{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,19]],"date-time":"2026-02-19T08:26:32Z","timestamp":1771489592647,"version":"3.50.1"},"reference-count":112,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2025,11,24]],"date-time":"2025-11-24T00:00:00Z","timestamp":1763942400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["MTI"],"abstract":"<jats:p>Fear of needles is common among child patients. It causes stress and can lead to difficulty in procedures and future treatment avoidance. Virtual reality (VR) has emerged as a promising tool to reduce pain and anxiety non-pharmacologically. However, a research gap exists regarding what VR content is most effective in decreasing periprocedural stress. This article reports a VR feasibility study conducted with 83 child patients aged 8\u201312 years during a cannulation procedure. It has a between-subjects design with four groups, comparing deep breathing and mindfulness-based relaxation in a virtual nature environment (VNE) to passive VNE and standard care. The results from both relaxation exercise groups have been previously reported. This follow-up article adds findings from passive VNE and control groups, comparing all four for effectiveness and patient experience. The key findings highlight that deep breathing was highly effective according to heart rate variability (HRV) data, but less enjoyable than the mindfulness-based relaxation, which achieved higher patient satisfaction but was less effective according to HRV. Passive VNEs were pleasant but did not cause measurable stress reduction. All VR interventions improved patient experience over standard care. Relaxation exercises in a VNE reduce periprocedural stress more efficiently than passive VNEs or standard care in pediatrics.<\/jats:p>","DOI":"10.3390\/mti9120115","type":"journal-article","created":{"date-parts":[[2025,11,24]],"date-time":"2025-11-24T13:09:25Z","timestamp":1763989765000},"page":"115","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Reducing Periprocedural Pain and Anxiety of Child Patients with Guided Relaxation Exercises in a Virtual Natural Environment: A Clinical Research Study"],"prefix":"10.3390","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8615-2878","authenticated-orcid":false,"given":"Ilmari","family":"Jysk\u00e4","sequence":"first","affiliation":[{"name":"TAUCHI Research Center, Faculty of Information Technology and Communication Sciences, Tampere University, FI-33014 Tampere, Finland"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7395-0769","authenticated-orcid":false,"given":"Markku","family":"Turunen","sequence":"additional","affiliation":[{"name":"TAUCHI Research Center, Faculty of Information Technology and Communication Sciences, Tampere University, FI-33014 Tampere, Finland"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6707-7975","authenticated-orcid":false,"given":"Kaija","family":"Puura","sequence":"additional","affiliation":[{"name":"TamCAM Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33014 Tampere, Finland"},{"name":"Department of Child Psychiatry, Tampere University Hospital, Central Hospital, P.O. Box 2000, FI-33521 Tampere, Finland"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-1763-7947","authenticated-orcid":false,"given":"Elina","family":"Karppa","sequence":"additional","affiliation":[{"name":"TamCAM Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33014 Tampere, Finland"},{"name":"Department of Pediatrics, Tampere University Hospital, Central Hospital, P.O. Box 2000, FI-33521 Tampere, Finland"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3270-7660","authenticated-orcid":false,"given":"Sauli","family":"Palmu","sequence":"additional","affiliation":[{"name":"TamCAM Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33014 Tampere, Finland"},{"name":"Department of Pediatrics, Tampere University Hospital, Central Hospital, P.O. Box 2000, FI-33521 Tampere, Finland"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6081-6819","authenticated-orcid":false,"given":"Jari","family":"Viik","sequence":"additional","affiliation":[{"name":"Finnish Cardiovascular Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33014 Tampere, Finland"}]}],"member":"1968","published-online":{"date-parts":[[2025,11,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1111\/jan.13818","article-title":"The Fear of Needles: A Systematic Review and Meta-Analysis","volume":"75","author":"McLenon","year":"2019","journal-title":"J. Adv. Nurs."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1177\/0894318419845391","article-title":"Children\u2019s Pain, Fear, and Anxiety During Invasive Procedures","volume":"32","year":"2019","journal-title":"Nurs. Sci. Q."