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Moreover, patients receiving an opioid prescription after short-stay surgeries have a 44% increased risk of long-term opioid use, and about one in 16 surgical patients becomes a long-term user. Current opioid abuse and addiction now place the US in an \u201copioid epidemic,\u201d and calls for alternative pain management mechanisms. To mitigate the preoperative anxiety and postoperative pain, we developed a virtual reality (VR) experience based on Attention Restoration Theory (ART) and integrated the user\u2019s heart rate variability (HRV) biofeedback to create an adaptive environment. A randomized control trial among 16 Total Knee Arthroplasty (TKA) patients undergoing surgery at Patewood Memorial Hospital, Greenville, SC demonstrated that patients experiencing the adaptive VR environment reported a significant decrease in preoperative anxiety ([Formula: see text]) and postoperative pain ([Formula: see text]) after the VR intervention. These results were also supported by the physiological measures where there was a significant increase in RR Interval (RRI) ([Formula: see text]) and a significant decrease in the low frequency (LF)\/high frequency (HF) ratio ([Formula: see text]) and respiration rate (RR) ([Formula: see text]).<\/jats:p>","DOI":"10.1142\/s1793351x20400152","type":"journal-article","created":{"date-parts":[[2020,11,2]],"date-time":"2020-11-02T09:26:41Z","timestamp":1604309201000},"page":"375-393","source":"Crossref","is-referenced-by-count":23,"title":["A Biofeedback Enhanced Adaptive Virtual Reality Environment for Managing Surgical Pain and Anxiety"],"prefix":"10.1142","volume":"14","author":[{"given":"Vishnunarayan Girishan","family":"Prabhu","sequence":"first","affiliation":[{"name":"Department of Industrial Engineering, Clemson University, 130 Freeman Hall, Clemson, SC 29634, USA"}]},{"given":"Laura","family":"Stanley","sequence":"additional","affiliation":[{"name":"Gianforte School of Computing, Montana State University, Bozeman, Montana 59715, USA"}]},{"given":"Robert","family":"Morgan","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, PRISMA Health\u00a0\u2014 Upstate, Greenville, SC 29605, USA"}]}],"member":"219","published-online":{"date-parts":[[2020,10,29]]},"reference":[{"issue":"102","key":"S1793351X20400152BIB001","first-page":"1","volume":"2017","author":"Hall M. 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