Effects of a Virtual Reality Hypnosis Intervention on Chronic Pain: A User Experience and Proof-of-concept Study

Effects of a Virtual Reality Hypnosis Intervention on Chronic Pain: A User Experience and Proof-of-concept Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of a Virtual Reality Hypnosis Intervention on Chronic Pain: A User Experience and Proof-of-concept Study Alexandra Chevestrier-Lefeuvre, Joséphine Guiné, Jade Véronneau, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6278623/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Chronic pain is a significant public health issue in Canada, with approximately one in four Canadians over the age of 15 living with this condition. Due to its impact on individuals—both physically and psychologically—and its financial burden on the healthcare system, it is crucial to develop cost-effective and efficient treatment methods. Hypnosis and virtual reality have emerged as promising solutions in this context. This study aims to evaluate the preliminary efficacy and feasibility of an intervention combining virtual reality and hypnosis. The study involved 30 patients with chronic pain who were invited to test a hypnosis application delivered through a virtual reality device. Levels of pain, anxiety, and relaxation were measured before and after the intervention, while satisfaction, cybersickness, and user experience were evaluated post-intervention. At the end of the intervention, participants were invited to participate in a semi-structured interview to provide feedback on their satisfaction with the experience. Participants reported high levels of satisfaction with the intervention, a positive user experience, and minimal symptoms of cybersickness. The intervention was effective in reducing anxiety (W = 173.5, p = .002) and pain (W = 253.5, p < .001) while significantly enhancing relaxation levels (W = 9.00, p < .001). This intervention demonstrated effectiveness in reducing pain and anxiety while improving relaxation levels among individuals with chronic pain, paving the way for further investigations of the involved mechanisms. Chronic pain Virtual Reality Hypnosis Intervention Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Chronic Pain Pain can be defined as an unpleasant sensory and emotional experience associated with, or resembling, actual or potential tissue damage. Among pain category, chronic pain is a pain that persists or recurs for more than three months. It involves multiple factors (i.e., biological, psychological, and social) contributing to the pain syndrome (1). In 2019, approximately 7.63 million people, or one in four Canadians aged 15 or older, lived with chronic pain. Chronic pain has significant impacts on physical and mental health, family and community life, society, and the economy, with a total direct and indirect cost of 38.3 to 40.4 billion dollars in 2019 in Canada (2). Chronic pain treatment can encompass several modalities such as pharmacological (e.g., non-steroidal anti-inflammatory drugs, opioids, cannabinoids, antidepressants), physical (e.g., rehabilitation therapy, low-power laser therapy, shockwave therapy, deep brain stimulation), or psychological therapies (e.g., cognitive and behavioral therapy, acceptance and commitment therapy, mindfulness-based interventions, hypnosis) (Public Health Agency of Canada, 2023). Healthcare pathway of patients with chronic pain includes several pitfalls. First, despite being effective in management of pain, some pharmacological treatments were shown to carry some risks. For instance, opioids can lead to side effects or overdose-related deaths which became a major public health issue in North America during the last years. Furthermore, the median wait time for an appointment at a public clinic offering specialized multidisciplinary services for diagnosing and managing chronic pain patients is at least six months, and in some regions of Canada, it can take up to five years to access appropriate pain treatment (3). Access to care is subject to inequality depending on the source of funding of the institutions, for instance the wait time for public clinics is about 12 times longer than for non-public clinics (3). For those reasons, it is now recognized that pain prevention and management must be addressed more broadly, not only as part of substance use measures but also as a parallel public health priority (2). Using a multidisciplinary approach to treat chronic pain is expected to be effective, and treatment plans should include multimodal medication options, physiotherapy, pain psychology, and selected interventions as needed (4). Among interventions that could be used to treat chronic pain, hypnosis appears to be a promising solution. Hypnosis is defined as “a procedure, or the state induced by that procedure, in which suggestion is used to evoke changes in sensation, perception, cognition, emotion, or