by Camila Pizá, BA, and Deirdre Logan, PhD

Emerging evidence supports virtual reality (VR) as a tool for management of acute and chronic pain (Ding et al., 2025), but limited literature exists specifically for VR applications for pediatric chronic pain (Hess et al., 2025). Children and adolescents have unique physical and cognitive developmental needs that must be addressed in addition to their pain experiences. Because youth with chronic pain face social, academic, medical, and even familial barriers that are distinct from those with acute pain conditions, proven VR techniques for acute pain may not be directly translatable. It is therefore important to elucidate VR mechanisms that target the unique needs of youth living with chronic pain and promote engagement in rehabilitation-focused pain interventions, such as physical therapy, occupational therapy, cognitive behavioral therapy, and mind-body techniques, among others.

Herein, we aim to describe the different potential mechanisms of action of VR for pediatric chronic pain and identify promising areas for further research. To inform this commentary, we reviewed literature published since 2017, emphasizing systematic reviews outlining VR applications for chronic pain management. Given the limited pediatric-specific literature on chronic pain, studies with pediatric or lifespan populations were included. We focused on evidence supporting various uses of VR in pediatric chronic pain rehabilitation and the efficacious promise of this technology. Through this review we classified five significant categories of VR applications for pediatric chronic pain management including: (1) movement promotion; (2) distraction to facilitate engaging in difficult treatments; (3) use of illusion/embodiment; (4) exposure to reduce fear of pain and behavioral avoidance; (5) relaxation skill coaching, without or without a biofeedback component.

Movement Promotion

Movement promotion is a central treatment goal in chronic pain rehabilitation, aiming to improve daily functional movement and reduce maladaptive activity/inactivity patterns. It typically involves graded reintroduction of activities that patients previously found most challenging or pain-provoking (O’Sullivan et al., 2015). Specifically, intensive interdisciplinary pain treatment (IIPT) programs for pediatric chronic pain populations offer patients targeted functional restoration-focused, graded activities with a team of physical, occupational, and recreational therapists, as well as psychologists, that help restore long-term physical functional and psychosocial goals (Harrison et al., 2019; Seth et al., 2025). Movement promotion in IIPT has been linked with psychosocial benefits such as improved self-efficacy, reduced fear of physical activity, and improved anxiety and depression (Giertych et al., 2025; Harrison et al., 2019; O’Sullivan et al., 2015).

The translation of movement promotion activities into VR experiences includes immersive games that target desired movements, including those developed specifically for pain patients (Griffin et al., 2020) and commercial games used in physical therapy (see Table 1). In their pilot study of a clinical VR program (“Fruity Feet”) designed specifically for pediatric patients with chronic extremity pain conditions, Griffin and colleagues (2020) found that after interacting with the VR tool, patients reported high levels of immersion and significantly decreased pain, avoidance, and functional limitations. Most interestingly, patients also reported increased distraction from their pain during VR. Other movement-based VR studies have demonstrated similar results (Chau et al., 2020; Meyns et al., 2017; Saby et al., 2024), illustrating the promise VR holds as a tool to facilitate functionally restorative movement for pediatric chronic pain patients.

Distraction

Distraction-based techniques have been used for both adult and pediatric pain treatment by stimulating cognitive activities like memory tasks, interactive play, music, and more. These tools are proven to reduce pain intensity and distress and promote improved physiologic arousal (Asefi Rad & Wippert, 2024; Bukola & Paula, 2017).Distraction in a VR setting involves allocating one’s cognitive and attentional capacity to the VR stimuli, thereby reducing pain perception and sensitivity as the brain is competitively diverted from processing pain signals and toward the immersive and engaging tool (Trost et al., 2021).Notably, distraction is believed to drive the effectiveness of acute VR interventions, facilitating outcomes such as reduced procedural and burn-injury pain, decreased chemotherapy-related symptoms, and improved emotional well-being during painful procedures and hospitalizations (Indovina et al., 2018; Trost et al., 2021).

