Introduction

The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage [1]. Acute pain, serving as a physiological signal of actual or potential tissue damage, arises from injuries or disease and is expected to subside upon the healing of its underlying cause. When pain outlasts the expected tissue healing period, persisting beyond 3 months and leading to significant emotional distress and/or functional disability, it is considered chronic [2, 3].

The immediate sensation of acute pain can evolve to trigger behavioral responses aimed at minimizing injury or avoiding further harm. Although evolutionarily advantageous and ontogenically useful in promoting survival, acute pain is by definition an unpleasant experience and can, in many cases, be significantly debilitating. Inadequately managed acute pain contributes to a range of physiological derangements, including poor cough and ventilation mechanics, increased sympathetic activity, increased inflammation and reduced immune function, and impaired wound healing, among many others [4, 5]. Moreover, poorly controlled acute pain contributes to increased healthcare expenses through longer hospital stays, resource utilization, and potential development of chronic pain [5]. Thus, adequate management of acute pain necessitates diverse and effective management strategies.

Chronic pain, in contrast to acute pain, represents a persistent condition extending for at least 3 months [1, 3]. While acute pain is in many circumstances an evolutionarily advantageous physiological mechanism, chronic pain is by definition maladaptive, reflecting changes in the nervous system that perpetuate pain even after the initial injury or noxious stimulus has resolved [6, 7]. The development of chronic pain is frequently associated with the insufficient or inappropriate management of acute pain, highlighting the critical importance of effective acute pain control in preventing this transition [8, 9]. Chronic pain is characterized not only by its duration but also by its multifaceted impact on the individual’s physical, psychological, and social well-being [8,9,10,11]. This condition can lead to significant functional impairment, reduced quality of life, and substantial financial burden [12]. Thus, treating chronic pain is an important, albeit resource-intensive endeavor.

Significant advancements in non-pharmacologic, minimally invasive techniques have recently transformed the landscape of pain management [13,14,15]. Within this context, extended reality (XR) has emerged as a pioneering and versatile modality capable of enhancing the relief of both acute and chronic pain through its broad range of applications. This narrative review provides an overview of recent XR-based applications in pain medicine, focusing on select studies conducted between 2020 and 2023, with the aim of shedding light on XR’s emerging role in pain management.

The Realm of Extended Reality: Definitions and Developments

VR is a computer-generated simulation of a three-dimensional (3D) environment which supplants the user’s real-world surroundings and can be interacted with in a seemingly natural manner. Augmented reality (AR) overlays digital elements such as images, sounds, or other data onto the real environment, thereby enriching the user’s perception of reality. Distinct from VR, AR enhances rather than replaces the physical world, enabling users to engage with both virtual and actual elements simultaneously. Mixed reality (MR) applications combine virtual and augmented realities. Of note, the term extended reality (XR) includes VR, AR, and MR applications (see Table 1, 2, and 3 for definitions and Fig. 1).

Table 1 Definitions of extended reality terms and concepts
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Table 2 Types of extended reality head mounted displays
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Table 3 Extended reality additional hardware and sensors
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Fig. 1
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Extended reality nomenclature and concepts

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Technological Evolution in Human Computer Interaction (HCI)

The history of XR, particularly VR and AR, is deeply intertwined with the evolution of human computer interaction (HCI). The advancement from text-based commands to intuitive graphical user interfaces (GUIs) made technology more accessible and user-friendly [16]. Touchscreen technology further revolutionized HCI by allowing for direct manipulation of digital elements, setting the stage for more interactive interfaces. These advancements in HCI have progressively enhanced user engagement, paving the way for the creation of more complex and realistic virtual environments [16]. The development of XR technologies is marked by continuous innovations, from Ivan Sutherland's “Sword of Damocles,” the first VR head-mounted display (HMD) system, to contemporary VR and AR applications [17]. This evolution has introduced novel ways for users to interact with digital environments, culminating in transformative experiences offered by XR. Modern XR systems offer high-resolution displays, accurate motion tracking, and advanced interactive capabilities, providing users with increasingly realistic and immersive experiences. The shift to intuitive, user-centered interfaces has been a critical factor in the growth of XR, increasingly democratizing access to immersive technologies and paving the way for their widespread adoption.