},{"key":"ref_3","first-page":"237796081875944","article-title":"Fear of Injections and Needle Phobia Among Children and Adolescents: An Overview of Psychological, Behavioral, and Contextual Factors","volume":"4","author":"Orenius","year":"2018","journal-title":"SAGE Open Nurs."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Duncanson, E., Le Leu, R.K., Shanahan, L., Macauley, L., Bennett, P.N., Weichula, R., McDonald, S., Burke, A.L., Collins, K.L., and Chur-Hansen, A. (2021). The Prevalence and Evidence-Based Management of Needle Fear in Adults with Chronic Disease: A Scoping Review. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0253048"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1097\/ACO.0000000000001255","article-title":"Safety and Quality in Paediatric Procedural Sedation: What Really Matters?","volume":"36","author":"Eich","year":"2023","journal-title":"Curr. Opin. Anesthesiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"893","DOI":"10.1007\/s11916-024-01246-2","article-title":"Virtual Reality in Acute and Chronic Pain Medicine: An Updated Review","volume":"28","author":"Moreau","year":"2024","journal-title":"Curr. Pain. Headache Rep."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1056\/NEJMvcm0706789","article-title":"Peripheral Intravenous Cannulation","volume":"359","author":"Ortega","year":"2008","journal-title":"N. Engl. J. Med."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Jysk\u00e4, I., Turunen, M., Chaychi Maleki, A., Karppa, E., Palmu, S., Viik, J., M\u00e4kel\u00e4, J., and Puura, K. (2023). Effects of Using Guided Deep Breathing Exercises in a Virtual Natural Environment to Reduce Stress during Pediatric Treatment. Healthcare, 11.","DOI":"10.3390\/healthcare11243140"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Jysk\u00e4, I., Turunen, M., Chaychi Maleki, A., Karppa, E., Palmu, S., M\u00e4kel\u00e4, J., and Puura, K. (2023). Design and User Experience of VirNE Application: Deep Breathing Exercise in a Virtual Natural Environment to Reduce Treatment Anxiety in Pediatrics. Healthcare, 11.","DOI":"10.3390\/healthcare11243129"},{"key":"ref_10","unstructured":"Jysk\u00e4, I., Turunen, M., Puura, K., Chaychi Maleki, A., Karppa, E., Palmu, S., Viik, J., and M\u00e4kel\u00e4, J. (Virtual Real., 2024). Mindfulness-Based Guided Relaxation Exercises in a Virtual Natural Environment to Reduce Periprocedural Pain and Anxiety in Pediatrics, Virtual Real., under review."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Stanney, K.M., Nye, H., Haddad, S., Hale, K.S., Padron, C.K., and Cohn, J.V. (2021). Extended Reality (Xr) Environments. Handbook of Human Factors and Ergonomics, John Wiley & Sons, Ltd.","DOI":"10.1002\/9781119636113.ch30"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1037\/0033-2909.95.3.516","article-title":"Distraction and Coping with Pain","volume":"95","author":"McCaul","year":"1984","journal-title":"Psychol. Bull."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Asefi Rad, A., and Wippert, P.-M. (2024). Insights into Pain Distraction and the Impact of Pain Catastrophizing on Pain Perception during Different Types of Distraction Tasks. Front. Pain Res., 5.","DOI":"10.3389\/fpain.2024.1266974"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1012","DOI":"10.1097\/j.pain.0000000000000913","article-title":"Mechanisms of Distraction in Acute Pain Perception and Modulation","volume":"158","author":"Birnie","year":"2017","journal-title":"Pain"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1186\/s13052-023-01518-4","article-title":"Active versus Passive Distraction for Reducing Procedural Pain and Anxiety in Children: A Meta-Analysis and Systematic Review","volume":"49","author":"Shen","year":"2023","journal-title":"Ital. J. Pediatr."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Smith, V., Warty, R.R., Sursas, J.A., Payne, O., Nair, A., Krishnan, S., da Silva Costa, F., Wallace, E.M., and Vollenhoven, B. (2020). The Effectiveness of Virtual Reality in Managing Acute Pain and Anxiety for Medical Inpatients: Systematic Review. J. Med. Internet Res., 22.","DOI":"10.2196\/preprints.17980"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1658","DOI":"10.1097\/j.pain.0000000000002883","article-title":"Effect Modifiers of Virtual Reality in Pain Management: A Systematic Review and Meta-Regression Analysis","volume":"164","author":"Lier","year":"2023","journal-title":"Pain"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Smith, K.L., Wang, Y., and Colloca, L. (2022). Impact of Virtual Reality Technology on Pain and Anxiety in Pediatric Burn Patients: A Systematic Review and Meta-Analysis. Front. Virtual Real., 2.","DOI":"10.3389\/frvir.2021.751735"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1097\/AJP.0000000000001029","article-title":"The State of Science in the Use of Virtual Reality in the Treatment of Acute and Chronic Pain: A Systematic Scoping Review","volume":"38","author":"Baker","year":"2022","journal-title":"Clin. J. Pain"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"672","DOI":"10.1016\/j.pmn.2022.05.004","article-title":"A Systematic Review of Virtual Reality Therapeutics for Acute Pain Management","volume":"23","author":"Dreesmann","year":"2022","journal-title":"Pain Manag. Nurs."