VR-based distraction techniques have also been used to facilitate engagement in difficult treatments for pediatric patients experiencing chronic pain. What makes distraction techniques especially interesting in chronic pain is that they are often embedded as a secondary effect into VR games with a different primary focus, such as movement promotion games (Griffin et al., 2020), and in exposure therapy (Huang et al., 2022).Therefore, distraction is a tool that allows patients to engage in activities that require focusing attention on something other than their pain, such as moving the affected body part or focusing on a relaxing guided virtual meditation while tolerating weight-bearing for lower extremity pain. Although not necessarily always the explicit focus, many commercially available VR games provide distraction that can be leveraged to facilitate patient engagement in painful and/or anxiety-provoking therapeutic tasks (see Table 1).

Table 1. Examples of Commercially Available VR Games That Can Be Useful for Chronic Pain Treatment

Game Title	Platform	Mechanism of Effect	Applications
Fruit Ninja VR	Meta Quest	Movement	Arm swinging to slice fruit flying through the air
Beat Saber		Movement	Use lightsabers to hit blocks to the beat of music
Walkabout Mini Golf VR	Meta Quest	Movement	Gentle reaching and walking playing mini golf in a virtual world
Job Simulator	Meta Quest	Movement	Participants pretend to work in jobs that engage them in standing, reaching and grabbing
Open Brush	Meta Quest	Movement	Big arm movements with painting and drawing
Elixir	Meta Quest	Movement	Participants Mix magic potions with their arms
Dance Central VR	Meta Quest	Movement	Participant dance movements on the screen
Carnival Games VR: Alley Adventure	Carnival Gams VR	Movement	Light exercise that improves hand-eye coordination and upper-body movement
Angry Birds VR: Isle of Pigs	Angry Birds VR; Meta Quest	Movement	Builds arm strength and range of motion
Gorilla Tag	Meta Quest	Movement	Arm swinging and climbing while playing tag with others
VR Masterchef Junior	Walmart VR; Meta Quest	Movement	Arm movement and coordination through VR cooking
OhShape	Meta Quest; OhShape	Movement	Full body stretching and flexibility through body shape matching
PowerBeats VR	Steam PowerBeats VR	Movement	Aerobic movement following rhythm with music
Nature Treks VR	Meta Quest	Relaxation	Exploration of nature scenes like beaches and forests
Color Space	Meta Quest	Movement; Relaxation	Participants use their hands to paint through slow, relaxing movements
Wander	Meta Quest	Distraction	Travel around the world through VR using Google Street View
Google Earth VR	Google VR	Distraction	Travel around the world through VR using Google Earth
Minecraft	Vivecraft	Distraction	Engaging VR Game
Guided Mediation VR	Guided Meditation VR	Distraction; Relaxation	Calming meditation
The Lab	Steam	Movement; Distraction	Exploration game with different engaging activities
The Blu	Steam	Distraction	Cinematic exploration game

Virtual Embodiment

Embodiment can be defined as the combined sense of having a body and being a body, which is tied to self-identity (Lundh & Foster, 2024). The experience of embodiment includes senses of agency, body ownership, and self-location (Guy et al., 2023). Notably, embodiment has been previously targeted through graded motor imagery (GMI) technology and mirror therapy (MT), such as having a patient observe their unaffected limb moving in a mirror, thereby producing the perception of the unaffected limb replacing the injured one. Limited results indicate that this therapy may improve pain and function by reorganizing cortical networks. Specifically, the MT component is hypothesized to provide a visual illusion of pain-free movement in response to cortical activation via GMI technology (Méndez-Rebolledo et al., 2017).

A small literature also suggests that experiencing embodiment through VR may have long-term, site-specific analgesic effects when observing one’s own body through a virtual avatar lens (Matamala-Gomez et al., 2019). Embodiment is a promising tool for adults experiencing chronic pain, as a recent pilot study found virtual embodiment may improve perceived disability and helplessness (Saby et al., 2024). While pediatric-specific embodiment studies are scant, many with insufficient sample sizes and unstandardized methods (Felnhofer & Weiss, 2023; Shahrbanian et al., 2009), research suggests children may be more susceptible to virtual environments than adults (Won et al., 2017). This is further supported by literature on neuroplasticity in youth where specific brain regions supporting executive, social, and emotional functions are highly responsive and malleable to external influences and shape later behavior (Kolb & Gibb, 2011). This heightened period of suggestibility may therefore amplify the impact of embodied experiences and environmental exposures of pediatric populations as compared to other age groups. Therefore, the apparent success in adult patients suggests further research into pediatric patients is warranted.