Technological Principles Behind VR and AR

The core of VR and AR technologies lies in creating immersive 3D environments through HMDs which rely on stereoscopic display, or the use of slightly different angles of the same scene, to simulate natural human depth perception (Fig. 2). HMDs have evolved to include integrated or external motion sensors for VR immersion as well as accurate digital overlays and depth perception systems for AR. Haptic feedback and refined spatial audio are integral components of current iterations, allowing for more accurate simulations of natural human touch and sound perception, respectively. Additional improvements in image-rendering engines and motion tracking systems now support increasingly realistic and interactive experiences (Fig. 3).

Fig. 2
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Diagrammatic representation of head mounted display (HMD) and hardware needed for XR

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Fig. 3
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Reproduced with permission from AugMend Health

Depiction of a mindfulness and assessment environment with an avatar.

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In the realm of XR applications, the qualitative characteristics of behavioral realism and immersion are fundamental in enriching user experience. Immersion, achieved through sophisticated graphics, spatial audio, and interactive elements, deepens the user’s sensory engagement, creating a more compelling sense of real presence within the virtual environment. Behavioral realism, which measures how closely interactions and behaviors within an XR environment mimic those in the real world, increases participant engagement in therapeutic or training interventions in which accurate replication of real-life scenarios is fundamental. The addition of biofeedback, or responsiveness to real-time physiological data, such as heart rate, electrophysiological signals, or breathing patterns, further enhances user engagement by allowing for personalized interactions with the virtual or augmented environment.

Extended Reality Applications in Pain Management

In the realm of medicine, VR and AR support a wide range of applications. AR has been leveraged to simulate operating room environments for surgical training and enhance learning experiences for physicians and patients. Meanwhile, VR has been extensively used for immersive therapies in several conditions, ranging from spinal cord injuries to pain management [18,19,20,21,22,23,24,25]. The use of VR in acute pain management, such as during burn wound care, dental procedures, and labor, has been shown to facilitate rapid reductions in pain intensity [26,27,28]. In chronic pain management, VR often goes beyond immediate relief, serving as a longstanding therapeutic tool by offering techniques for relaxation, physical rehabilitation, cognitive behavioral therapy, and pain education [29]. This dual capability of VR, encompassing strategies for both immediate pain relief and enduring pain management, highlights its promise in contributing to the future landscape of pain management.

Mechanism of Action

The utility of XR applications in medicine is a direct result of their capability to interface with and engage human perception [30]. By stimulating the visual, auditory, and haptic senses, these technologies create immersive experiences that significantly modulate the user’s attention, thoughts, and emotions [16, 29]. In pain management, specifically, XR facilitates therapeutic neurocognitive and psychological states through distraction, focus-shifting, and skill-building [31]. These mechanisms form a continuum, reflecting a progression in the patient’s active role in managing pain [31]. VR-mediated distraction analgesia involves shifting sensory and cognitive focus away from pain processing toward an immersive virtual world [32, 33]. VR is thus particularly suited to provide analgesia during painful medical interventions for the awake patient or in periods of sharp, fleeting pain such as during labor and post-surgical recovery [34]. Attention modulation, or focus shifting, further refines this approach by encouraging users to systematically alter their focus within the VR environment, aiding in more effectively diverting attention from both acute and chronic pain [31, 35]. For chronic pain, the emphasis shifts to skill-building, which empowers patients to develop and refine self-regulatory techniques for managing their pain over the long term [31, 36]. In addition to facilitating these neurocognitive adaptations, VR also offers therapeutic benefits for chronic pain by directly improving physical function endpoints closely related to pain relief, such as enhancing range of motion, building isokinetic strength, and bolstering static muscular endurance [37, 38].