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Nordg\u00e5rd, R., and L\u00e5g, T. (2021). The Effects of Virtual Reality on Procedural Pain and Anxiety in Pediatrics: A Systematic Review and Meta-Analysis. Front. Virtual Real., 2.","DOI":"10.3389\/frvir.2021.699383"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Czech, O., Wrzeciono, A., Rutkowska, A., Guzik, A., Kiper, P., and Rutkowski, S. (2021). Virtual Reality Interventions for Needle-Related Procedural Pain, Fear and Anxiety\u2014A Systematic Review and Meta-Analysis. J. Clin. Med., 10.","DOI":"10.3390\/jcm10153248"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"3","DOI":"10.5817\/CP2020-1-3","article-title":"Mobile Virtual Reality Distraction Reduces Needle Pain and Stress in Children?","volume":"14","author":"Piskorz","year":"2020","journal-title":"Cyberpsychology J. Psychosoc. Res. Cyberspace"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Xiang, H., Shen, J., Wheeler, K.K., Patterson, J., Lever, K., Armstrong, M., Shi, J., Thakkar, R.K., Groner, J.I., and Noffsinger, D. (2021). Efficacy of Smartphone Active and Passive Virtual Reality Distraction vs Standard Care on Burn Pain Among Pediatric Patients: A Randomized Clinical Trial. JAMA Netw. Open, 4.","DOI":"10.1001\/jamanetworkopen.2021.12082"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1307","DOI":"10.1007\/s10055-022-00633-7","article-title":"Passive or Interactive Virtual Reality? The Effectiveness for Pain and Anxiety Reduction in Pediatric Patients","volume":"26","year":"2022","journal-title":"Virtual Real."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Shetty, A., Delanerolle, G., Zeng, Y., Shi, J.Q., Ebrahim, R., Pang, J., Hapangama, D., Sillem, M., Shetty, S., and Shetty, B. (2022). A Systematic Review and Meta-Analysis of Digital Application Use in Clinical Research in Pain Medicine. Front. Digit. Health, 4.","DOI":"10.3389\/fdgth.2022.850601"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1111\/jan.15473","article-title":"Effectiveness of Virtual Reality Intervention on Reducing the Pain, Anxiety and Fear of Needle-Related Procedures in Paediatric Patients: A Systematic Review and Meta-Analysis","volume":"79","author":"Gao","year":"2023","journal-title":"J. Adv. Nurs."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"104115","DOI":"10.1016\/j.ijnurstu.2021.104115","article-title":"Effectiveness of Virtual Reality in the Management of Paediatric Anxiety during the Peri-operative Period: A Systematic Review and Meta-Analysis","volume":"125","author":"Simonetti","year":"2022","journal-title":"Int. J. Nurs. Stud."},{"key":"ref_29","first-page":"99","article-title":"Promoting Emotional Well-Being in Hospitalized Children and Adolescents with Virtual Reality: Usability and Acceptability of a Randomized Controlled Trial","volume":"38","year":"2020","journal-title":"CIN Comput. Inform. Nurs."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Halbig, A., Babu, S.K., Gatter, S., Latoschik, M.E., Brukamp, K., and von Mammen, S. (2022). Opportunities and Challenges of Virtual Reality in Healthcare\u2014A Domain Experts Inquiry. Front. Virtual Real., 3.","DOI":"10.3389\/frvir.2022.837616"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1016\/j.copsyc.2021.02.004","article-title":"Advances in Immersive Virtual Reality Interventions for Mental Disorders: A New Reality?","volume":"41","author":"Geraets","year":"2021","journal-title":"Curr. Opin. Psychol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1177\/20494637221109108","article-title":"Cost Effectiveness of Virtual Reality Game Compared to Clinic Based McKenzie Extension Therapy for Chronic Non-Specific Low Back Pain","volume":"16","author":"Fatoye","year":"2022","journal-title":"Br. J. Pain"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Caruso, T.J., O\u2019Connell, C., Qian, J.J., Kung, T., Wang, E., Kinnebrew, S., Pearson, M., Kist, M., Menendez, M., and Rodriguez, S.T. (2020). Retrospective Review of the Safety and Efficacy of Virtual Reality in a Pediatric Hospital. Pediatr. Qual. Saf., 5.","DOI":"10.1097\/pq9.0000000000000293"},{"key":"ref_34","first-page":"701","article-title":"Cybersickness. A Systematic Literature Review of Adverse Effects Related to Virtual Reality","volume":"39","year":"2022","journal-title":"Neurolog\u00eda"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Kolasinski, E.M. (1995). Simulator Sickness in Virtual