Exposure to Reduce Fear of Pain

Exposure therapy is a widely established treatment for improving avoidance behaviors and functional limitations, including in the chronic pain context. One study found that graded in-vivo exposure treatment significantly improved pain-related fears, avoidance behaviors, and pain acceptance (Simons et al., 2019). Virtual reality exposure therapy (VRET) is also an effective treatment for phobias, including agoraphobia and arachnophobia, anxiety-related disorders, and even PTSD (Carl et al., 2019; Parsons & Rizzo, 2008). In adult chronic pain patients, Trost et al. (2014, 2015) first applied VRET to facilitate movement associated with increased pain and avoidance behaviors, demonstrating the powerful benefit of exposure therapy in chronic pain management.

In researching VRET for pediatric populations, our findings demonstrate limited and conflicting results. One systematic review and meta-analysis of thirty-one trials examining the effectiveness of VR for pain management in different age groups found that VRET was effective at alleviating acute pain, lowering anxiety levels, and decreasing pulse rate, compared to a standard-care control group. However, we found only one study of pediatric chronic pain comparing VRET to a control condition, and this study found no group difference in increased pain tolerance (Huang et al., 2022). Not only does the lack of chronic pain studies limit the generalizability of findings, but so does the small sample size and unclear risk of bias noted by the authors, specifically selection and detection bias. Given this study did find youth were more attracted to and interested in VR technology, there needs to be more clinical research conducted on the effectiveness of VRET for a wide range of pediatric chronic pain patients.

Relaxation Skill Coaching With and Without Biofeedback

Relaxation skills include meditation, progressive muscle relaxation, diaphragmatic breathing, and guided imagery, among others. Relaxation skill coaching is efficacious and commonly used in treatment for anxiety disorders (Manzoni et al., 2008) and has increasingly become a common intervention for pain management (Vambheim et al., 2021). Specifically, within chronic pain, relaxation skill coaching is thought to significantly reduce psychological and physical stress on the body and improve secondary outcomes, including anxiety and depression, well-being, and effective coping (Vambheim et al., 2021). The impact of relaxation skill coaching for chronic pain patients can also be measured and amplified through biofeedback. Incorporating feedback on the physiological changes they experienced during relaxation (e.g., heart rate, respiration, etc.) allows patients to self-regulate their physiological responses to pain and stress.

Relaxation skill coaching has also been effectively utilized as a VR mechanism for acute and chronic pain management, with and without biofeedback technology (Ahmadpour et al., 2019; Calderone et al., 2025; Eijlers et al., 2019). While a limited number of small clinical studies have examined its effect on pediatric chronic pain, emerging results are promising and demonstrate VR relaxation/biofeedback mechanisms are efficacious in reducing pain and stress in pediatric populations (Ahmadpour et al., 2019; Recker et al., 2025; Wong et al., 2022). There are a number of commercially available VR games for relaxation that provide immersive, calming environments (see Table 1). Given the encouraging early findings, researchers should focus on conducting larger, well-controlled trials of VR-based relaxation skill coaching. Further, comparative studies would be helpful for determining whether the addition of biofeedback enhances VR-based relaxation training outcomes.

Conclusion

VR is a promising alternative or adjunct to pharmacological therapies for pediatric chronic pain treatment, with multiple potential mechanisms of effect. When selecting the type of VR to use for pediatric chronic pain management, it is important to consider the clinical outcomes associated with each VR application. For example, movement promotion can improve physical functioning and work in tandem with distraction applications to redirect attention away from pain, aiding in decreased pain and improved emotional well-being. Similarly, embodiment-based interventions may be associated with pain reduction and improved perceived disability via reorganization of cortical networks. Lastly, while data is limited, VR exposure therapy can target pain-related fear and avoidance, while relaxation skill coaching may help with pain and stress reduction and enhance coping.

Although the current literature is promising, the research base is small, with variable results to date. As such, we lack strong, specific evidence for VR’s effects in pediatric chronic pain management. Our exploration suggests the need for larger, well-controlled trials with standardized measures to thoroughly evaluate the effects of the multiple potential mechanisms of VR for pediatric chronic pain management. There is also a need for further investigation into the long-term outcomes of these VR mechanisms, especially those that improve functional limitations and reduce overall fear of pain, as seen most notably with movement and exposure-based VR mechanisms.