Although the detailed neurobiological mechanisms of XR’s effects on pain still require further exploration, it has been hypothesized that immersive XR experiences might lead to disruption of maladaptive corticothalamic pathways involved in pathologic pain processing [39]. For example, a fully immersive simulation of gait biomechanics was determined to increase thalamic gamma-aminobutyric acid (GABA) levels in patients with spinal cord injuries (SCI) and increase activity in cortical regions involved in sensorimotor execution and control in patients with spinal cord injuries (SCI) [40]. A VR meditative intervention for patients with opioid use disorder (OUD) experiencing pain was associated with decreases in task-related postcentral gyrus (PCG) activation, a key area of the pain neuromatrix [41]. XR-facilitated experiences may exert their therapeutic effects by modulating additional brain regions implicated in the brain’s descending pain-control system known to be regulated by attention, emotion, and memory, including the periaqueductal gray (PAG) and the anterior cingulate cortex (ACC) [42,43,44].

XR Applications in Acute Pain

The effectiveness of VR in helping manage acute pain has been supported through numerous clinical trials across a wide range of conditions and clinical settings (Table 4).

Table 4 Studies using virtual reality for acute pain conditions
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Labor and Delivery

In a randomized controlled trial (RCT) studying 40 women in labor, the VR treatment arm witnessed an average decrease of 0.52 in the visual analog score (VAS) versus an increase of 0.58 (p = 0.03) in the control arm [27]. Additionally, the control arm experienced a higher average maternal heart rate (86.8/min) postintervention compared to the VR arm (76.3/min, p = 0.01). A double-blind, RCT investigating VR-delivered cognitive behavioral techniques for patients in the active labor phase reported significant reduction in pain intensity as measured by the VAS and the Verbal Rating Scale (VRS) [45]. The study included 5 groups: A (VR videos of newborn photographs with classical music), B (VR video of newborn photograph album), C (introductory film regarding Turkey), D (only classical music), and E (routine hospital care). While all techniques led to average reductions in labor pain, the VR groups A and B were more effective than the other assessed interventions, with Groups A and B reporting average reductions of 21.94% and 22.26% in VAS and 33.33% and 31.82% in VRS scores, respectively. These findings suggest that the effectiveness of VR in pain management may critically depend on the specific content provided and its interplay with the user’s psychological state.

Additional insights emerge from evidence suggesting that VR interventions in labor and delivery may be more effective in addressing specific dimensions of pain [46, 47]. An RCT assessing VR-delivered analgesia via the Pain Inventory, a validated pain intensity and quality questionnaire, identified reductions in the cognitive and sensory dimensions, but not in the affective dimension of pain [48]. The intervention consisted of an immersive 360-degree environment featuring a serene beach and was associated with reductions of 5.83% and 6.43% in the cognitive and sensory aspects of pain, respectively. These findings underscore the nuanced efficacy of VR in the context of labor and delivery, hinting at its capacity for selective mitigation of specific acute pain dimensions.

Acute Perioperative Pain

Research on VR applications for periprocedural acute pain in the pediatric population has revealed beneficial effects on psychological endpoints associated with pain, although results on its efficacy in pain intensity have been mixed. For example, providing pediatric patients with a VR application featuring a roller coaster simulation during intravenous catheter placement increased satisfaction from anxiety management when compared to standard two-dimensional distraction methods [49]. Similarly, a mindfulness-based VR intervention resulted in superior improvements in short-term anxiety as measured by the Spielberger State-Trait Anxiety Inventory compared to conventional distraction methods among pediatric patients waiting in the emergency department [50]. Of note, although both interventions led to greater reductions in average pain intensity endpoints compared to traditional methods, neither reached statistical significance [49, 50]. Along these lines, a three-arm RCT comparing VR, cold vibrations, and conventional management identified no differences in pain intensity reduction among pediatric patients undergoing peripheral IV catheterization [51]. A fourth study in this population, testing a multisensory VR intervention during peripheral IV catheter placement, yielded statistically significant reductions in pain intensity when compared to conventional distraction methods, amounting to average patient-reported reductions of 1.34 points in pain intensity as measured by the Faces Pain Scale–Revised (FPS-R) [52]. Similarly, a VR application providing distraction and procedural information to pediatric patients undergoing venipuncture procedures was found to lead to moderate reductions in FPS-R scores [53] Intraprocedural VR-enabled distraction has also been associated with shorter recovery times when compared to standard of care for pediatric patients undergoing minor surgical procedures without sedation [54].

