Abstract
Background
Patients undergoing gastroscopy may experience discomfort and heightened anxiety because they remain conscious throughout the procedure and may fear possible complications.
Objective
This study examined whether a virtual reality (VR)-based relaxation intervention influences pain intensity, anxiety levels, and physiological anxiety indicators in patients undergoing gastroscopy.
Methods
A randomized controlled, parallel-group design was used. The sample consisted of 78 patients, with 39 allocated to the VR intervention group and 39 to the control group. Patients in the intervention group viewed a five-minute relaxation program via VR goggles before and during the procedure, while the control group received standard care. Data were collected using the Patient Information Form, Visual Analog Scale-Pain (VAS-P), Visual Analog Scale-Anxiety (VAS-A), and Physiological Parameters of Anxiety Monitoring Form.
Results
Compared with the control group, patients receiving VR showed significantly lower post-intervention VAS-P and VAS-A scores, heart rate, systolic and diastolic blood pressure, and respiratory rate. Oxygen saturation levels were significantly higher (p < 0.05).
Conclusion
The VR relaxation intervention was associated with lower levels of pain, anxiety, and physiological stress responses, as well as higher oxygen saturation during gastroscopy. These findings suggest that VR applications may be considered as a supportive adjunct in gastroscopy nursing care to enhance patient comfort and safety.
Keywords
Introduction
In contemporary medicine, endoscopic procedures are widely regarded as the gold standard for the diagnosis and treatment of gastrointestinal diseases due to their essential role in clinical practice. Among these procedures, upper gastrointestinal endoscopy (gastroscopy) is a minimally invasive technique that allows direct visualization of the esophagus, stomach, and duodenum using a flexible, camera-equipped instrument. 1 Despite its minimally invasive nature, gastroscopy is frequently associated with patient discomfort, including gagging, retching, choking sensations, and panic related to oropharyngeal stimulation. These experiences may lead to negative attitudes toward gastroscopy and adversely affect patient cooperation and procedural success. 2 To improve tolerability during gastroscopy, various supportive strategies are commonly used, including topical pharyngeal anesthesia, sedo-analgesia, and non-pharmacological interventions.1,3 These experiences not only reduce physical comfort but also contribute to psychological stress and discomfort. 4 Pain is not only a subjective experience but also brings about various physiological changes. For instance, a rise in heart rate and respiratory rate can result from an increase in myocardial oxygen demand induced by peripheral nervous system stimulation. The perception of pain causes an increase in the release of stress hormones, which in turn increases muscle tension. In muscles that remain constantly contracted, lactic acid builds up, triggering muscle fatigue.5,6 In addition, the increased oxygen demand of muscle cells can pave the way for the development of muscle spasms. 7 In addition to these physiological effects, the psychological processes experienced before gastroscopy are also extremely important for patients. Individuals may experience increasing anxiety in the period between deciding to undergo gastroscopy and the actual procedure. This anxiety may stem from a lack of information, previous negative experiences, or feelings of uncertainty about the procedure, and it may negatively affect patient satisfaction and cooperation with healthcare professionals in the pre-procedure period. 8
Various approaches, such as sedation, anesthesia, and non-pharmacological interventions, are widely used during gastroscopy to increase patient comfort and minimize potential complications. Virtual reality (VR) applications have recently arisen as a viable non-pharmacological alternative to traditional pain and anxiety treatments, thanks to the increasing use of technology in healthcare.9,10 VR technology provides an immersive 360-degree simulation environment that surrounds the user with both visual and auditory stimuli. This computer-assisted three-dimensional experience allows individuals to feel like active participants in a virtual environment, temporarily distancing themselves from reality. Compared to traditional distraction methods, the interactive and immersive nature of VR technology demonstrates higher effectiveness in diverting attention away from pain. 11 Furthermore, in today's world, where healthcare services are being reshaped with patient-centered approaches, personalizing medical experiences and increasing patient satisfaction are of great importance. In this context, VR applications provide significant advantages for modern individuals who are familiar with digital technologies and artificial intelligence, not only as effective distraction tools but also in terms of providing realistic, diverse, and user-friendly content. 11
Despite the fact that a number of studies have examined the use of VR during gastroscopy, the findings regarding pain and anxiety remain inconsistent. Moreover, relatively few studies have assessed physiological indicators of anxiety, limiting the generalizability of existing evidence. Therefore, the aim of this study was to examine the association between the use of a VR intervention and levels of pain, anxiety, and selected physiological parameters in patients undergoing gastroscopy.
