of TAU). Percentages exceed 100% because some participants underwent multiple procedures during the session. See Table 1 . Table 1. Demographics, burn injury characteristics, and baseline psychiatric symptoms VR ( n = 8) TAU ( n = 7) M (SD)/ n (%) M (SD)/ n (%) Age 35.6 (17.2) 37.3 (16.1) Gender Men 5 (62.5%) 4 (57.1%) Women 3 (37.5%) 3 (42.9%) Race/Ethnicity White 5 (62.5%) 2 (28.6%) African American/Black 2 (25.0%) 2 (28.6%) Asian/Pacific Islander 0 (0.0%) 1 (14.3%) Latinx 1 (12.5%) 2 (28.6%) Burn injury type Flame 1 (12.5%) 3 (42.9%) Scald 6 (75.0%) 3 (42.9%) Contact 1 (12.5%) 1 (14.3%) Burn injury location Head/neck 0 (0.0%) 1 (6.7%) Lower extremities only 4 (26.7%) 3 (20.0%) Upper extremities only 1 (6.7%) 1 (6.7%) Both upper and lower extremities 2 (13.3%) 0 (0.0%) Pelvic/groin/buttocks 1 (6.7%) 2 (13.3%) Burn injury degree Second degree 6 (75.0%) 5 (71.4%) Third degree 2 (25.0%) 2 (28.6%) Burn Injury TBSA M = 3.1% (Range = 1–7%) M = 5.6% (Range = 1–9%) Time from Admission to Study Procedure M = 5.6 days (Range = 2–12 days) M = 5.3 days (Range = 1–10 days) Painful procedure(s) 1 Dressing removal/application 7 (87.5%) 6 (85.7%) Wound cleaning 6 (75.0%) 5 (71.4%) Staple removal 0 (0.0%) 2 (28.6%) Physical therapy 1 (12.5%) 0 (0.0%) Trait anxiety 19.0 (8.8) 17.6 (9.5) SCID-IV screener Alcohol 3 (37.5%) 6 (85.7%) Drugs 1 (12.5%) 3 (42.9%) Prescription medications 0 (0.0%) 0 (0.0%) Panic attacks 4 (50.0%) 4 (57.1%) Agoraphobia 2 (25.0%) 3 (42.9%) Social phobia 4 (50.0%) 2 (28.6%) Specific phobia 5 (62.5%) 5 (71.4%) Obsessions 5 (62.5%) 2 (28.6%) Compulsions 3 (37.5%) 5 (71.4%) Generalized anxiety 5 (62.5%) 4 (57.1%) Anorexia nervosa 3 (37.5%) 4 (57.1%) Binge eating 4 (50.0%) 4 (57.1%) SCID-5 mood module 2 Current MDE 0 (0.0%) 1 (14.3%) Past MDE 1 (12.5%) 2 (28.6%) Current hypomanic episode 0 (0.0%) 0 (0.0%) Past manic or hypomanic episode 0 (0.0%) 3 (42.9%) Dysthymia 0 (0.0%) 2 (28.6%) Open in a new tab 1 Patients may have received more than one painful procedure at the same time and thus percentages do not sum to 100%. 2 Current hypomanic episode, past manic or hypomanic episode, and dysthymia reflect endorsement of screening items and do not represent confirmed DSM-5 diagnoses. Exclusion due to bipolar I disorder was determined via electronic medical record review. MDE = major depressive episode VR Acceptability and Satisfaction Indices On scales from 0 to 100, participants in the VR group rated the experience as highly fun ( M = 77.5; SD = 20.9; range = 50.0–100.0), moderately immersive ( M = 63.3; SD = 35.6; range = 0.0–100.0) with minimal side effects of nausea ( M = 8.7; SD = 13.1; range = 0.0–30.0) or motion sickness ( M = 7.6; SD = 11.6; range = 0.0–30.0). Qualitative feedback was also highly positive; several participants stated the VR was “amazing”, “fun”, and “good for distraction”. Some noted that it reduced awareness of touch and made the procedure feel faster. One participant provided feedback that the noise and visual stimulation was too overwhelming when pain was at its peak and another suggested that the environment may be better suited for children. Side effects were minimal though one participant reported a headache and temporary eye blurriness which he noted occurred with prior recreational use of VR. See Fig. 2 . Fig. 2. Open in a new tab VR experiences. Note: VR = virtual reality; ratings were conducted on scales from 0 to 100 Secondary Aim: Pain Severity, Analgesic Use, and Anxiety Pain Severity Although participants were randomized, mean pain ratings differed descriptively between groups at baseline (VR = 43.8, TAU = 54.3). Within-group effect sizes indicated that pain decreased from baseline (prior to randomization assignment) to pre-procedure (after randomization was disclosed) in both groups, with a larger reduction in VR ( d z = − 0.48) compared to TAU ( d z = − 0.33). Once procedures began, VR blunted the initial rise in pain, with a smaller increase from pre- to mid-procedure ( d z = 0.27) than TAU ( d z = 0.63). From mid- to post-procedure, overall pain in VR continued to rise slightly ( d z = 0.34), whereas TAU participants experienced a substantial decrease ( d z = − 1.15), resulting in similar overall pain levels between groups by the end of the procedure. Although overall post-procedure pain ratings were comparable, domain-specific