motor behavior control” (5). The efficacy of hypnosis was demonstrated in several studies, showing improvements in appraisal of pain (6)but on a physiological level (7–9). Despite seeming a fruitful therapeutic solution, hypnosis requires specialized professionals and can be time-consuming in regard of administrative constraints. For those reasons, it seems necessary to develop innovative complementary interventions that could be widely disseminated (10). Virtual Reality Analgesia and Virtual Reality Hypnosis (VRH) Virtual reality (VR) developed tremendously in healthcare settings during the last decades (11). VR-based analgesia can be implemented at different levels of complexity. Sometimes, distraction is achieved through strange, evocative, and beautiful images in the virtual environment (12,13), or by programming fast-paced interactive activities similar to video games (14). Virtual Reality Hypnosis (VRH) represents a combination of virtual reality and hypnosis and first appeared in a clinical research context in 2004 for a patient suffering from a severe burn (15). Among existing programs, some VRH interventions have shown to reduce clinical and experimental pain in randomized controlled trials (16,17). VRH has also shown promising effects in reducing pain and stress (18). Nevertheless, there remains a lack of studies on VRH in specifically supporting people with chronic pain. Moreover, the ability of these studies to account for predictive factors for the effective use of this technology (i.e., adherence, feasibility, user experience) hasn’t been widely evaluated. Additionally, current VR programs do not offer real-time adaptability of the audiovisual environment based on the patient's experience (19). Thus, there is a need to develop and evaluate new dynamic VRH paradigms in the field of chronic pain. Following the recommendations of the ORBIT model for the development of non-pharmacological interventions (20–22), after having defined the interventions (Phase 1a), studies should aim at refining those if needed (Phase 1b) and preliminary test their efficacy on intended outcomes through a proof-of-concept study (Phase 2a). In that sense, according to the ORBIT model, this study constitutes a Phase 1b and Phase 2a study. Objectives The main objective of this study is to investigate the efficacy of an intervention integrating procedures that combine hypnosis and virtual reality in supporting patients with chronic pain, as well as the user experience of such an intervention. Materials and Methods The data supporting the findings of this study are available on an OSF repository via the following link: https://osf.io/vbh72/?view_only=af1597d4cc5c4850a513d2fc9b3cc7de then in the “1- User experience and proof-of-concept” study folder. Population The study was proposed to patients with miscellaneous chronic pain. The inclusion criteria were being 18 years or older, being French-speaking, having a diagnosis of chronic pain, and having previously experienced hypnosis. Exclusion criteria included declared deafness, blindness, confusion, or other conditions that may impair communication (e.g., psychosis, dementia). Procedure Participants recruitment began on February 23, 2024, and concluded on April 22, 2024. After having provided their informed written consent, study participants were welcomed at Maisonneuve-Rosemont Hospital (Montréal, Quebec, Canada) by a psychology doctoral student or psychologist, and then guided to a consultation room dedicated to the experiment. In this hospital setting, the atmosphere was conducive to concentration, with a comfortable chair and adequate lighting to facilitate the experience, the interview, and the completion of questionnaires. Once they were installed, participants were asked to provide socio-demographic and clinical variables, and their feelings of pain, anxiety, and relaxation were assessed before the VRH session. Then, they used the VRH intervention in the presence of a member of the research team. After the VRH session, participants completed a questionnaire evaluating their satisfaction, user experience with VRH, cyber-sickness, and a questionnaire assessing their feelings of pain, anxiety, and relaxation after the VRH session. Eventually, the first 15 participants participated in a semi-structured individual interview to provide further explanations regarding the scores given in the questionnaires. A graphical representation of the procedure is displayed in Figure 1. Insert Figure 1 Measured Variables Sociodemographic and clinical variables questionnaire consisted of gender, age, marital status, scholar level, professional status, and medication for chronic pain. Before and after the VRH session, participants were asked to evaluate their levels of pain, anxiety, and relaxation on 11-points numerical rating scale from 0 to 10. For pain, 0 meant “no