Methods
Design
This investigation employed a parallel-group randomized controlled trial design and was registered at ClinicalTrials.gov (Identifier: NCT05585749).
Participants and setting
Participants were recruited from the gastroscopy unit of a university-affiliated hospital in Turkey between September 2022 and July 2023. Eligible individuals were adults aged 18 or older, capable of effective communication, and scheduled for non-sedated oral gastroduodenoscopy (OGD). No sedative or systemic pharmacological agents, including analgesics or antispasmodics (e.g. hyoscine butylbromide), were administered during the procedures, and supplemental oxygen was not provided. Routine topical pharyngeal anesthesia (lidocaine throat spray) was applied according to standard clinical practice when required. Exclusion criteria included emergency gastroscopy, neurological conditions (e.g. migraine, vertigo, and chronic headaches), or sensory impairments affecting hearing or vision. The gastroscopy unit was staffed by four gastroenterologists and four nurses, with two procedure rooms and one recovery room, performing approximately 20 procedures daily. The sample size was determined using a priori power analysis with G*Power version 3.1.9.4. Based on the data reported by Yılmaz and Dinçer, 10 the effect size was calculated as 0.89. Considering an effect size of 0.89, a significance level of 0.05, and a power of 0.95, a minimum of 34 participants per group (68 in total) was required. During the study period, 202 candidates were assessed; 98 did not meet the eligibility criteria, and 26 declined participation, resulting in a final sample of 78 participants, with 39 allocated to each of the intervention and control groups. Randomization was performed using a list of numbers (1s and 2s) generated via Random.org by an independent researcher, ensuring unbiased group assignment. Throughout both the design and reporting phases of the trial, the principles of the Consolidated Standards of Reporting Trials (CONSORT) were followed. To enhance clarity of the study design, a CONSORT flow diagram illustrating participant enrollment, allocation, follow-up, and analysis has been presented in Figure 1. Blinding was not applied to participants or researchers conducting the intervention; however, statistical analyses were performed by a blinded analyst to minimize bias.

Consolidated Standards of Reporting Trials (CONSORT) diagram.
Pilot study
A pilot study was conducted with 10 patients to test the feasibility of the application and the comprehensibility of the data collection tools before starting the research. The data obtained from this pilot study were not included in the main study group.
Measurements
Research data were collected through face-to-face interviews using the following tools: Patient Information Form, Visual Analog Scale-Anxiety (VAS-A), Visual Analog Scale-Pain (VAS-P), and the Physiological Parameters of Anxiety Monitoring Form.
Nursing interventions
Intervention group
In the intervention group, patients received VR intervention using VR Z4 Binocular Glasses (China) equipped with built-in headphones and motion sensors. A compatible smartphone was inserted into the device to provide a 360° immersive environment with head-tracking capability. The licensed VR content consisted of a 360° video of Benson's Progressive Muscle Relaxation Exercise, accompanied by nature scenes and relaxing background music.
Pre-test measurements (Patient Information Form, VAS-A, VAS-P, and Physiological Parameters of Anxiety Monitoring Form) were collected before the gastroscopy procedure. The VR relaxation video was initiated approximately 5 min prior to the procedure. VR glasses remained in place throughout the procedure and were removed immediately after the procedure was completed.
Pre-test measurements were collected before the gastroscopy procedure using the Patient Information Form, VAS-A, VAS-P, and Physiological Parameters of Anxiety Monitoring Form. The VR relaxation video was started approximately 5 min prior to the procedure.
VR glasses remained in place throughout the esophagogastroduodenoscopy (OGD) procedure and were removed immediately after its completion. The intervention was applied specifically during OGD, which allows safe placement of VR glasses without interfering with scope insertion, airway visualization, or patient monitoring. No supplemental oxygen was administered. The VR glasses were well tolerated by all participants, and no adverse events or safety concerns occurred.
Post-test measurements using the same forms were collected approximately 15–20 min after the gastroscopy procedure. No sham or placebo intervention was conducted.