ratings (cognitive, sensory, and affective) were lower in VR. The widest numerical gap was observed in cognitive pain ( M = 33.3 in VR vs. 94.0 in TAU); however, these comparisons are descriptive only. Ratings for average affective pain were 41.7 in VR and 64.0 in TAU, while ratings for average sensory pain were 52.5 in VR and 78.0 in TAU. From post-procedure to two-hour follow-up, pain declined in VR ( d z = − 0.39) and increased slightly in TAU ( d z = 0.14). See Fig. 3 and Table 2 . Fig. 3. Open in a new tab Pain and Anxiety Ratings Peri-Procedure by Study Arm. Note : Panel (a) Pain severity at baseline (pre-randomization), immediately pre-procedure, mid-procedure, immediately post-procedure, and two-hours after procedure. Panel (b) Anxiety severity at baseline (pre-randomization), immediately pre-procedure, immediately post-procedure, and two-hours after procedure. Panel (c) domain-specific pain ratings of cognitive (i.e., time thinking about pain), affective (i.e., pain unpleasantness), and sensory (i.e., worst pain). VR = virtual reality; TAU = treatment as usual. Ratings were conducted on scales of 0–100 Table 2. Pain severity and anxiety symptoms by study arm VR ( n = 8) M ( SD ) TAU ( n = 7) M ( SD ) Pain Baseline pain (0–100) 43.8 (25.6) 54.3 (25.1) Pre-procedure pain (0–100) 29.4 (24.3) 45.9 (27.2) Mid-procedure pain (0–100) 35.0 (35.9) 62.9 (25.6) Post-procedure pain (0–100) 44.4 (26.1) 39.3 (24.2) Post-procedure cognitive pain (0–100) 33.3 (39.3) 94.0 (13.0) Post-procedure affective pain (0–100) 41.7 (34.8) 64.0 (28.8) Post-procedure sensory pain (0–100) 52.5 (39.5) 78.0 (24.9) Two-hour follow up pain (0–100) 35.0 (25.1) 44.3 (31.0) Anxiety Baseline anxiety (0–100) 21.9 (27.5) 31.4 (37.0) Pre-procedure anxiety (0–100) 25.0 (36.3) 60.0 (38.8) Post-procedure anxiety (0–100) 20.0 (22.8) 45.8 (40.1) Two-hour follow up anxiety (0–100) 22.5 (22.5) 34.2 (37.5) Open in a new tab VR virtual reality, TAU treatment as usual Pain Medications During the 6 h before and after the procedure, 71.4% of TAU patients required pharmacological analgesia (opioids or non-opioids) compared to only half of VR patients (50.0%). Additionally, 57.1% of TAU patients required an opioid analgesic for procedure-associated pain compared to only 37.5% of VR patients. Lastly, 57.1% of TAU patients required IV analgesia compared to only 25.0% of VR patients. Anxiety Symptoms Anxiety scores in the VR group remained relatively low and stable across timepoints while the TAU group showed greater variability (see Table 2 ). There was no significant spike in anxiety pre-procedure in VR ( d z = 0.06), whereas TAU showed a large increase ( d z = 0.80). From pre- to post-procedure, anxiety decreased in both groups ( d z = − 0.19 in VR and d z = − 0.48 in TAU). From post-procedure to two-hour follow-up, VR participants’ anxiety rose slightly ( d z = 0.14), whereas TAU participants’ anxiety continued to decrease ( d z = − 0.90), resulting in similar anxiety levels between groups by the end of the follow-up. See Fig. 3 and Table 2 . Discussion The primary aim of the present study was to determine the feasibility and acceptability of portable, hands-free VR for non-pharmacologic acute pain management in hospitalized adult burn patients. The mobile-phone based VR approach has low technological and cost barriers, making it especially promising for use in settings with limited resources where next-generation VR may be unavailable or unaffordable. The recruitment rate of 29.4% was comparable to other burn studies (e.g., Armstrong et al., 2023 ; Blokzijl et al., 2023 ), supporting feasibility within this population. Feasibility was further supported by high ratings of fun, 100% completion, and minimal side effects, which also replicate prior VR burn studies (e.g., Hoffman et al., 2008 ). These findings suggest that VR-enhanced distraction is a highly feasible and acceptable adjunct to pharmacologic interventions for pain in this population. The secondary objectives of this study included examining changes in pain, analgesic use, and anxiety peri-procedure across study arms. Data provides preliminary support that VR may mitigate anticipatory and peri-procedure pain and anxiety. Both groups showed pain reductions from baseline to pre-procedure, but the decline was steeper in VR participants, suggesting