The observed variability in pain intensity outcomes for VR interventions in pediatric perioperative pain may partly stem from differential responses to VR depending on individual patient characteristics [55, 56•, 57]. Notably, among pediatric patients with high pain catastrophizing baseline tendencies, VR was associated with less nervousness about pain during procedures than was GI [57]. Additionally, it was determined that patients with sickle cell disease experienced greater reductions in procedural anxiety with VR than with GI [57].

In the adult population, numerous VR applications have been tested intraoperatively during procedures that do not require general anesthesia [58, 59]. A recent RCT revealed that patients assigned to VR-supported 3D environments with elements of music therapy and gamification reported lower average VAS scores during atrial fibrillation ablation procedures when compared to patients in the control group (3.5 vs 4.3; p = 0.004) [60]. Another notable recent intervention is a VR-supported immersive and interactive 8-min video called “Forest of Serenity,” which simulated a peaceful rainforest and a lake with animated wildlife, among patients undergoing outpatient hysteroscopy [61]. This intervention was associated with greater reductions in VAS scores (6.0 vs. 3.7, p = 0.009) among women undergoing outpatient hysteroscopies when compared to standard of care. A recent example of XR in the adult intraoperative setting is the use of a VR-based application that featured relaxing virtual environments during total knee arthroplasty (TKA) under spinal anesthesia [62]. A small preliminary study (n = 20) of VR in this setting not only found an average reduction in post-operative VAS scores of 2.2 points, but was also associated with fewer intraoperative adverse events [63]. Furthermore, fewer patients in the VR group required sedation (20% vs 100%) or experienced hypotensive events (10% vs 60%) compared to the control group.

While VR-based interventions delivered intraoperatively contribute to improved pain outcomes in the immediate postoperative period [64], VR can also support the delivery of postoperative care in painful procedures [65]. When VR-enabled distraction is coupled with pharmacologic analgesia during wound dressing changes following a hemorrhoidectomy, it has been associated with significant reductions in acute pain when compared to pharmacologic analgesia alone [66]. Similar effects on acute pain intensity have been identified when using VR during wound dressing changes among patients with burn injuries [67] and postoperatively following the drainage of perianal abscesses [68].

Acute Pain Associated with Dental Procedures

VR-based interventions in dental periprocedural care stand out, given their demonstrated effectiveness in reducing pain intensity while positively affecting psychological endpoints that modulate the pain experience, including procedural anxiety and fear [69]. An RCT comparing VR-based distraction against tell-show-do (TSD) behavioral techniques during pediatric dental procedures identified decreases in pain intensity as measured by the Wong Baker FACES Pain Rating Scale (WBFS), procedural fear as measured by the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS), and procedural time in the VR arm [70]. Perhaps unsurprisingly, a vast majority of child participants involved in numerous RCTs stated that they prefer VR to the alternative [71]. Another study revealed that even brief VR sessions can significantly reduce dental anxiety among adults prior to operations in a primary dental care setting [28]. Of note, the effectiveness of VR-based interventions in reducing pain intensity may be restricted to a limited set of dental procedures, as one RCT demonstrated a reduction in pain intensity during rubber dam placement but not during local anesthesia administration [72].

Acute Pain in Special Populations

VR has shown promise in addressing acute pain in specific populations with particular pain management requirements [73,74,75]. For example, an RCT observed that veterans assigned to explore immersive VR environments to cope with acute pain and anxiety experienced a significant decline in pain intensity as measured by the Defense and Veterans Pain Rating Scale (DVPRS) [76]. On average, participants experienced a 1.2-point (12%) decline in pain intensity and a 92% reduction in anxiety levels, as measured by a scale developed by the Western North Carolina Veterans Affairs Health Care System (WNC VA HCS). Additionally, emerging evidence suggests that patients with chronic kidney disease on hemodialysis may benefit from VR-based interventions for acute pain management needs [77]. Lastly, a clinical trial is underway to assess whether the use of a VR-based application during venous fistula punctures, which are notably unpleasant procedures, is associated with decreased acute pain intensity scores [78].

Extended Reality Applications in Chronic Pain

Building on XR’s success in helping manage acute pain, several studies provide evidence of its promise as an effective non-invasive and non-pharmacological approach to help address the complex challenges of chronic pain, thereby providing a potential pathway for improving patient outcomes, particularly quality of life [79] (Table 5).

