Effects of virtual reality distraction on pain, stress, and heart rate during pediatric ingrown toenail surgery: A randomized controlled trial

Objective

Immersive virtual reality (VR) shows efficacy in reducing pediatric procedural pain and stress, yet studies remain heterogeneous and conflate stress with anxiety while neglecting physiological measures such as heart rate (HR). The role of goal-directed attention remains underexplored, as no studies have controlled for VR-interactivity to isolate its contribution under clinically relevant conditions. Thus, this RCT investigates the effects of goal-directed VR vs. free-interaction VR vs. standard-of-care (SoC) distraction (controls) on self-reported pain, stress, and HR during ingrown toenail surgery under local anesthesia in children and adolescents.

Study design

Sixty patients aged 10–17 years (M_age = 13.90, SD_age = 1.85, 23 % female) were randomized to either a (1) focused VR group with a specific task, or (2) an exploratory VR group without a task, or (3) a SoC-control group. Patients’ self-reported pain (VAS, primary outcome), self-reported stress and HR (both secondary), were analyzed using Linear Mixed Effect Models.

Results

Self-reported pain and stress followed expected trajectories across the perioperative period, with no overall benefit of VR. Exploratory VR was associated with higher self-reported pain during surgery and smaller post-surgical stress reductions. Both VR conditions significantly reduced HR during anesthesia (needle insertion phase) compared to controls, with this effect persisting into later surgical stages in the exploratory VR group.

Conclusions

While both VR conditions reduced physiological arousal, particularly during anesthesia, focused VR conferred modest benefits in self-reported pain and stress. Findings underscore the need to study cognitive task demands in VR-based distraction and suggest feasibility in pediatric surgery under local anesthesia.