Control group
Patients randomly assigned to the control group underwent initial (pre-test) measurements using the Patient Information Form, VAS-A, VAS-P, and the Physiological Parameters of Anxiety Monitoring Form before the gastroscopy procedure. No interventions were performed on the control group before or during the procedure; they received routine nursing care. Post-procedure measurements using the same forms were collected approximately 15–20 min after the gastroscopy procedure was completed.
Data evaluation
The statistical analysis was carried out using SPSS version 22.0. Descriptive statistics, including frequencies, means, and standard deviations, were used to summarize demographic data. Categorical data from distinct groups were analyzed using the chi-square test. Independent samples t-tests were used to compare the means between the two groups, while paired samples t-tests were used to evaluate changes within each group over time (e.g. pre- and post-gastroscopy). Skewness and kurtosis were reviewed to assess normality assumptions. Cohen's d was calculated to determine effect sizes, with the following interpretation: d < 0.2, small effect; 0.2 ≤ d < 0.8, moderate effect; d ≥ 0.8, large effect. 18 A p-value <0.05 was considered statistically significant.
Ethical principles of the research
Prior to study initiation, written informed consent was obtained from all participants. In addition, verbal informed consent was also obtained to ensure participants’ full understanding of the study procedures. The requirement for written informed consent was not waived. Ethical approval was granted by the Fırat University Non-Interventional Research Ethics Committee (Approval No. 2022/04-22, date: 17 March 2022) and by the institution where the research was conducted. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. All participant data were kept strictly confidential and used solely for research purposes.
Results
The control and intervention groups were statistically equivalent in terms of baseline demographic and clinical characteristics prior to the gastroscopy procedure (Table 1).
Comparison of findings related to the descriptive characteristics of patients in the control and intervention groups (n
χ2: chi-square test; t: independent groups t-test.
At baseline (pre-gastroscopy), there were no significant differences between the intervention and control groups in VAS-P (2.51 ± 1.16 vs. 2.97 ± 2.03, t = −1.230, p = 0.223) or VAS-A scores (3.61 ± 1.44 vs. 3.71 ± 1.19, t = −0.342, p = 0.733). Similarly, no significant differences were observed between the groups in physiological parameters, including systolic blood pressure (135.12 ± 8.84 vs. 134.35 ± 9.94 mmHg, t = 0.361, p = 0.719), diastolic blood pressure (80.76 ± 8.70 vs. 79.48 ± 11.45 mmHg, t = –0.556, p = 0.580), heart rate (77.43 ± 5.60 vs. 77.82 ± 6.15 breaths/min, t = 0.223, p = 0.774), respiratory rate (20.97 ± 1.93 vs. 21.74 ± 2.96 breaths/min, t = −1.357, p = 0.179), and oxygen saturation (94.38 ± 2.28 vs. 94.17 ± 2.23%, t = 0.400, p = 0.690) (Tables 2 and 3).
Comparison of intra-group and inter-group mean VAS-Pain and VAS-Anxiety scores pre-gastroscopy and post-gastroscopy.
ty: dependent groups t-test; tx: independent groups t-test; d: Cohen’s d; *p < 0.05 is considered statistically significant.
Comparison of physiological anxiety parameters pre-gastroscopy and post-gastroscopy.
ty: dependent groups t-test; tx: independent groups t-test; d: Cohen’s d; *p < 0.05 is considered statistically significant.
Post-gastroscopy, the intervention group showed significant reductions in VAS-P (1.64 ± 0.84, t = 6.108, p = 0.001, d = 0.966) and VAS-A scores (1.71 ± 0.79, t = 9.308, p < 0.001, d = 1.490), while the control group did not show significant intra-group changes (VAS-P: 2.53 ± 1.42, t = 1.665, p = 0.104; VAS-A: 4.30 ± 1.71, t = –1.744, p = 0.089). Between-group comparisons post-gastroscopy revealed significant differences favoring the intervention group for both VAS-P (t = –3.377, p = 0.001, d = 0.765) and VAS-A (t = –8.542, p < 0.001, d = 1.934) (Table 2).
