Breathing, Relaxation, and Pain Distraction: Evidence-Based Approaches in VR
Pain is both sensory and emotional. Extended reality (XR) allows us to train both tracks by modulating attention through distraction, calming physiology through breathwork and progressive muscle relaxation, and reshaping pain appraisal through mindfulness and coping skills. When thoughtfully integrated into rehabilitation, these tools can become powerful adjuncts for reducing pain, stress, and fear avoidance.
Distraction: Closing the Attentional Gate
Immersive VR reliably reduces acute procedural pain compared to usual care or 2D controls in pooled randomized controlled trials, with high patient acceptability and minimal risk (Luo et al., 2024). Multisensory and engaging scenes compete with nociceptive input and reduce threat appraisal, effectively “closing the attentional gate.” Newer studies extend these benefits to chronic pain management through repeated, home-based tele-VR sessions (Zhao et al., 2025).
In practice, I have seen this effect firsthand. One patient, confined to bed and relying on narcotic pain medication, initially resisted therapy because his pain was overwhelming. Once immersed in a distraction-based VR environment, his focus shifted entirely. His breathing slowed, his muscles softened, and his expression changed. Within minutes, his reported pain dropped from a 9 to a 2. When the nurse returned with his next medication dose, he declined it, saying he finally felt ready to get up and walk. This moment captured what the data shows: distraction through immersion is not avoidance; it is engagement through relief.
Breathing: Down-Regulating Arousal
Diaphragmatic breathing has long been shown to reduce stress and, in select populations, lower perceived pain intensity. Recent RCTs demonstrate immediate reductions in anxiety and pain after even a single guided session (Serrano-Ibáñez et al., 2024). Reviews from 2024 confirm its role in decreasing physiological stress markers across populations.
Virtual reality amplifies these effects through biofeedback and a sense of presence, helping patients see, hear, and feel their own calming patterns. Trials of VR-based breathing interventions are currently underway (NCT07064629; ClinicalTrials.gov, 2025), exploring how real-time feedback and immersive environments can strengthen self-regulation. Clinically, this gives patients an accessible, evidence-based way to reclaim control over their physiology, which is especially valuable for those whose pain triggers anxiety spirals.
Progressive Muscle Relaxation (PMR): Release to Relieve
PMR is another proven tool that consistently lowers stress and anxiety while showing growing benefits in pain populations (Frontiers Psychology, 2024; Dovepress Review, 2023). VR adds dimension and context, guiding users through personalized, scenic environments that support progressive release through both audio and visual cues.
For patients who struggle to connect with traditional PMR recordings, immersive scenes can make the difference between passive listening and active participation. Ongoing studies (NCT05478941) are evaluating whether VR-guided PMR can amplify these outcomes compared to audio-only formats. This is an exciting direction that may redefine how we teach and scale relaxation training in clinical care.
Mindfulness and Skills Training: Changing Pain’s Meaning
Beyond distraction and relaxation, mindfulness-based VR programs aim to reshape how patients relate to pain itself. By teaching awareness and acceptance, these experiences target the meaning of pain rather than its immediate sensation. Early evidence (Frontiers Pain, 2024) suggests that VR-guided mindfulness reduces interference and anxiety in chronic pain conditions.
This mirrors the FDA-authorized VR program for chronic low back pain (FDA, 2021), which teaches coping and self-regulation skills as part of a home-based behavioral therapy protocol. In the clinic, we see similar potential. Mindfulness-based VR does not just quiet pain; it restores agency, helping patients approach movement and recovery with confidence rather than fear.
Special Populations: Palliative and Oncology Care
A 2025 systematic review in palliative oncology care (Journal of Pain and Symptom Management) found that VR significantly reduced pain relative to control interventions. For patients facing high symptom burdens and limited mobility, immersive environments offer not just distraction but relief with dignity. This provides a gentle, low-effort pathway to comfort and calm.
Clinical Takeaway
Each approach serves a unique purpose. Use immersive distraction for acute, high-intensity pain such as procedures or flares. Combine breathing and PMR for autonomic quieting and sustained calm. Integrate mindfulness and coping skills to build resilience and change long-term pain appraisal. Dose matters, and short daily sessions can compound over time.
From the bedside to the headset, VR gives patients new ways to move, breathe, and believe in their ability to recover. Sometimes that belief is enough to get out of bed when they could not before.
References (APA)
Deng, H., et al. (2025). VR for pain in palliative cancer: Systematic review & meta-analysis. Journal of Pain and Symptom Management.JPSM Journal
Food and Drug Administration. (2021). De Novo classification: DEN210014 (RelieVRx).FDA Access Data
JBI Systematic Review (2024). Effectiveness of diaphragmatic breathing for reducing stress.POWERbreathe
Luo, H., et al. (2024). VR for procedural pain: Systematic review & meta-analysis. BMC Medicine, 22, 266.BioMed Central
Pardini, S., et al. (2023). Personalized VR + PMR: RCT protocol. JMIR Research Protocols, 12, e44183.researchprotocols.org
Serrano-Ibáñez, A. E., et al. (2024). Single-session diaphragmatic breathing in chronic pain/anxiety. Current Psychology.SpringerLink
Shankar, R., et al. (2025). VR-based mindfulness interventions: Protocol. JMIR Research Protocols, 14, e68231.researchprotocols.org
Veling, W., et al. (2021). VR relaxation in psychiatric care. JMIR Mental Health, 8(7), e20640.VRelax
Zhao, Y., et al. (2025). Telehealth VR reduces chronic pain: Crossover trial. npj Digital Medicine, 8, 53.Nature
ClinicalTrials.gov. (2025). VR breathing biofeedback (NCT07064629).ClinicalTrials