Environments, Army Research Institute for the Behavioral and Social Sciences.","DOI":"10.21236\/ADA295861"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Mantovani, E., Zucchella, C., Bottiroli, S., Federico, A., Giugno, R., Sandrini, G., Chiamulera, C., and Tamburin, S. (2020). Telemedicine and Virtual Reality for Cognitive Rehabilitation: A Roadmap for the COVID-19 Pandemic. Front. Neurol., 11.","DOI":"10.3389\/fneur.2020.00926"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"851","DOI":"10.1080\/10447318.2020.1848161","article-title":"A Reflection on Virtual Reality Design for Psychological, Cognitive and Behavioral Interventions: Design Needs, Opportunities and Challenges","volume":"37","author":"Tabbaa","year":"2021","journal-title":"Int. J. Hum.\u2013Comput. Interact."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"645","DOI":"10.1111\/jan.15065","article-title":"Virtual Reality Interventions and the Outcome Measures of Adult Patients in Acute Care Settings Undergoing Surgical Procedures: An Integrative Review","volume":"78","author":"Wang","year":"2022","journal-title":"J. Adv. Nurs."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1007\/s11469-020-00363-4","article-title":"Effects of Shinrin-Yoku (Forest Bathing) and Nature Therapy on Mental Health: A Systematic Review and Meta-Analysis","volume":"20","author":"Kotera","year":"2022","journal-title":"Int. J. Ment. Health Addict."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Browning, M.H.E.M., Shipley, N., McAnirlin, O., Becker, D., Yu, C.-P., Hartig, T., and Dzhambov, A.M. (2020). An Actual Natural Setting Improves Mood Better Than Its Virtual Counterpart: A Meta-Analysis of Experimental Data. Front. Psychol., 11.","DOI":"10.3389\/fpsyg.2020.02200"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"102044","DOI":"10.1016\/j.jenvp.2023.102044","article-title":"Virtual Nature, Psychological and Psychophysiological Outcomes: A Systematic Review","volume":"89","author":"Spano","year":"2023","journal-title":"J. Environ. Psychol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1037\/str0000300","article-title":"Nature through Virtual Reality as a Stress-Reduction Tool: A Systematic Review","volume":"30","author":"Gentile","year":"2023","journal-title":"Int. J. Stress Manag."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Lee, M., Kim, E., Choe, J., Choi, S., Ha, S., and Kim, G. (2022). Psychological Effects of Green Experiences in a Virtual Environment: A Systematic Review. Forests, 13.","DOI":"10.3390\/f13101625"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"100772","DOI":"10.1016\/j.invent.2024.100772","article-title":"The Effects of Digital Nature and Actual Nature on Stress Reduction: A Meta-Analysis and Systematic Review","volume":"38","author":"Fan","year":"2024","journal-title":"Internet Interv."},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Ratcliffe, E. (2021). Sound and Soundscape in Restorative Natural Environments: A Narrative Literature Review. Front. Psychol., 12.","DOI":"10.3389\/fpsyg.2021.570563"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"126865","DOI":"10.1016\/j.ufug.2020.126865","article-title":"Effects of Brightness Levels on Stress Recovery When Viewing a Virtual Reality Forest with Simulated Natural Light","volume":"56","author":"Li","year":"2020","journal-title":"Urban For. Urban Green."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"112227","DOI":"10.1016\/j.buildenv.2024.112227","article-title":"Beyond Greenery: Exploring Influences of Exposure to Natural Blue Elements on Patients Using Virtual Reality","volume":"267","author":"Tafti","year":"2024","journal-title":"Build. Environ."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1016\/j.ijheh.2011.05.001","article-title":"The Impact of Blue Space on Human Health and Well-Being\u2014Salutogenetic Health Effects of Inland Surface Waters: A Review","volume":"214","author":"Kistemann","year":"2011","journal-title":"Int. J. Hyg. Environ. Health"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"101775","DOI":"10.1016\/j.jenvp.2022.101775","article-title":"Stress Recovery from Virtual Exposure to a Brown (Desert) Environment versus a Green Environment","volume":"81","author":"Yin","year":"2022","journal-title":"J. Environ. Psychol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1007\/s11355-022-00523-9","article-title":"Durations of Virtual Exposure to Built and Natural Landscapes Impact Self-Reported Stress Recovery: Evidence from Three Countries","volume":"19","author":"Suppakittpaisarn","year":"2023","journal-title":"Landscape Ecol. Eng."