Physiological parameters in the intervention group improved significantly post-gastroscopy, including systolic blood pressure (124.61 ± 9.41, t = –6.108, p < 0.001, d = 0.978), diastolic blood pressure (72.56 ± 8.80, t = 3.792, p < 0.001, d = 0.914), heart rate (74.84 ± 3.03, t = 2.708, p = 0.010, d = 0.434), respiratory rate (19.58 ± 1.39, t = 3.432, p = 0.001, d = 0.550), and oxygen saturation (95.84 ± 0.93, t = –4.002, p < 0.001, d = 0.641). In the control group, no significant intra-group changes were observed in systolic and diastolic blood pressure, heart rate, or respiratory rate, while oxygen saturation increased slightly (94.74 ± 2.11, t = –2.434, p = 0.020, d = 0.390). Post-gastroscopy between-group comparisons showed significant improvements favoring the intervention group for all physiological parameters (systolic blood pressure: t = –4.134, p < 0.001, d = 0.936; diastolic blood pressure: t = –4.350, p < 0.001, d = 1.581; heart rate: t = –6.403, p < 0.001, d = 1.450; respiratory rate: t = –2.558, p = 0.013, d = 0.579; oxygen saturation: t = 2.983, p = 0.004, d = 0.675) (Table 3).
Discussion
The findings of this study were evaluated in the context of the current literature. The similarity of demographic and clinical characteristics between the intervention and control groups indicates that baseline factors were unlikely to influence differences in pain, anxiety, or physiological outcomes.
This study demonstrated that VR significantly reduced pain levels in patients undergoing gastroscopy. This result is consistent with previous reviews and meta-analyses indicating that VR is an effective, non-invasive distraction tool for reducing procedure-related discomfort. 11 Çakır and Evirgen 19 similarly highlighted that VR may reduce analgesic requirements and is practical and safe for nursing implementation. Various randomized controlled studies have also confirmed the pain-reducing effects of VR in different clinical procedures.10,13,16,17,20,21 VR's ability to visually and auditorily engage the patient is thought to decrease pain perception through immersive distraction, aligning with neurocognitive theories that shifting attention toward pleasant stimuli reduces perceived pain intensity. 22 In line with the literature, our findings suggest that VR may be considered a useful non-pharmacological strategy to manage pain during gastroscopy.
The study also revealed that VR significantly reduced anxiety levels during gastroscopy. Similar findings were reported by Kim et al., 23 who found that pre-procedural VR use decreased anxiety before endoscopy. VR has also been shown to reduce anxiety during sedation-free procedures such as upper endoscopy and bronchoscopy.16,24 Several studies have confirmed VR's anxiolytic effects in a range of clinical settings,13,17,25–27 although a small number did not detect significant differences.14,28 The theoretical basis for VR's anxiolytic impact is grounded in the redirection of attention away from stress-inducing stimuli and toward immersive, visually and auditorily engaging environments. 29 The results of this study reinforce existing evidence and support the use of VR as a feasible, non-invasive nursing intervention aimed at improving patient comfort and reducing anxiety during gastroscopy.
Additionally, VR use resulted in significant improvements in physiological parameters such as blood pressure, heart rate, respiratory rate, and oxygen saturation. These findings align with earlier studies indicating that VR can reduce physiological arousal by attenuating anxiety-related sympathetic activation.13–17,26 Taken together, these outcomes suggest that VR may be a beneficial adjunct in modulating physiological stress responses during gastroscopy.
Strengths and limitations of the study
This study has several strengths. It provides a multidimensional evaluation of the effects of VR by simultaneously examining psychological outcomes (pain and anxiety) and objective physiological parameters. The randomized controlled design and a priori sample size calculation enhance the methodological rigor of the study. In addition, the low cost, non-invasive nature, and ease of implementation of the VR intervention support its feasibility for integration into routine nursing practice. Reporting effect sizes alongside statistical significance further strengthens the interpretation of the clinical relevance of the findings.
A minor, non-significant increase in post-procedural VAS-A scores was observed in the control group, while VAS-P scores decreased slightly, but also without statistical significance. This indicates that undergoing gastroscopy without VR support may not effectively reduce anxiety, even when perceived pain shows a small decline. The discrepancy between slight pain reduction and increased anxiety underscores that pain and anxiety do not always change in parallel. These findings highlight the added value of VR intervention in simultaneously mitigating both anxiety and pain, emphasizing its potential as an effective non-pharmacological support during gastroscopy procedures.