While there are many potential beneficial outcomes associated with VR-based therapies that warrant further investigation, researchers must also address potential risks or contraindications associated with VR use in pediatric populations. Literature examining the safety of virtual reality use in children suggests VR use may be associated with cybersickness symptoms, including dizziness and nausea, and increased anxiety and discomfort (Bexson et al., 2024); Caruso et al., 2020; Goldsworthy et al., 2023). However, overall, the symptoms appear to be rare and exposure dependent. Therefore, pre-existing conditions must be considered, with explicit exclusion criteria, and an emphasis on clinician or caregiver monitoring must be included in all clinical or commercial instruction.

Additionally, while VR interventions have become increasingly accessible clinically and commercially, there are still barriers to clinical uptake, that limit VR’s accessibility and feasibility for pediatric chronic pain patients. Notably, a recent study found clinician-reported knowledge gaps of VR and inadequate training for clinical uptake of VR, technological malfunctions, and financial restrictions. These barriers were associated with clinicians’ lack of motivation to adopt VR technology in clinical settings (Felnhofer et al., 2025). Therefore, in addition to the need for further research, further effort is needed to make utilization of this immersive technology more accessible to pediatric chronic pain treatment providers. Lastly, in addition to understanding clinician experiences, it is crucial to incorporate patient and parent perspectives to inform the feasible and effective use of VR tools for pediatric chronic pain management.

Acknowledgements: The authors acknowledge the assistance of Tina Afshari, B.A., who compiled the information included in Table 1.

Camila Pizá, BA
Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital
email: camila.piza@childrens.harvard.edu

Deirdre Logan, PhD
Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital
Department of Psychiatry, Harvard Medical School, Boston, MA

References

Ahmadpour N, Randall H, Choksi H, Gao A, Vaughan C, Poronnik P. Virtual reality interventions for acute and chronic pain management. Int J Biochem Cell Biol. 2019;114:105568. doi:10.1016/j.biocel.2019.105568

Asefi Rad A, Wippert PM. Insights into pain distraction and the impact of pain catastrophizing on pain perception during different types of distraction tasks. Front Pain Res. 2024;5:1266974. doi:10.3389/fpain.2024.1266974

Bexson C, Oldham G, Wray J. Safety of virtual reality use in children: A systematic review. Eur J Pediatr. 2024;183(5):2071-2090. doi:10.1007/s00431-024-05488-5

Bukola IM, Paula D. The effectiveness of distraction as procedural pain management technique in pediatric oncology patients: A meta-analysis and systematic review. J Pain Symptom Manage. 2017;54(4):589-600.e1. doi:10.1016/j.jpainsymman.2017.07.006

Calderone A, Mazzurco Masi VM, De Luca R, Gangemi A, Bonanno M, Floridia D, Corallo F, Morone G, Quartarone A, Maggio MG, Calabrò RS. The impact of biofeedback in enhancing chronic pain rehabilitation: A systematic review of mechanisms and outcomes. Heliyon. 2025;11(2):e41917. doi:10.1016/j.heliyon.2025.e41917

Carl E, Stein AT, Levihn-Coon A, Pogue JR, Rothbaum B, Emmelkamp P, Asmundson GJG, Carlbring P, Power MB. Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. J Anxiety Disord. 2019;61:27-36. doi:10.1016/j.janxdis.2018.08.003

Caruso TJ, O’Connell C, Qian JJ, Kung T, Wang E, Kinnebrew S, Pearson M, Kist M, Menendez M, Rodriguez ST. Retrospective review of the safety and efficacy of virtual reality in a pediatric hospital. Pediatr Qual Saf. 2020;5(2):e293. doi:10.1097/pq9.0000000000000293

Chau B, Phelan I, Ta P, Chi B, Loyola K, Yeo E, Dunn J, Humbert S, Hata J, Haglund R, Luna L, Kampmeier G, McCowan B. Immersive virtual reality for pain relief in upper limb complex regional pain syndrome: A pilot study. Innov Clin Neurosci. 2020;17(4-6):47-52.