},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Smith, A., Wyles, K.J., Hernandez, S.M., Clarke, S., Schofield, P., and Hughes, S.W. (2024). Harnessing the Therapeutic Effects of Nature for Chronic Pain: A Role for Immersive Virtual Reality? A Narrative Review. Eur. J. Pain, 29.","DOI":"10.1002\/ejp.4727"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"107008","DOI":"10.1016\/j.chb.2021.107008","article-title":"Measures and Modalities in Restorative Virtual Natural Environments: An Integrative Narrative Review","volume":"126","author":"Nukarinen","year":"2022","journal-title":"Comput. Hum. Behav."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1007\/s10072-016-2790-8","article-title":"The Role of Deep Breathing on Stress","volume":"38","author":"Perciavalle","year":"2017","journal-title":"Neurol. Sci."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"101315","DOI":"10.1016\/j.ctcp.2021.101315","article-title":"Effects of Diaphragmatic Deep Breathing Exercises on Prehypertensive or Hypertensive Adults: A Literature Review","volume":"43","author":"Yau","year":"2021","journal-title":"Complement. Ther. Clin. Pract."},{"key":"ref_55","first-page":"79","article-title":"Breathing, Attention & Consciousness in Sync: The Role of Breathing Training, Metacognition & Virtual Reality","volume":"29","author":"Mitsea","year":"2022","journal-title":"Tech. Soc. Sci. J."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1080\/17518423.2020.1839981","article-title":"Safety and Tolerability of an Innovative Virtual Reality-Based Deep Breathing Exercise in Concussion Rehabilitation: A Pilot Study","volume":"24","author":"Cook","year":"2021","journal-title":"Dev. Neurorehabilit."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s10484-023-09611-4","article-title":"Virtual Reality Breathing Interventions for Mental Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials","volume":"49","author":"Adriaanse","year":"2024","journal-title":"Appl. Psychophysiol. Biofeedback"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"738","DOI":"10.1080\/13607863.2023.2270442","article-title":"Designing and Developing a Nature-Based Virtual Reality with Heart Rate Variability Biofeedback for Surgical Anxiety and Pain Management: Evidence from Total Knee Arthroplasty Patients","volume":"28","author":"Stanley","year":"2024","journal-title":"Aging Ment. Health"},{"key":"ref_59","doi-asserted-by":"crossref","unstructured":"Blum, J., Rockstroh, C., and G\u00f6ritz, A.S. (2019). Heart Rate Variability Biofeedback Based on Slow-Paced Breathing with Immersive Virtual Reality Nature Scenery. Front. Psychol., 10.","DOI":"10.3389\/fpsyg.2019.02172"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1007\/s10055-020-00471-5","article-title":"A Mobile VR-Based Respiratory Biofeedback Game to Foster Diaphragmatic Breathing","volume":"25","author":"Rockstroh","year":"2021","journal-title":"Virtual Real."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"1580","DOI":"10.1109\/TAFFC.2024.3352424","article-title":"Novel VR-Based Biofeedback Systems: A Comparison Between Heart Rate Variability- and Electrodermal Activity-Driven Approaches","volume":"15","author":"Baldini","year":"2024","journal-title":"IEEE Trans. Affect. Comput."},{"key":"ref_62","unstructured":"Sujato, B. (2011). A History of Mindfulness, Bhikkhu Sujato."},{"key":"ref_63","unstructured":"Lehrer, P.M., Woolfolk, R.L., and Sime, W.E. (2007). Mindfulness Meditation. Principles and Practice of Stress Management, Guilford Press. [3rd ed.]."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1093\/jpepsy\/jsad003","article-title":"Living with Physical Health Conditions: A Systematic Review of Mindfulness-Based Interventions for Children, Adolescents, and Their Parents","volume":"48","author":"Hughes","year":"2023","journal-title":"J. Pediatr. Psychol."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"487","DOI":"10.1016\/j.chc.2014.03.002","article-title":"Meditation and Mindfulness in Clinical Practice","volume":"23","author":"Simkin","year":"2014","journal-title":"Child Adolesc. Psychiatr. Clin. N. Am."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1111\/acem.14412","article-title":"Take-Pause: Efficacy of Mindfulness-Based Virtual Reality as an Intervention in the Pediatric Emergency Department","volume":"29","author":"Butt","year":"2022","journal-title":"Acad. Emerg. Med."},{"key":"ref_67","doi-asserted-by":"crossref","unstructured":"Wren, A.A., Neiman, N., Caruso, T.J., Rodriguez, S., Taylor, K., Madill, M., Rives, H., and Nguyen, L. (2021). Mindfulness-Based Virtual Reality Intervention for Children and Young Adults with Inflammatory Bowel Disease: A Pilot Feasibility and Acceptability Study. Children, 8.","DOI":"10.3390\/children8050368"},{"key":"ref_68","doi-asserted-by":"crossref","unstructured":"Bernaerts, S., Bonroy, B., Daems, J., Sels, R., Struyf, D., Gies, I., and van de Veerdonk, W. (2022). Virtual Reality for Distraction and Relaxation in a Pediatric Hospital Setting: An Interventional Study with a Mixed-Methods Design. Front. Digit. Health, 4.","DOI":"10.3389\/fdgth.2022.866119"},{"key":"ref_69","unstructured":"Haas, J.K. (2014). A History of the Unity Game Engine, Worcester Polytechnic Institute."