Table 5 Studies using virtual reality for chronic pain conditions: chronic lower back and neck pain, fibromyalgia, adult and pediatric cancer pain, pelvic pain/endometriosis
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Chronic Low Back Pain

Perhaps owing to its high prevalence and substantial public health burden [80], the most extensively studied condition in the realm of XR applications for chronic pain is chronic low back pain (CLBP). In a trial involving 1067 participants, RelieVRx was demonstrated to be more effective than a sham treatment in alleviating chronic low-back pain, with reductions of 2.0 points on the NRS reported [81]. Similar effects on pain intensity were reported by an RCT studying EaseVRx, an immersive application supporting CBT, mindfulness interventions, and pain neuroscience education [82].

A range of VR applications may improve secondary outcomes that directly impact patients’ pain experiences and prognoses. A 3-arm RCT using a VR-based digital therapeutic system for pain (DTxP) that provided psychological therapy demonstrated superiority compared to both a sham placebo and standard of care alternatives in improving kinesophobia [83]. An RCT using a VR-based 8-week training program resulted not only to reductions in symptoms of CLBP, but also to an average decrease in risk of falls in women > 65 years of age [84]. A pilot RCT (n = 41) utilizing a 4-week VR behavioral therapy-based pain management intervention revealed that fewer patients utilized opioids at week 4 (28%) as compared to week 1 (47%), with no changes from week 1 to 4 observed in the control group [85]. Though preliminary, VR may play a future role in reducing opioid intake in chronic pain patients and may also lead to prognostic benefits specific to certain demographics.

Chronic Neck Pain

Similar to CLBP, chronic neck pain is a debilitating and prevalent condition in which VR has demonstrated success in improving pain-related prognostic factors [86]. However, without accounting for variability in protocols and interventions, the relative effects compared to controls on pain intensity are currently not as robust. An RCT determined that two immersive environments supported by Oculus Go VR headsets were superior to motor control neck exercises in improving pain pressure threshold, joint position sense error, and overall functional status among patients with chronic pain [87]. Furthermore, a second study investigating the effects of two VR mobile applications was determined to be more effective than exercise alone in reducing kinesophobia [88]. However, both of the aforementioned studies reported no differences on pain intensity between the experimental and control group [87, 88].

Spinal Cord Injury

VR has emerged as a promising intervention in the management of pain for patients with spinal cord injuries (SCIs), offering immersive environments capable of facilitating simulations of gait biomechanics for patients with quadriplegia [89]. Regarding outcomes specific to pain, two recent RCTs concluded that Nature Trek, a 3D immersive VR experience supported by the Oculus Rift HMD, was superior to a 2D screen-based VR application in reducing the intensity of SCI-related neuropathic pain [90, 91]. Moreover, the most recent of these studies observed electroencephalography (EEG) changes unique to the more immersive 3D experience, although more data are needed to assess whether these EEG changes are reliable biomarkers of VR interventions in SCI [91].

Endometriosis

Endometriosis, characterized by the presence of endometrial-like tissue outside of the uterus, often leads to chronic pelvic pain, a cardinal symptom affecting approximately 75% of those diagnosed [92, 93]. This severe, debilitating pain can significantly impair quality of life and poses a persistent challenge in both diagnosis and management [94, 95]. Notably, two recent RCTs comparing Endocare, a 20-min program offering a combination of auditory and visual procedures through a 3D VR environment, to a 2D equivalent counterpart found superior pain intensity reductions in the experimental group [96, 97]. These findings suggest a promising potential of immersive VR technologies in enhancing pain management strategies for endometriosis, warranting further exploration through larger clinical studies.

Cancer Pain

Cancer pain, often resulting from the disease process itself or as a side effect of treatments such as chemotherapy, radiation, or surgery, adversely affects quality of life [98]. Moreover, undertreated cancer pain may increase morbidity and mortality [99]. The combination of VR and conventional therapies may be beneficial in alleviating pain and anxiety as witnessed in the adult and pediatric in-patient population when undergoing painful procedures or antineoplastic therapies [100, 101]. In line with these findings, recent RCTs have demonstrated VR’s efficacy in helping alleviate pain intensity among children with cancer undergoing subcutaneous port needle insertions [102]. In the adult population, recent studies have yielded improvements in pain intensity among patients with malignant hemopathies undergoing bone marrow biopsies [103] and patients undergoing antiblastic therapy [104].