pain at all” and 10 “Very important pain”. For anxiety, 0 meant “No anxiety at all” and 10 “Very important anxiety”. For relaxation, 0 meant “Not relaxed at all” and 10 “Very important relaxation”. Participants satisfaction was assessed using 10 questions from the Kazdin (1977) questionnaire(23). Those questions were rated on an 11-point Likert scale (0 = "strongly disagree" to 10 = "strongly agree"). The user experience was assessed with the User Experience Questionnaire (UEQ, 26 items, bipolar 7-point Likert scale)(24) evaluating six components: attractiveness, perspicacity, efficiency, dependability, stimulation and novelty. Answers can range from -3 to +3. Values between -0.8 and 0.8 represent a neutral evaluation, values above 0,8 represent a positive evaluation and, values below -0,8 represent a negative evaluation. Cybersickness, referring to symptoms induced by virtual reality immersion, was evaluated with a 16-items questionnaire (25). Answers are comprised between 0 and 3 (0 = Not at all to 3 = Severely). It should be noted that cybersickness is a normal physiological response to an unusual stimulus (26). Interviews The interviews were conducted with the first 15 participants of the study. The interviews allowed participants to expand on their responses, exploring questions regarding the sensations they experienced during the session (i.e., physical, emotional, impressions), their opinions on the VRH prototype (i.e., visuals, hypnosis, audio, headset comfort), strengths and weaknesses of the prototype, recommendations, and the feasibility of using it at home. Virtual Reality Material A virtual reality headset with an integrated audio system, the Meta Quest Pro, released in 2022, was used. A tablet connected to the headset hosted the "Hypnosis" app developed by Super Splendide. Super Splendide (www.supersplendide.com) specializes in virtual reality application development. In collaboration with researchers in the field of medical hypnosis and patient partners, Super Splendide developed an intervention program (VRH) that combines VR and medical hypnosis (H) leading patients to immerse themselves in a caring and safe imaginary world where they are invited to experience something that distracts them from their negative emotions and pain. The interface includes various hypnosis induction options used during this study, such as oxygen-mimicking bubbles (see Picture 1a). Additionally, it features different landscapes accompanied by nature sounds (i.e., wind, rain, birds, river, waves, campfire) and music (i.e., piano, minimalist orchestral music) (see Picture 1b). The VRH session lasts 20 minutes and ends by the seaside. Participants do not interact with the environment and are simply invited to watch the 3D animation of three different beaches and relax during the session. The sounds include the ocean, birds, wind, crackling campfire, and relaxing music. Moreover, the hypnosis script includes relaxation suggestions, bodily sensations, and a final suggestion so that participants can replicate the pleasant sensation experienced during the VRH session at any time. Insert Picture 1a Insert Picture 1b VRH Intervention The intervention was structured as a hypnosis session: (1) A calming immersion was provided to anchor absorption (progression controlled by the therapist) through soothing audiovisual stimuli (oxygen bubbles); (2) The experience featured a calming natural environment (see Picture 2); (3) A hypnosis script was provided to facilitate dissociation from the body and escape into the secure environment; (4) Participants were led to a wakeful state, with progression controlled by the therapist. Insert Picture 2 Data analysis Quantitative analysis Sociodemographic and clinical data, satisfaction, user experiences, and cybersickness were analyzed descriptively, displaying mean and standard deviation. Efficacy of the VRH intervention was tested by comparing scores of pain, anxiety, and relaxation before and after the intervention. Given the small sample size, non-parametric test (Wilcoxon signed-rank) was used. Statistical testing was done at a two-tailed α level of 0.05. Data were analyzed using jamovi 2.3.18 software package. Verbatim analysis Interview were recorded and transcribed by ACL and JV. Recurrent themes were identified in the discourse of participants through a general inductive approach (27,28). Themes are defined as significantly recurring patterns in the discourse. The qualitative data analysis was conducted in several stages using Google Colab, a coding software that transcribe audio recordings into written text. The interview transcriptions were then validated against the digital audio recordings. Subsequently, using QDAMiner, a qualitative analysis software; (1) Important elements were coded, and relevant data for each codewer identified; (2) Themes were searched by examining the constructed