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"1230","DOI":"10.1097\/00004583-199910000-00011","article-title":"Psychometric Properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A Replication Study","volume":"38","author":"Birmaher","year":"1999","journal-title":"J. Am. Acad. Child. Adolesc. Psychiatry"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"1323","DOI":"10.1002\/nop2.330","article-title":"Validation of a Visual Analogue Scale for the Evaluation of the Postoperative Anxiety: A Prospective Observational Study","volume":"6","author":"Labaste","year":"2019","journal-title":"Nurs. Open"},{"key":"ref_72","first-page":"1389","article-title":"Validation of Visual Analogue Scale for Anxiety (VAS-A) in Preanesthesia Evaluation","volume":"79","author":"Facco","year":"2013","journal-title":"Minerva Anestesiol."},{"key":"ref_73","doi-asserted-by":"crossref","unstructured":"Jysk\u00e4, I., Puura, K., and Turunen, M. (2022). Therapeutic Potential of Interactive Audiovisual 360-Degree Virtual Reality Environments for Anxiety Reduction\u2014A Case Study with an Abstract Art Application. Appl. Sci., 12.","DOI":"10.3390\/app12189316"},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1016\/j.ijpsycho.2015.08.004","article-title":"Heart Rate Variability as a Transdiagnostic Biomarker of Psychopathology","volume":"98","author":"Beauchaine","year":"2015","journal-title":"Int. J. Psychophysiol."},{"key":"ref_75","first-page":"288","article-title":"The Relationship Between Mental and Physical Health: Insights from the Study of Heart Rate Variability","volume":"89","author":"Kemp","year":"2013","journal-title":"Int. J. Psychophysiol. Off. J. Int. Organ. Psychophysiol."},{"key":"ref_76","doi-asserted-by":"crossref","unstructured":"Shaffer, F., and Ginsberg, J.P. (2017). An Overview of Heart Rate Variability Metrics and Norms. Front. Public Health, 5.","DOI":"10.3389\/fpubh.2017.00258"},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"66","DOI":"10.12710\/cardiometry.2017.10.6676","article-title":"Heart Rate Variability Analysis: Physiological Foundations and Main Methods","volume":"10","author":"Baevsky","year":"2017","journal-title":"Cardiometry"},{"key":"ref_78","doi-asserted-by":"crossref","unstructured":"von Rosenberg, W., Chanwimalueang, T., Adjei, T., Jaffer, U., Goverdovsky, V., and Mandic, D.P. (2017). Resolving Ambiguities in the LF\/HF Ratio: LF-HF Scatter Plots for the Categorization of Mental and Physical Stress from HRV. Front. Physiol., 8.","DOI":"10.3389\/fphys.2017.00360"},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1016\/j.neubiorev.2016.03.007","article-title":"Sex Differences in Healthy Human Heart Rate Variability: A Meta-Analysis","volume":"64","author":"Koenig","year":"2016","journal-title":"Neurosci. Biobehav. Rev."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1093\/jpepsy\/jsab122","article-title":"\u201cThere\u2019s Nothing Wrong with You\u201d: Pain-Related Stigma in Adolescents with Chronic Pain","volume":"47","author":"Wakefield","year":"2022","journal-title":"J. Pediatr. Psychol."},{"key":"ref_81","first-page":"e502","article-title":"Comparison of Skin Conductance Measurements and Subjective Pain Scores in Children with Minor Injuries","volume":"102","author":"Strehle","year":"2013","journal-title":"Acta Paediatr."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"314","DOI":"10.1093\/jpepsy\/jsx103","article-title":"Assessment of Pain Anxiety, Pain Catastrophizing, and Fear of Pain in Children and Adolescents with Chronic Pain: A Systematic Review and Meta-Analysis","volume":"43","author":"Fisher","year":"2018","journal-title":"J. Pediatr. Psychol."},{"key":"ref_83","doi-asserted-by":"crossref","unstructured":"Karppa, E., Puura, K., Jysk\u00e4, I., Turunen, M., and Palmu, S. (2024). Case Report: Virtual natural environment solution helped a child cope with a painful procedure. Front. Pediatr., 12.","DOI":"10.3389\/fped.2024.1355046"},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"490","DOI":"10.1080\/14733285.2019.1685076","article-title":"Engaging with Nature: Nature Affords Well-Being for Families and Young People in Finland","volume":"18","author":"Rantala","year":"2020","journal-title":"Child. Geogr."},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"775","DOI":"10.1080\/10447318.2024.2338327","article-title":"Optimizing Virtual Nature for Psychological and Physiological Well-Being: A Systematic Review of the Moderating Effects of Duration, Nature Type, Sample Characteristics, and Immersiveness and Potential Risks of Bias","volume":"41","author":"Bolouki","year":"2025","journal-title":"Int. J. Hum.