XR has also been explored as a tool to support patients with cancer in their long-term recovery from surgeries [105]. In a comparative analysis, postoperative patients with breast cancer engaging in a daily physical exercise program delivered through an AR-based home rehabilitation system demonstrated greater enhancements in shoulder range of motion and quality of life compared to those who received the same program via traditional paper-based methods [106]. Conversely, a smaller RCT on the same population found that while a VR-based intervention was not superior to standard physiotherapy in improving shoulder range of motion (ROM) and strength, it was more effective in diminishing pain-related fear [107]. Notably, both of these XR applications were supported by the Xbox One Kinect platform, a relatively low-cost alternative to more sophisticated XR platforms, highlighting the potential for certain XR interventions to become cost-effective and accessible solution in postoperative rehabilitation and recovery for cancer patients.

Limitations of Using XR in Pain Management

Cybersickness in VR

Cybersickness, akin to motion sickness, presents a challenge particularly for the patient in acute pain, who may already be administered medications that may induce nausea, such as opioids. The prevailing theory attributes cybersickness to a sensory mismatch arising from a discrepancy between actual physical movement and the perceived motion experienced in a VR environment [108]. The utilization of VR, particularly its immersive forms, has been associated with the onset of symptoms such as nausea, disorientation, and headaches, factors which could deter patients from opting for VR-based interventions [109, 110]. Studies indicate a notable incidence of these symptoms, with reports suggesting that as many as 80% of participants engaging in immersive VR experiences may suffer from cybersickness [111, 112]. Notably, a disparity in the susceptibility to cybersickness has been observed across age groups. Research employing the Fast Motion Sickness Scale (FMS) revealed a significantly higher impact on individuals aged 40–59 compared to those aged 19–39 (FMS scores: 7.76 vs 4.28, p = 0.001) [112]. In response to these challenges, recent methods have been utilized to mitigate cybersickness. Technological advancements in VR hardware have significantly contributed to reducing cybersickness [113]. Cybersickness, which was a notable issue in older generation HMDs, has seen a dramatic improvement with newer hardware. These modern HMDs account for depth of field and field of vision in their rendering of environments, along with improved refresh rates of visual content, which have been proven to improve cybersickness [113]. Moreover, the design of the VR environment itself plays a crucial role in reducing cybersickness, as indicated by recent research [114]. Thoughtful and user-centric design, which takes into account the user’s physical and cognitive experiences within the virtual space, can significantly diminish the occurrence of cybersickness, making VR more accessible and comfortable for a wider range of users [114]. An additional study investigated the potential of transcranial oscillatory stimulation of the vestibular cortex as a method to reduce the frequency-dependent symptoms of cybersickness in VR. The findings from this study indicate that targeted neurostimulation can effectively alleviate the sensory mismatch leading to cybersickness, offering a promising avenue for enhancing the comfort and feasibility of VR interventions, especially in sensitive populations [115].

Challenges in Study Designs

VR research in chronic pain management often faces methodological shortcoming such as small sample sizes and limited follow-up periods. These limitations have largely impeded a robust evaluation of the long-term effectiveness of VR in treating chronic pain specifically [83]. The lack of standardized VR-specific outcome measures and the heterogeneity of VR-based interventions make synthesizing findings a challenging endeavor [116]. The paucity of the use of control conditions that more closely resemble the immersive 3D experience, such as high-fidelity 2D environment or a non-immersive 3D experience, has been identified as a barrier to accurately estimating the relative efficacy of newer VR interventions [117].