Ding M, Traiba H, Hector P. Virtual reality interventions and chronic pain: A scoping review. J Med Internet Res. 2025;27:e59922. doi:10.2196/59922

Eijlers R, Utens EMWJ, Staals LM, De Nijs PFA, Berghmans JM, Wijnen RMH, Hillegers MHJ, Dierckx B, Legerstee JS. Systematic review and meta-analysis of virtual reality in pediatrics: Effects on pain and anxiety. Anesth Analg. 2019;129(5):1344-1353. doi:10.1213/ANE.0000000000004165

Felnhofer A, Pfannerstill F, Gänsler L Kothgassner OD, Humer E, Büttner J, Probst T. Barriers to adopting therapeutic virtual reality: The perspective of clinical psychologists and psychotherapists. Front Psychiatry. 2025;16:1549090. doi:10.3389/fpsyt.2025.1549090

Felnhofer A, Weiss L. Overcoming pain with virtual reality: Exploring the potential of VR as a tool for pediatric pain management. Digit Psychol. 2023;4(1):27-34. doi:10.24989/dp.v4i1.2224

Giertych A, Crane J, Goozeé S, Maoz I, Mehri N, Amirdelfan K, Navani A. Clinical effectiveness of a functional restoration program compared to conventional medical management in patients with chronic pain: A multicenter, retrospective observational analysis. Am J Phys Med Rehabil. 2025;104(8):735-742. doi:10.1097/PHM.0000000000002713

Goldsworthy A, Chawla J, Baumann O, Birt J, Gough S. Extended reality use in paediatric intensive care: A scoping review. J Intensive Care Med. 2023;38(9):856-877. doi:10.1177/08850666231185721

Griffin A, Wilson L, Feinstein AB, Bortz A, Heirich MS, Gilkerson R, Wagner JF, Menendez M, Caruso TJ, Rodriguez S, Naidu S, Golianu B, Simons LE. Virtual reality in pain rehabilitation for youth with chronic pain: Pilot feasibility study. JMIR Rehabil Assist Technol. 2020;7(2):e22620. doi:10.2196/22620

Guy M, Normand J-M, Jeunet-Kelway C, Moreau G. The sense of embodiment in virtual reality and its assessment methods. Front Virtual Real. 2023;4:1141683. doi:10.3389/frvir.2023.1141683

Harrison LE, Pate JW, Richardson PA, Ickmans K, Wicksell RK, Simons LE. Best-evidence for the rehabilitation of chronic pain part 1: Pediatric pain. J Clin Med. 2019;8(9):1267. doi:10.3390/jcm8091267

Hess CW, Rosenbloom BN, Mesaroli G, Lopez C, Ngo N, Cohen E, Ouellette C, Gold JI, Logan D, Simons LE, Stinson JN. Extended reality (XR) in pediatric acute and chronic pain: Systematic review and evidence gap map. JMIR Pediatr Parent. 2025;8:e63854. doi:10.2196/63854

Huang Q, Lin J, Han R, Peng C, Huang A. Using virtual reality exposure therapy in pain management: A systematic review and meta-analysis of randomized controlled trials. Value Health. 2022;25(2):288-301. doi:10.1016/j.jval.2021.04.1285

Indovina P, Barone D, Gallo L, Chirico A, De Pietro G, Giordano A. Virtual reality as a distraction intervention to relieve pain and distress during medical procedures: A comprehensive literature review. Clin J Pain. 2018;34(9):858-877. doi:10.1097/AJP.0000000000000599

Kolb B, Gibb R. Brain plasticity and behaviour in the developing brain. J Can Acad Child Adolesc Psychiatry. 2011;20(4):265-276.