\u2013Comput. Interact."},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"102621","DOI":"10.1016\/j.ejon.2024.102621","article-title":"The Effect of a Biofeedback-Based Virtual Reality Game on Pain, Fear and Anxiety Levels during Port Catheter Needle Insertion in Pediatric Oncology Patients: A Randomized Controlled Study","volume":"70","author":"Semerci","year":"2024","journal-title":"Eur. J. Oncol. Nurs."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1016\/j.pedn.2024.09.008","article-title":"Golden Breath: Feasibility and Acceptability of a Biofeedback-Based Virtual Reality Game on Reducing Children\u2019s Needle-Related Pain and Fear","volume":"79","author":"Aydos","year":"2024","journal-title":"J. Pediatr. Nurs."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1002\/pne2.12078","article-title":"The Use of Virtual Reality during Medical Procedures in a Pediatric Orthopedic Setting: A Mixed-Methods Pilot Feasibility Study","volume":"6","author":"Addab","year":"2024","journal-title":"Paediatr. Neonatal Pain"},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"101268","DOI":"10.1016\/j.ienj.2023.101268","article-title":"Can Virtual Reality Reduce Pain and Anxiety in Pediatric Emergency Care and Promote Positive Response of Parents of Children? A Quasi-Experimental Study","volume":"68","year":"2023","journal-title":"Int. Emerg. Nurs."},{"key":"ref_90","doi-asserted-by":"crossref","unstructured":"Gold, J.I., SooHoo, M., Laikin, A.M., Lane, A.S., and Klein, M.J. (2021). Effect of an Immersive Virtual Reality Intervention on Pain and Anxiety Associated with Peripheral Intravenous Catheter Placement in the Pediatric Setting: A Randomized Clinical Trial. JAMA Netw. Open, 4.","DOI":"10.1001\/jamanetworkopen.2021.22569"},{"key":"ref_91","doi-asserted-by":"crossref","unstructured":"Reitze, A., Voigt, M., Klawonn, F., Dusch, M., Grigull, L., and M\u00fccke, U. (2024). Impact of Virtual Reality on Peri-Interventional Pain, Anxiety and Distress in a Pediatric Oncology Outpatient Clinic: A Randomized Controlled Trial. BMC Pediatr., 24.","DOI":"10.1186\/s12887-024-04952-3"},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"101804","DOI":"10.1016\/j.ejon.2020.101804","article-title":"Exploring the Use of Immersive Virtual Reality to Enhance Psychological Well-Being in Pediatric Oncology: A Pilot Randomized Controlled Trial","volume":"48","author":"Tennant","year":"2020","journal-title":"Eur. J. Oncol. Nurs."},{"key":"ref_93","doi-asserted-by":"crossref","unstructured":"Badke, C.M., Krogh-Jespersen, S., Flynn, R.M., Shukla, A., Essner, B.S., and Malakooti, M.R. (2022). Virtual Reality in the Pediatric Intensive Care Unit: Patient Emotional and Physiologic Responses. Front. Digit. Health, 4.","DOI":"10.3389\/fdgth.2022.867961"},{"key":"ref_94","doi-asserted-by":"crossref","unstructured":"Felemban, O.M., Alshamrani, R.M., Aljeddawi, D.H., and Bagher, S.M. (2021). Effect of Virtual Reality Distraction on Pain and Anxiety during Infiltration Anesthesia in Pediatric Patients: A Randomized Clinical Trial. BMC Oral Health, 21.","DOI":"10.1186\/s12903-021-01678-x"},{"key":"ref_95","doi-asserted-by":"crossref","unstructured":"Wong, C.L., and Choi, K.C. (2023). Effects of an Immersive Virtual Reality Intervention on Pain and Anxiety Among Pediatric Patients Undergoing Venipuncture: A Randomized Clinical Trial. JAMA Netw. Open, 6.","DOI":"10.1001\/jamanetworkopen.2023.0001"},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1016\/j.mcpdig.2023.05.001","article-title":"Virtual Reality Hypnoanxiolysis and Analgesia for Emergency Department Needle-Related Procedures: A Prospective Interventional Cohort Pilot Study Implementation","volume":"1","author":"Barrett","year":"2023","journal-title":"Mayo Clin. Proc. Digit. Health"},{"key":"ref_97","doi-asserted-by":"crossref","unstructured":"Baltaci, N., Bal, S., Ko\u00e7, E., and Edis, E.K. (2024). Effects of Virtual Reality and Nature Sounds on Pain and Anxiety during Hysterosalpingography: A Randomized Controlled Trial. Rev. Assoc. Med. Bras., 70.","DOI":"10.1590\/1806-9282.20231599"},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"102532","DOI":"10.1016\/j.cpcardiol.2024.102532","article-title":"Effectiveness of Virtual Reality on Pain and Anxiety in Patients Undergoing Cardiac Procedures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials","volume":"49","author":"Micheluzzi","year":"2024","journal-title":"Curr. Probl. Cardiol."},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"103884","DOI":"10.1016\/j.landurbplan.2020.103884","article-title":"The Effect of Audio Fidelity and Virtual Reality on the Perception of Virtual Greenspace","volume":"202","author":"Lindquist","year":"2020","journal-title":"Landsc. Urban Plan."