Relative Lack of Data on AR in Pain Management

In the field of pain management, there exists a notable disparity in the volume and depth of research data between VR and AR applications. This discrepancy is particularly pronounced when considering the unique capabilities of AR, such as overlaying digital information onto the physical environment, which could offer distinct advantages in pain treatment scenarios. However, the current literature on AR in pain management is limited, both in terms of the number of studies and the scope of their findings [118]. This lack of extensive research on AR not only hinders the full exploration of its therapeutic possibilities but also limits the development of evidence-based guidelines for its application in clinical settings for pain management.

XR Content and User Experience

The specific nature and rendering quality of XR content significantly affects its therapeutic effectiveness. The analysis of XR experiences in mental health and chronic pain management studies underscores the critical need for personalization [119]. The effectiveness of XR is enhanced when tailored to individual psychological profiles, addressing specific symptoms and triggers [120]. VR interventions for chronic pain have been determined to result in notable improvements in pain, functioning, and mobility, with the greatest benefits observed in programs customized to individual patient needs [121]. Additionally, the efficacy of VR in pain management may be contingent upon the engagement quality of the VR content. Suboptimal or unengaging VR experiences may fail to provide the necessary distraction from pain [85]. Research has demonstrated varying degrees of pain reduction associated with VR interventions, with the effectiveness partly attributed to differences in the nature and interactivity of VR content [122]. Specifically, “active VR,” which involves user interaction and navigation within the virtual environment, has demonstrated higher analgesic effectiveness compared to “passive VR” [122]. This suggests that the type and degree of user interaction within VR play a critical role in determining its therapeutic efficacy in pain management.

Furthermore, the heterogeneity of VR content employed in various studies explored in this review highlights the intricacies involved in evaluating the overall effectiveness of VR in pain management. Although VR interventions are generally found to be more effective than non-VR counterparts, the wide array of VR applications used in studies complicates direct efficacy comparisons across different studies. Despite these challenges, both laboratory and clinical research consistently demonstrate VR’s capacity to reduce pain intensity, underscoring its potential utility as a pain management tool [122].

Ethical and Safety Concerns

Ethical and safety concerns in clinical VR applications are crucial, particularly when addressing vulnerable populations, such as children and the elderly. Tailoring VR experiences to individual needs and ensuring responsible usage in complex psychiatric conditions are critical steps in enhancing safety and mitigating potential harm to the patient [123, 124]. Alongside these considerations, it is imperative to acknowledge the contraindications of VR in certain populations. VR interventions may not be suitable for individuals with conditions that predispose them to adverse reactions, such as severe motion sickness or epilepsy. This necessitates rigorous screening processes and informed consent protocols, especially when dealing with vulnerable groups who might be at increased risk [125]. Moreover, the development of comprehensive ethical frameworks and robust safety protocols for VR therapy across medical disciplines is essential to prioritize and maintain patient well-being [126]. For populations where VR is contraindicated, alternative therapeutic approaches should be considered to ensure safety and effectiveness. This highlights the need for ongoing research into the comprehensive assessment of VR contraindications and the development of inclusive therapeutic strategies that accommodate the diverse needs of all patients [125].

Future Directions

Further research in the application of XR for pain management should prioritize the customization of XR content specific to various pain conditions and settings and the integration of XR with advanced data processing systems powered by artificial intelligence (AI). In XR for chronic pain specifically, emphasis should be placed on assessing long-term effects, prioritizing skill-building applications, and standardizing protocols for the evaluation of pain-related outcomes [81]. Moreover, research endeavors should focus on elucidating the neurobiological mechanisms of VR analgesia, developing personalized interventions, and overcoming technological barriers to cost-effective implementation. The confluence of AI and telemedicine in VR applications presents a prospective landscape in which such interventions are not only personalized and scalable but also broadly accessible [127, 128•]. This advancement holds significant promise for transforming pain management, particularly in settings with limited resources, in which conventional methods face constraints.

Conclusion

VR holds considerable potential as a pain management tool uniquely capable of distracting, educating, and therapeutically engaging patients. Despite existing challenges, its benefits in augmenting pain management practices are evident and recent studies continue to support its use. With ongoing technological advancements and evolving research, VR is set to become a fundamental component of pain management protocols, effectively complementing traditional pain therapies. As research progresses, the integration of VR into routine pain management practice promises new insights and breakthroughs in patient care, potentially transforming how acute and chronic pain is managed in clinical settings.