Several limitations should also be acknowledged. First, the study was conducted in a single center with a specific patient population undergoing non-sedated gastroscopy, which may limit the generalizability of the results to other clinical settings or endoscopic procedures. Second, qualitative data reflecting patients’ subjective experiences, such as comfort, acceptability, and satisfaction, were not collected, limiting insight into how the intervention was perceived at an individual level. Third, neither participants nor researchers could be blinded due to the nature of the intervention; however, blinding during statistical analysis partially mitigated the risk of bias. In addition, the psychometric properties of single-item measures such as VAS-A and VAS-P were not examined in depth, which may affect the precision of subjective assessments.
Another important limitation is the absence of a sham-VR control condition. Without a sham-VR arm, it is not possible to fully distinguish the specific effects of immersive VR from non-specific factors such as expectancy effects, increased attention, novelty of the device, or enhanced staff–patient interaction. Consequently, the observed reductions in pain, anxiety, and physiological stress responses may have been partially influenced by these non-specific effects, potentially leading to an overestimation of the true intervention effect. Future randomized controlled trials incorporating a sham-VR condition (e.g. an inactive headset or non-immersive visual content) are warranted to more precisely isolate the specific therapeutic effects of VR and strengthen causal interpretations.
Future directions
Future research should incorporate qualitative assessments of patients’ subjective experiences, including comfort, acceptability, usability, and satisfaction with VR. Studies comparing VR use across different gastrointestinal endoscopic procedures (e.g. gastroscopy/OGD, transnasal endoscopy, and colonoscopy), evaluating different types of VR content (nature scenes, guided relaxation, and breathing exercises), and determining optimal exposure duration are recommended. Research examining the impact of VR on staff–patient communication, overall procedural satisfaction, workflow efficiency, and cost-effectiveness would further support clinical integration. Incorporating real-time patient-reported experiences during procedures could help clarify the clinical relevance and acceptability of VR interventions.
Conclusion
This study found that patients in the VR intervention group reported lower levels of anxiety and pain during gastroscopy, and were also associated with more favorable physiological indicators, including blood pressure, heart rate, respiratory rate, and oxygen saturation. These findings suggest that VR may be a feasible adjunct to enhance patient comfort during gastroscopy procedures.
Supplemental Material
sj-docx-1-dhj-10.1177_20552076261416801 - Supplemental material for The effect of virtual reality on pain, anxiety, and physiological parameters in patients undergoing gastroscopy
Supplemental material, sj-docx-1-dhj-10.1177_20552076261416801 for The effect of virtual reality on pain, anxiety, and physiological parameters in patients undergoing gastroscopy by Gülcan Bahçecioğlu Turan and Hatice Özdemir in DIGITAL HEALTH
Footnotes
Acknowledgements
This article is derived from the research project entitled “The Effect of Virtual Reality Application on Pain Intensity and Anxiety Levels in Patients Undergoing Endoscopy,” which was supported by the Scientific and Technological Research Council of Turkey (TÜBİTAK) under the 2209-A Research Project Support Programme for Undergraduate Students.
Ethics approval and consent to participate
Prior to the study, written and verbal informed consent were obtained from all participants. Ethical approval for the study was granted by the Fırat University Non-Interventional Research Ethics Committee (Approval No. 2022/04-22, date: 17 March 2022), as well as by the institution where the research was conducted. The study adhered to the ethical principles of the Declaration of Helsinki. All participant data were kept strictly confidential and used solely for research purposes.
Consent for publication
Not applicable. This manuscript does not include identifying images or personal or clinical details of participants that compromise anonymity.
Authorship statement
All listed authors meet the authorship criteria, and all authors agree with the manuscript's content.
Clinical applications
VR technology may be considered for use in clinical practice to support patient comfort during invasive procedures, particularly in patients undergoing gastroscopy without sedation or with minimal sedation. Based on the findings of this study, VR applications may serve as a practical, non-invasive adjunct to standard care and may help reduce patient anxiety and discomfort, although further studies with sham-controlled designs are needed to confirm these effects and their impact on medication use.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Fırat University Scientific Research Projects Coordination Unit (FUBAP) within the scope of project number SYO.26.03
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
The data supporting this study's findings are available from the corresponding author upon reasonable request.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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