possible expectancy effects. Furthermore, TAU participants experienced a sharp increase in anxiety from baseline to pre-procedure, while VR participants maintained relatively stable low levels, suggesting that VR buffered anticipatory anxiety. As anticipatory anxiety can worsen procedural pain (Schupp et al., 2005 ), VR’s ability to reduce anticipatory anxiety may be an important pathway to reducing pain. Few existing VR studies have assessed pain before and after randomization disclosure, so these results shed light on potential pre-procedural effects. Nevertheless, given the lack of an experimental control condition and standardization across pain medication use, these differences should be interpreted cautiously. During procedures, VR appeared to blunt pain increases relative to TAU. While TAU showed a typical pain trajectory, with a peak during the procedure and gradual decline afterward, VR group demonstrated lower and more stable pain responses throughout the procedure. Pain increased from mid-intervention to post-intervention for those in VR, which may reflect a “rebound effect” when patients transitioned out of the immersive virtual environment and re-engaged with the hospital setting. Despite similar overall pain ratings post-procedure between groups, domain-specific pain measures revealed clearer benefits of VR, particularly reduced time thinking about pain, which aligns with previous studies (Hoffman et al., 2000 ) and supports VR’s purported mechanism of diverting attention away from painful stimuli. Anxiety remained relatively stable across timepoints in VR participants, whereas TAU participants showed a sharp spike in anxiety pre-procedure followed by declines at later timepoints. Two hours post-procedure, pain decreased in the VR group and increased in TAU, suggesting that VR may have lasting effects. Notably, a smaller proportion of VR participants required post-procedural pharmacologic analgesia, including opioids, underscoring VR’s potential clinical impact. Strengths and Limitations A strength of this study was the use of multiple assessment timepoints, which allowed us to capture the anticipatory and fluctuating nature of pain and anxiety more precisely than the pre-post or post-only designs of many VR burn studies (e.g,. Carrougher et al., 2009 ; Hoffman et al., 2000 ). Another strength included the portability, relatively low cost, and hands-free nature of the equipment utilized which helped reduce significant accessibility barriers for burn patients. Limitations included the small sample size which precluded inferential testing and limited the ability to control for potentially important variables such as patient characteristics, burn characteristics, and pain medication use. Although participants were randomized, the small sample may have resulted in chance baseline differences in pain ratings at baseline, making it challenging to interpret changes over time. These factors may have impacted pain and anxiety symptoms, and findings should therefore be interpreted cautiously. Moreover, the study was not conducted fully as originally planned, which may have introduced expectancy effects. Although the study was open to patients over the age of 8, the enrolled sample was comprised of only adults over 18, limiting generalizability to pediatric populations. Additionally, our study was unblinded; the research coordinator was unblinded to the randomization scheme and medical staff were aware of the condition which may have resulted in inadvertently treating VR patients differently. Since VR studies are inherently difficult to blind, future trials may consider VR-based control conditions (e.g., still images) to reduce potential bias in care. Lastly, there was some variation in the amount of time between hospital admission and the study procedure, as well as the number of procedures received over that time frame, which may have impacted pain and anxiety ratings. Due to practical constraints, these factors could not be standardized across participants. Lessons Learned and Future Directions Multidisciplinary collaboration across the psychiatry and burn teams was critical. A hands-on recruitment model (e.g., attending multidisciplinary rounds and screening EMR) was more successful than relying on referrals from the burn team and designated “point