codes and identifying broader patterns; (3) Themes and data were cross-examined and coherence measured (redefine, combine, split, or remove themes); (4) Detailed descriptions and naming of each theme were conducted; (5) Thematic tables were created in Google Colab; (6) A report was written, containing examples of data and contextualizing the results (27). It should be noted that some statements were modified to ensure appropriate syntax without altering the meaning. Ethical statement Ethical approval was provided by the Ethics Committee of the Centre Intégré Universitaire de Santé et de Services Sociaux de l'Est-de-l’Île-de-Montréal at Maisonneuve-Rosemont Hospital, located at 5415 Boulevard de l'Assomption, Montreal, Canada, on December 15, 2023 (Ethics Committee Project Number: 2024-3539). Thus, the study was conducted in accordance with ethical guidelines and recommendations, the 1964 Helsinki declaration and its later amendments, and the 2016 APA Ethical Principles of Psychologists and Code of Conduct. Results Socio-Demographic and Clinical The study population consisted of 30 patients with an average age of 53.9 ± 11.7 years; with a majority of women (n = 25) compared to men (n = 5). Regarding employment status, seven participants are employed full-time, one is part time, eight are retired, nine are on temporary sick leave, and five are on disability due to their condition. An extended description of sociodemographic and clinical characteristics of participants is displayed in Table 1. Insert Table 1 Satisfaction The results show that participants rated "The VRH program is adequate for supporting a patient with chronic pain" with a mean score of 8.87 ± 1.55, and "The VRH program can be implemented in a pain clinic" with a mean score of 9.33 ± 1.18. Results related to perceived efficacity of VRH showed that participants rated the VRH as improving quality of life (8.77 ± 1.28), reducing distress (8.70 ± 1.32), reducing anxiety (9.03 ± 1.16), improving mood (8.90 ± 1.06), reducing pain (8.07 ± 1.44), fatigue (7.92 ± 1.90), and nausea (6.25 ± 3.15), as well as decreasing side effects from treatments (6.65 ± 2.71). User Experience Attractiveness received a score of 2.56 ± 0.39, perspicuity was rated with a score of 2.42 ± 0.45, efficiency was scored 1.35 ± 0.75, dependability received a score of 1.66 ± 0.55, stimulation was rated with a score of 2.18 ± 0.62, and novelty scored 2.13 ± 0.76. Cybersickness The results showed that general discomfort had a mean score of 0.67 ± 0.88. Fatigue was rated with a mean of 0.83 ± 0.91. Participants reported relatively low levels of headache (0.33 ± 0.66), eye strain (0.30 ± 0.65), and difficulty of focusing (0.47 ± 0.73). Increased salivation was very low at 0.07 ± 0.25, while sweating (0.10 ± 0.40) and nausea (0.20 ± 0.48) were also low. Difficulty concentrating had a mean score of 0.38 ± 0.68, and head heaviness was slightly higher at 0.60 ± 0.77. Blurring was rated at 0.27 ± 0.64, and dizziness with eyes open had a mean of 0.20 ± 0.48. Dizziness with eyes closed, and vertigo, all had similarly low mean values (0.07 ± 0.25 for each). Finally, stomach awareness scored 0.20 ± 0.55, and burping was rated low with a mean of 0.07 ± 0.37 (see Table 2). Insert Table 2 Levels of pain, anxiety, and relaxation, before and after intervention The results showed that the pre- and post- VRH differed significantly regarding pain level (W = 253.5; p <.001; rank biserial correlation = 0.837) (Figure. 2), anxiety level (W = 173.5; p =.002; rank biserial correlation = 0.826) (Figure. 3), and relaxation level (W = 9.00; p <.001; rank biserial correlation = -0.949). (Figure. 4) Insert Figure 2 Insert Figure 3 Insert Figure 4 Thematic analysis In this section, 5 themes are presented. Theme 1 addresses the participants' feelings following the RVH session, Theme 2 deals with the users' experience with this tool. Theme 3 includes the relevance of using this tool at home for individuals with chronic pain. Theme 4 discusses recommendations regarding the prototype and the RVH session. Theme 5 explores preconceived notions and expectations regarding this tool. Theme 1: Feelings after the RVH session Psychological aspects . After the experience, most of participants mentioned feeling relaxed and at ease (13/15), others experienced a sense of well-being (6/15) and described it as a peaceful, calm, and soothing moment (4/15). Some felt transported to another world (4/15), two participants reported feelings of joy and fun (2/15), and some participants mentioned that this was the occasion to take a moment for themselves. "For me, in my anxiety issues, it’s often loneliness that weighs on me. But here, I was fine being alone with myself. It was a moment, like an inner peace." (P1) "I even found it soothing to feel enveloped. I really felt like I was in a bubble." (P2) However, one participant experienced a