},{"key":"ref_100","doi-asserted-by":"crossref","unstructured":"Yamashita, Y., Aijima, R., and Danjo, A. (2023). Clinical Effects of Different Virtual Reality Presentation Content on Anxiety and Pain: A Randomized Controlled Trial. Sci. Rep., 13.","DOI":"10.1038\/s41598-023-47764-8"},{"key":"ref_101","doi-asserted-by":"crossref","first-page":"5924040","DOI":"10.1155\/2021\/5924040","article-title":"Effectiveness of Progressive Muscle Relaxation, Deep Breathing, and Guided Imagery in Promoting Psychological and Physiological States of Relaxation","volume":"2021","author":"Toussaint","year":"2021","journal-title":"Evid.-Based Complement. Altern. Med."},{"key":"ref_102","doi-asserted-by":"crossref","first-page":"2743","DOI":"10.1007\/s12671-021-01738-x","article-title":"Mindful Versus Diaphragmatic Breathing: Spirituality Moderates the Impact on Heart Rate Variability","volume":"12","author":"Hunt","year":"2021","journal-title":"Mindfulness"},{"key":"ref_103","doi-asserted-by":"crossref","unstructured":"de Brito Sena, M.A., Damiano, R.F., Lucchetti, G., and Peres, M.F.P. (2021). Defining Spirituality in Healthcare: A Systematic Review and Conceptual Framework. Front. Psychol., 12.","DOI":"10.3389\/fpsyg.2021.756080"},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1007\/s10902-008-9126-1","article-title":"Spirituality, Religiousness, and Happiness in Children Aged 8\u201312 Years","volume":"11","author":"Holder","year":"2010","journal-title":"J. Happiness Stud."},{"key":"ref_105","doi-asserted-by":"crossref","first-page":"103275","DOI":"10.1016\/j.ijhcs.2024.103275","article-title":"Virtual Reality Experiences for Breathing and Relaxation Training: The Effects of Real vs. Placebo Biofeedback","volume":"188","author":"Chittaro","year":"2024","journal-title":"Int. J. Hum.-Comput. Stud."},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1007\/s12671-021-01783-6","article-title":"A Narrative Review of Mindfulness-Based Interventions Using Virtual Reality","volume":"13","author":"Arpaia","year":"2022","journal-title":"Mindfulness"},{"key":"ref_107","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1016\/j.explore.2022.08.001","article-title":"The Effectiveness of Immersive Virtual Reality (VR) Based Mindfulness Training on Improvement Mental-Health in Adults: A Narrative Systematic Review","volume":"19","author":"Ma","year":"2023","journal-title":"Explore"},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1016\/j.pmn.2022.03.013","article-title":"Virtual Reality-Based Mindfulness for Chronic Pain Management: A Scoping Review","volume":"23","author":"Mayne","year":"2022","journal-title":"Pain Manag. Nurs."},{"key":"ref_109","doi-asserted-by":"crossref","first-page":"102356","DOI":"10.1016\/j.ctim.2020.102356","article-title":"Feasibility of Implementing a Virtual Reality Program as an Adjuvant Tool for Peri-Operative Pain Control; Results of a Randomized Controlled Trial in Minimally Invasive Foregut Surgery","volume":"49","author":"Haisley","year":"2020","journal-title":"Complement. Ther. Med."},{"key":"ref_110","doi-asserted-by":"crossref","first-page":"1698","DOI":"10.1097\/j.pain.0000000000001877","article-title":"The Efficacy of Mindfulness-Based Interventions in Acute Pain: A Systematic Review and Meta-Analysis","volume":"161","author":"Shires","year":"2020","journal-title":"Pain"},{"key":"ref_111","doi-asserted-by":"crossref","unstructured":"Hu, X.-S., Beard, K., Sherbel, M.C., Nascimento, T.D., Petty, S., Pantzlaff, E., Schwitzer, D., Kaciroti, N., Maslowski, E., and Ashman, L.M. (2021). Brain Mechanisms of Virtual Reality Breathing Versus Traditional Mindful Breathing in Pain Modulation: Observational Functional Near-Infrared Spectroscopy Study. J. Med. Internet Res., 23.","DOI":"10.2196\/preprints.27298"},{"key":"ref_112","doi-asserted-by":"crossref","first-page":"1082","DOI":"10.1016\/j.bja.2023.09.001","article-title":"The Analgesic Effects and Neural Oscillatory Mechanisms of Virtual Reality Scenes Based on Distraction and Mindfulness Strategies in Human Volunteers","volume":"131","author":"Li","year":"2023","journal-title":"Br. J. Anaesth."}],"container-title":["Multimodal Technologies and Interaction"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2414-4088\/9\/12\/115\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,24]],"date-time":"2025-11-24T13:56:57Z","timestamp":1763992617000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2414-4088\/9\/12\/115"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,24]]},"references-count":112,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["mti9120115"],"URL":"https:\/\/doi.org\/10.3390\/mti9120115","relation":{},"ISSN":["2414-4088"],"issn-type":[{"value":"2414-4088","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,24]]}}}