people” in the burn center improved coordination. If possible, future studies may opt to utilize a research assistant embedded in the burn unit. Additionally, recruitment was limited by stringent eligibility criteria, including language barriers, length of hospital stay, and prior medical/psychiatric conditions. Future studies may benefit from utilizing translators, expanding eligibility criteria (e.g., allowing larger burn sizes), and earlier recruitment post-admission to maximize enrollment. Several lessons were also learned regarding intervention execution. Allowing patients to try the VR system prior to their painful procedure helped reduce uncertainty, particularly among those unfamiliar with the technology. Intervention standardization proved to be challenging (e.g., staff conversing with patients during procedure, background music, and the presence of other patients). Patient preferences for the VR content emerged during qualitative feedback; offering a choice of multiple environments in the future may be beneficial. VR intervention length should ideally be aligned with medical procedure length. Although patients did not report disrupted immersion, research staff noted that restarting the 15 min program during longer procedures and briefly removing the headset may have reduced immersion. Qualitative feedback also suggested that perhaps VR may be better suited for moderate rather than severe pain, warranting further examination. Finally, lessons were learned regarding assessments. The research coordinator collected pain ratings aloud during the procedure, which may have interrupted VR immersion. Future studies may benefit from incorporating pain ratings into the headset interface (e.g., via eye gaze or as part of the game). Since our mid-procedure pain ratings were particularly important to observe differences between treatment arms, future studies should consider striking a balance between adding additional assessment time points to more accurately capture pain and anxiety trajectories while simultaneously minimizing disruption of immersion. Key Takeaways Mobile-phone based VR-enhanced distraction that is relatively low cost, hands-free, and portable appears to be a highly acceptable and feasible adjunct to pharmacologic pain interventions in an inpatient burn center. Preliminary data indicate that VR may reduce anticipatory and peri-procedural pain (particularly time thinking about pain) and anxiety, as well as reduce analgesic use following medical procedures. Fully-powered randomized controlled trials with more rigorous control conditions are needed. Acknowledgements The authors would like to acknowledge the following individuals for their help with the study and/or with the preparation of this manuscript: Olivia Baryluk; Chelsea Boydstun, MD; Hana Elhassan, MD; Cameron Gibson, MD; Christina Lee, MD; Rachelle Lodescar, MD; Pooja Jethani, MD; and Crystal Wang, MD. Author Contribution ME: Conceptualization, methodology, formal analysis, investigation, writing – original draft, visualization, project administration AAM: conceptualization, methodology, investigation, project administration, writing – review and editing KW: conceptualization, methodology, supervision, writing – review and editing AG: investigation, writing – review and editing APH: investigation, writing – review and editing, supervision PHC: investigation, writing – review and editing, supervision CZ: formal analysis, writing – original draft JD: conceptualization, methodology, writing – original draft, project administration, funding acquisition, supervision. Funding Funding, equipment, and software were obtained from AppliedVR. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Conflicts of Interest The authors report no conflicts of interest. Footnotes Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References Abend, R., Dan, O., Maoz, K., Raz, S., & Bar-Haim, Y. (2014). Reliability, validity and sensitivity of a computerized visual analog scale measuring state anxiety. Journal of Behavior Therapy and Experimental Psychiatry, 45 , 447–453. 10.1016/j.jbtep.2014.06.004 [ DOI ] [ PubMed ] [ Google Scholar ] Albazee, E., Alrajehi, A., Alsahli, F. M., Alqemlas, A., Aldhaen, A., Alkandari, A., Alkandari, H., & Alkanderi, W. (2025). 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