Lundh LG, Foster L. Embodiment as a synthesis of having a body and being a body, and its role in self-identity and mental health. New Ideas Psychol. 2024;74:101083. doi:10.1016/j.newideapsych.2024.101083

Manzoni GM, Pagnini F, Castelnuovo G, Molinari E. Relaxation training for anxiety: A ten-years systematic review with meta-analysis. BMC Psychiatry. 2008;8:41. doi:10.1186/1471-244X-8-41

Matamala-Gomez M, Donegan T, Bottiroli S, Sandrini G, Sanchez-Vives MV, Tassorelli C. Immersive virtual reality and virtual embodiment for pain relief. Front Hum Neurosci. 2019;13:279. doi:10.3389/fnhum.2019.00279

Méndez-Rebolledo G, Gatica-Rojas V, Torres-Cueco R, Albornoz-Verdugo M, Guzmán-Muñoz E. Update on the effects of graded motor imagery and mirror therapy on complex regional pain syndrome type 1: A systematic review. J Back Musculoskelet Rehabil. 2017;30(3):441-449. doi:10.3233/BMR-150500

Meyns P, Pans L, Plasmans K, Plasmans K, Heyrman L, Desloovere K, Molenaers G. The effect of additional virtual reality training on balance in children with cerebral palsy after lower limb surgery: A feasibility study. Games Health J. 2017;6(1):39-48. doi:10.1089/g4h.2016.0069

O’Sullivan K, Dankaerts W, O’Sullivan L, O’Sullivan PB. Cognitive functional therapy for disabling nonspecific chronic low back pain: Multiple case-cohort study. Phys Ther. 2015;95(11):1478-1488. doi:10.2522/ptj.20140406

Parsons TD, Rizzo AA. Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. J Behav Ther Exp Psychiatry. 2008;39(3):250-261. doi:10.1016/j.jbtep.2007.07.007

Recker K, Silliman J, Gifford K, Patel P, Santana L, Hildenbrand AK, Palit S, Wasserman R. Virtual reality respiratory biofeedback in an outpatient pediatric pain rehabilitation program: Mixed methods pilot study. JMIR Rehabil Assist Technol. 2025;12:e66352. doi:10.2196/66352

Saby A, Alvarez A, Smolins D, Petros J, Nguyen L, Trijillo M, Aygün O. Effects of embodiment in virtual reality for treatment of chronic pain: Pilot open-label study. JMIR Form Res. 2024;8:e34162. doi:10.2196/34162

Seth M, Vieni K, Hottinger K, Bentley K. Physical function and perceived pain following inpatient intensive interdisciplinary pain treatment for children and adolescents. PM R. 2025;17(7):752-760. doi:10.1002/pmrj.13325

Shahrbanian S, Ma X, Korner-Bitensky N, Simmonds MJ. Scientific evidence for the effectiveness of virtual reality for pain reduction in adults with acute or chronic pain. Stud Health Technol Inform. 2009;144:40-43.

Simons LE, Harrison LE, O’Brien SF, Heirich MS, Loecher N, Boothroyd DB, Vlaeyen JWS, Wicksell RK, Schofield D, Hood KK, Orendurff M, Chan S, Lyons S. Graded exposure treatment for adolescents with chronic pain (GET Living): Protocol for a randomized controlled trial enhanced with single case experimental design. Contemp Clin Trials Commun. 2019;16:100448. doi:10.1016/j.conctc.2019.100448

Trost Z, France C, Anam M, Shum C. Virtual reality approaches to pain: Toward a state of the science. Pain. 2021;162(2):325-331. doi:10.1097/j.pain.0000000000002060

Trost Z, Parsons TD. Beyond distraction: Virtual reality graded exposure therapy as treatment for pain-related fear and disability in chronic pain. J Appl Biobehav Res. 2014;19(2):106-126. doi:10.1111/jabr.12021

Trost Z, Zielke M, Guck A, Nowlin L, Zakhidov D, France CR, Keefe F. The promise and challenge of virtual gaming technologies for chronic pain: The case of graded exposure for low back pain. Pain Manag. 2015;5(3):197-206. doi:10.2217/pmt.15.6

Vambheim SM, Kyllo TM, Hegland S, Bystad M. Relaxation techniques as an intervention for chronic pain: A systematic review of randomized controlled trials. Heliyon. 2021;7(8):e07837. doi:10.1016/j.heliyon.2021.e07837

Won A, Bailey J, Bailenson J, Tataru C, Yoon I, Golianu B. Immersive virtual reality for pediatric pain. Children (Basel). 2017;4(7):52. doi:10.3390/children4070052

Wong KP, Tse MMY, Qin J. Effectiveness of virtual reality-based interventions for managing chronic pain on pain reduction, anxiety, depression and mood: A systematic review. Healthcare (Basel). 2022;10(10):2047. doi:10.3390/healthcare10102047