Mayo Clinic Proceedings Home
MCP Digital Health Home

The Use of Virtual Reality to Reduce Preoperative Anxiety in First-Time Sternotomy Patients: A Randomized Controlled Pilot Trial



      To report the first randomized controlled trial to investigate if immersive virtual reality (VR) treatment can reduce patient perceptions of anxiety compared with a tablet-based control treatment in adults undergoing a first-time sternotomy.


      Twenty first-time sternotomy patients were prospectively randomized (blinded to investigator) to a control or VR intervention. The VR intervention was a game module “Bear Blast” (AppliedVR) displayed using a Samsung Gear Oculus VR headset. The control intervention was a tablet-based game with comparable audio, visual, and tactile components. The State-Trait Anxiety Inventory was administered before and after the assigned intervention. Self-reported anxiety measures between the control and VR groups were evaluated using an unpaired t test. Changes in self-reported anxiety measures pre- and post-intervention were evaluated with a paired t test for both the control and VR groups. The study took place from May 1, 2017, through January 1, 2019 (Institutional Review Board 16-009784).


      Both control and VR groups were 90.0% male, with a mean ± SD age of 63.4 ± 9.11 and 69.5 ± 6.9 years, respectively. VR users experienced significant reductions in feeling tense and strained, and significant improvements in feeling calm when compared with tablet controls (P<0.05). They also experienced significant reductions in feeling strained, upset, and tense when compared with their own self-reported anxiety measure pre- and post-intervention (P<0.05). Critically, control patients had no change in these categories.


      Immersive VR is an effective, nonpharmacologic approach to reducing preoperative anxiety in adults undergoing cardiac surgery and shows the validity and utility of this technology in adult patients.

      Abbreviations and Acronyms:

      STAI (state-trait anxiety inventory), VR (virtual reality)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Vingerhoets G.
        Perioperative anxiety and depression in open-heart surgery.
        Psychosomatics. 1998; 39: 30-37
        • Tolksdorf W.
        • Berlin J.
        • Rey E.
        • et al.
        Preoperative stress. Study of the mental behavior and parameters of physiological stress in non-premedicated patients during the preoperative period [in German].
        Anaesthesist. 1984; 33: 212-217
        • Yang P.-L.
        • Huang G.-S.
        • Tsai C.-S.
        • Lou M.-F.
        Sleep quality and emotional correlates in Taiwanese coronary artery bypass graft patients 1 week and 1 month after hospital discharge: a repeated descriptive correlational study.
        PloS One. 2015; 10: e0136431
        • Linn B.S.
        • Linn M.W.
        • Klimas N.G.
        Effects of psychophysical stress on surgical outcome.
        Psychosom Medicine. 1988; 50: 230-244
        • Vaughn F.
        • Wichowski H.
        • Bosworth G.
        Does preoperative anxiety level predict postoperative pain?.
        AORN J. 2007; 85: 589-604
        • Kain Z.N.
        • Sevarino F.
        • Pincus S.
        • et al.
        Attenuation of the preoperative stress response with midazolam: effects on postoperative outcomes.
        Anesthesiology. 2000; 93: 141-147
        • Patel A.
        • Schieble T.
        • Davidson M.
        • et al.
        Distraction with a hand-held video game reduces pediatric preoperative anxiety.
        Paediatr Anaesth. 2006; 16: 1019-1027
        • Seiden S.C.
        • McMullan S.
        • Sequera-Ramos L.
        • et al.
        Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: a noninferiority randomized trial.
        Paediatr Anaesth. 2014; 24: 1217-1223
        • Parsons T.D.
        • Rizzo A.A.
        Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: a meta-analysis.
        J Behav Ther Exp Psychiatry. 2008; 39: 250-261
        • Carrougher G.J.
        • Hoffman H.G.
        • Nakamura D.
        • et al.
        The effect of virtual reality on pain and range of motion in adults with burn injuries.
        J Burn Care Res. 2009; 30: 785-791
        • Hoffman H.G.
        • Doctor J.N.
        • Patterson D.R.
        • Carrougher G.J.
        • Furness 3rd, T.A.
        Virtual reality as an adjunctive pain control during burn wound care in adolescent patients.
        Pain. 2000; 85: 305-309
        • Hoffman H.G.
        • Patterson D.R.
        • Seibel E.
        • Soltani M.
        • Jewett-Leahy L.
        • Sharar S.R.
        Virtual reality pain control during burn wound debridement in the hydrotank.
        Clin J Pain. 2008; 24: 299-304
        • Kipping B.
        • Rodger S.
        • Miller K.
        • Kimble R.M.
        Virtual reality for acute pain reduction in adolescents undergoing burn wound care: a prospective randomized controlled trial.
        Burns. 2012; 38: 650-657
        • Spielberger C.D.
        State-Trait Anxiety Inventory.
        in: Weiner I.R. Craighead W.E. The Corsini Encyclopedia of Psychology. Wiley, Hoboken, NJ2010: 1
        • Robertson A.
        • Khan R.
        • Fick D.
        • et al.
        The effect of virtual reality in reducing preoperative anxiety in patients prior to arthroscopic knee surgery: a randomised controlled trial. Paper presented at: Serious Games and Applications for Health (SeGAH), 2017 IEEE 5th International Conference.
        April 2-4, 2017 (Perth, Western Australia)
        • Hansen M.M.
        A feasibility pilot study on the use of complementary therapies delivered via mobile technologies on Icelandic surgical patients' reports of anxiety, pain, and self-efficacy in healing.
        BMC Complement Altern Med. 2015; 15: 92
        • Bekelis K.
        • Calnan D.
        • Simmons N.
        • MacKenzie T.A.
        • Kakoulides G.
        Effect of an immersive preoperative virtual reality experience on patient reported outcomes: a randomized controlled trial.
        Ann Surg. 2017; 265: 1068-1073
        • Ganry L.
        • Hersant B.
        • SidAhmed-Mezi M.
        • Dhonneur G.
        • Meningaud J.
        Using virtual reality to control preoperative anxiety in ambulatory surgery patients: a pilot study in maxillofacial and plastic surgery.
        J Stomatol Oral Maxillofac Surg. 2018; 119: 257-261
        • Munafò M.R.
        • Stevenson J.
        Anxiety and surgical recovery: reinterpreting the literature.
        J Psychosom Res. 2001; 51: 589-596
        • Theunissen M.
        • Peters M.L.
        • Bruce J.
        • Gramke H.-F.
        • Marcus M.A.
        Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain.
        Clin J Pain. 2012; 28: 819-841
        • Kain Z.N.
        • Sevarino F.
        • Alexander G.M.
        • Pincus S.
        • Mayes L.C.
        Preoperative anxiety and postoperative pain in women undergoing hysterectomy: a repeated-measures design.
        J Psychosom Res. 2000; 49: 417-422
        • Williams J.B.
        • Alexander K.P.
        • Morin J.F.
        • et al.
        Preoperative anxiety as a predictor of mortality and major morbidity in patients aged >70 years undergoing cardiac surgery.
        Am J Cardiol. 2013; 111: 137-142
        • Maurice-Szamburski A.
        • Auquier P.
        • Viarre-Oreal V.
        • et al.
        Effect of sedative premedication on patient experience after general anesthesia: a randomized clinical trial.
        JAMA. 2015; 313: 916-925
        • Kassie G.M.
        • Nguyen T.A.
        • Kalisch Ellett L.M.
        • Pratt N.L.
        • Roughead E.E.
        Preoperative medication use and postoperative delirium: a systematic review.
        BMC Geriatr. 2017; 17: 298
        • Rivera R.
        • Antognini Joseph F.
        Perioperative drug therapy in elderly patients.
        Anesthesiology. 2009; 110: 1176-1181
        • Maples-Keller J.L.
        • Bunnell B.E.
        • Kim S.J.
        • Rothbaum B.O.
        The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders.
        Harv Rev Psychiatry. 2017; 25: 103-113
        • Delshad S.D.
        • Almario C.V.
        • Fuller G.
        • Luong D.
        • Spiegel B.M.R.
        Economic analysis of implementing virtual reality therapy for pain among hospitalized patients.
        NPJ Digit Med. 2018; 1: 22

      Linked Article

      • Improving Reality Virtually: Advent of the Virtual “Digi-ceutical”?
        Mayo Clinic ProceedingsVol. 95Issue 6
        • Preview
          Management of the psychological state through pharmacological and nonpharmacological treatments has been a focus of health care for millennia. Ancient therapies, such as ingesting devil peppers in ancient India or bowssening (immersing in water) in medieval Europe, relied on distraction rather than alteration of neurobiochemistry to alleviate anxiety. In modern times, pharmacological therapies such as benzodiazepines have replaced such ancient techniques. However, given the concerns of pharmacological interactions, risk of postoperative delirium, and physiological dependence, there has been interest in identifying alternative nonpharmacological solutions that alleviate anxiety, depression, and other psychological disturbances.
        • Full-Text
        • PDF