# Fifty young patients used an underwater virtual world or guided imagery during two unsedated procedures and virtual reality helped most when fears about pain were already high

> By filling a patient's sight and hearing with an interactive underwater world, virtual reality can draw attention away from a needle or dressing change. A clinical trial involving children and young adults found that this immersive approach eased procedure pain about as...

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Byline: ARGO.net Editorial Team
Published: 2026-08-18T01:30:03+00:00
Categories: Explainer, Health

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By filling a patient's sight and hearing with an interactive underwater world, **virtual reality** can draw attention away from a needle or dressing change. A clinical trial involving children and young adults found that this immersive approach eased procedure pain about as well as guided imagery, while producing a clearer reduction in short-term anxiety.

The [randomized controlled trial](https://www.jmir.org/2022/4/e30260/), published in the Journal of Medical Internet Research in 2022, compared VR with **guided imagery**, which uses breathing instructions and detailed descriptions of a calming scene. Researchers also found clues that a patient's usual anxiety level and expectations about pain could influence which method provides greater relief.

Such differences could be useful for young people receiving treatment for cancer, sickle cell disease and other blood disorders. Many undergo the same uncomfortable procedures for months or years. A distraction method that suits the individual patient may help make this repeated care easier to manage.

## How the crossover trial tested both methods

Researchers recruited patients from hematology, oncology and blood and marrow transplant services at a large children's hospital in Wisconsin. Eligible participants were 8 to 25 years old, had received their diagnosis at least one month earlier and were undergoing a procedure without sedation.

The procedures included drawing blood from a vein, accessing an implanted port, or changing the dressing around a central line. The team screened 102 people and enrolled 67. Fifty-two completed both interventions and missing information reduced the [final analysis](https://pmc.ncbi.nlm.nih.gov/articles/PMC9062714/) to [50 participants](https://pubmed.ncbi.nlm.nih.gov/35436209/). Their median age was 13.

The **randomized crossover trial** allowed every participant to try both methods during separate procedures. Some received VR first, while the others began with guided imagery. The visits were generally separated by 5 to 40 days and each person underwent the same type of procedure at both visits. The order was randomly assigned, with further study details recorded in the [ClinicalTrials.gov registry](https://clinicaltrials.gov/study/NCT04892160).

Participants answered questions before and after each procedure. They rated pain, nervousness, time spent thinking about pain and their current anxiety. Research staff also watched for outward signs of distress, including facial expression, movement, vocal sounds and cooperation.

## An underwater experience in two forms

Both interventions lasted about 15 minutes and used an underwater setting, which helped the researchers compare the ways information was delivered. The VR condition used **KindVR Aqua**, an interactive program viewed through a Samsung Gear VR headset with noise-cancelling headphones.

Participants moved through a digital ocean filled with sea creatures. They could watch the scene passively or use a handheld controller to launch balls at the animals, changing their colors and earning points. Active play required attention and simple physical responses. Nearly all participants, 47 of 50, chose to interact with the virtual environment.

The guided imagery recording described a similar ocean. Patients heard instructions for deep breathing, followed by detailed descriptions of swimming through clear water and seeing marine animals. Headphones reduced outside sound, while the patient remained able to see the treatment room and the procedure.

Before the trial began, principal investigator **Jennifer Hoag** explained the central research question in a [Children's Wisconsin announcement](https://childrenswi.org/At-Every-Turn/Stories/2017/10/virtual-reality-cancer-care): "We want to know if the more immersive components of virtual reality benefit patients in additional ways when it comes to anxiety and pain."

## VR and guided imagery eased pain equally

After each procedure, patients used a scale from 0 to 100 to report their worst pain and average pain. They also rated how nervous they had felt about pain and how much time they had spent thinking about it. The researchers found no significant overall difference between VR and guided imagery on any of these measures.

Staff observations reached a similar result. Scores based on visible distress and cooperation did not differ between the two conditions. Children and young adults also reported comparable pain outcomes, although the study's age groups were small.

Hoag and her colleagues summarized the central result in the paper: "In our sample, VR worked as well as GI to manage the pain and distress associated with common procedures." The finding places VR alongside an established, simple method for managing **procedural pain**.

Most participants reported fairly low pain during the procedures. Such low scores can leave little room for an intervention to produce a measurable improvement. Patients who face more painful procedures may experience different results, which would require testing in another trial.

## VR produced a clearer drop in procedure anxiety

Researchers measured **state anxiety**, meaning the level of anxiety a person feels at a particular moment. Anxiety scores fell from before to after the procedure during both interventions. The decrease reached statistical significance during VR, with a probability value below.001. The change during guided imagery had a probability value of.07 and did not reach the study's significance threshold.

The immersive environment may have occupied more of the patient's attention during the procedure. VR combined visual movement, sound and active play inside a scene that blocked the treatment room from view. Guided imagery relied on listening and imagination, leaving more room for sights in the clinic to compete for attention.

Among the 12 participants with sickle cell disease, anxiety fell more during VR than during guided imagery. The small subgroup prevents broad conclusions, although the result offers a useful direction for future studies involving patients who experience recurring pain crises and frequent needle procedures.

## Fears about pain changed the response

The team also measured **pain catastrophizing**, a term for thought patterns that make pain feel overwhelming, threatening, or impossible to control. Examples include repeatedly thinking about the expected pain and feeling helpless when it begins. Seven participants, representing 14 percent of the final group, had elevated scores.

Higher catastrophizing scores were linked with greater worst pain and average pain during both interventions. A different pattern appeared when the researchers examined nervousness. Greater catastrophizing was associated with more nervousness about pain during guided imagery, while the same relationship was absent during VR.

Rumination and helplessness followed a similar pattern. Participants with stronger tendencies to dwell on pain or feel powerless reported more nervousness during guided imagery, while those tendencies were not tied to nervousness during VR. The virtual environment may have given these patients a demanding task that reduced the attention available for worried thoughts.

Only a small number of participants had high catastrophizing scores, so the finding remains preliminary. A larger trial focused on children with strong fears about pain could test whether immersive distraction consistently weakens the link between those fears and distress during treatment.

## Guided imagery helped patients with lasting anxiety

**Trait anxiety** describes a person's general tendency to experience anxiety across many situations. It differs from the temporary fear that may rise before a needle procedure. The researchers expected highly anxious patients to gain more from the immersive qualities of VR, yet the results suggested a more complex response.

During VR, higher trait anxiety remained linked with every area of self-reported pain measured by the team. During guided imagery, trait anxiety was related to worst pain and nervousness, while it was not significantly related to average pain or time spent thinking about pain.

The study authors proposed that guided imagery offered two useful features for patients with lasting anxiety. Slow, deep breathing could lower physical arousal, while the ability to see the room could provide a greater sense of control. Some patients may feel calmer when they can follow the nurse's actions and anticipate each step.

VR may suit patients whose distress rises mainly around a particular procedure. Guided imagery may suit those who often feel anxious and benefit from breathing exercises combined with awareness of their surroundings. Clinical teams would need to consider patient preference alongside these early patterns.

## Why the 50-person sample limits the findings

A final group of 50 participants provided enough information for the planned comparison, although it offered limited power for examining smaller subgroups. Only seven participants had elevated pain catastrophizing and the diagnostic groups included 31 patients with cancer, 12 with sickle cell disease and seven with other conditions.

The study took place at one medical center and used a convenience sample. Participants also underwent different procedures, including port access and blood draws. Variations in diagnosis, treatment history and procedure type may have influenced how individuals responded.

There was no low-distraction control group because supportive distraction was already considered standard care at the hospital. As a result, the trial directly shows how VR compared with guided imagery. It cannot measure how much either method improved pain compared with receiving minimal distraction.

Low pain and anxiety scores created another limitation. The researchers suggested that future work could examine more difficult procedures, such as lumbar punctures or the placement of a tube through the nose into the stomach. Larger studies could also recruit participants with similar diagnoses or select patients who already report substantial procedure distress.

## How tailored distraction could improve care

The findings support a more personal approach to **non-drug pain care**. A short assessment of a patient's usual anxiety, fears about pain and wish to watch the procedure could help staff choose between an immersive headset and a guided recording.

VR equipment requires cleaning, technical support and screening for conditions that may make headset use unsuitable. The trial excluded people with certain physical impairments, active skin infections, a history of seizure disorder, or developmental delays that prevented completion of the study measures. Guided imagery requires simpler equipment and can be delivered through an audio recording.

Patient choice may also influence success. A child who enjoys games could engage deeply with the virtual ocean, while another may prefer breathing slowly and listening to a calm voice. Keeping both options available would allow nurses and mental health specialists to adjust support across repeated visits.

The trial presents **individualized distraction** as a practical direction for routine procedures where sedation is considered unnecessary. VR and guided imagery achieved similar overall pain results, while the anxiety findings suggest that the patient's thoughts and emotional habits can influence the experience. Larger trials can now test whether matching the method to those traits brings steadier relief.