panic attack during the session. "Since I was young, I’ve had significant anxiety and panic attacks. […] I’m disappointed in a sense because, you know, I think it works, but well, it’s like that. We try to identify a little bit what’s going on in that head. I don’t quite understand." (P8) Physical sensation. Most participants said that VRH helped forgetting the pain during the sessions, reducing it afterward (9/15), and decreasing any physical tension they had prior to the sessions (3/15). "I feel so good in my body. I have less pain. I’m floating." (P11) "I feel less tension here, less tension in my neck. So, it’s like, a soothing effect." (P7) Some also described a sense of floating and detachment from their body (2/15). "I feel so good in my body. I have less pain. I’m floating. During the experience, I felt like I was floating in my body. So, I feel like I no longer have pain" (P11) However, three participants noted an unpleasant sensation due to discomfort from the seating, which exacerbated their pain (3/15). "On the physical side, I think it’s maybe the chair, which might not be the most comfortable for me in the long run. In fact, it's one of the areas where I have the most pain underneath, and it’s because I’m short. The fact of sitting made the pain in my thigh worse, whereas initially, it was in my toe. So, these are the two areas with the most significant pain."(P2) Most of participants reported no side effects following the session (11/15). Two people mentioned neck pain (2/15). One participant experienced discomfort and nausea due to the bubble induction (1/15). Theme 2: User experience Positive aspects: audio-visual content Most participants noted the realism and quality of the images (13/15). "Image quality was number one. Really. It was very beautiful, I felt like I was really there”. (P2) "It was realistic. It was really beautiful, and what was fun was that when you turned or went down, you saw even more things." (P5) Additionally, the images and the bubble induction were deemed appropriate for relaxation. (7/15). "I really liked the bubbles. The bubbles made it even more real when we started the hypnosis. I sometimes imagined bubbles. Whereas here, it was different. It felt like I was really at the bottom of the sea. I saw everything rising. I was holding my breath. I felt free. I felt like I was breathing underwater.” (P9) Moreover, being the only person in the scenery was appropriate to reconnect with oneself (2/15). A large part of the participants stated that the sound and images was appropriate and synchronized which create a good immersive experience. (9/15). Other noticed that the music was also good for the relaxation (2/15). "The sound with the image is perfect. It adds to it, it’s like we are really present, because if there wasn’t the sound, I’m not sure the relaxation would have been the same." (P10) Some participants reported that the visuals were very consistent with the hypnotic script (5/15). Furthermore, the pace of the voice appreciated (4/10), and it was also evaluated as suitable and relaxing (4/10). "It was calm enough, I felt good because it was a good voice. It was reassuring" (P11). Negative Aspects: Material The first negative aspect mentioned was the discomfort of the headset, either due to its weight or the strap at the back of it, which prevented a comfortable sitting position (6/15). The chair itself was also judged uncomfortable (4/15). "Maybe the fact that it touches, it gives an unpleasant feeling. It’s the neck that touches and if the chair wasn’t so high, it would be much more comfortable." (P13) Negative Aspects: Interface Regarding the visual aspects, the image could be blurred in the background, on the horizon (4/10). In addition, the transitions between videos were unpleasant, for some (4/10). Furthermore, the music and videos came back in a loop after a certain time, which could distract from staying in the experience. Regarding the audio, one person mentioned that the sound and rhythm of the music were loud at the time of the induction (P5) and another person would have liked more in-depth musical research, such as putting a known pianist (P3). Hypnosis vs. VRH Given that all participants had been introduced to hypnosis before this VRH session, they were asked about the differences between hypnosis alone and VRH. Almost half of the participants indicated that VR was an immersive experience that reduced distractions compared to hypnosis alone (7/15). And that it even facilitates hypnosis (7/15). "It’s really an immersion, we are really plunged into the experience. Because there’s nothing to distract us. Even if the eyes are open and we look around, we are really immersed in the experience. I find it creates a beautiful disconnection between body and mind." (P6) "I find it much more relaxing to do, to enter a moment you want when you see images and music, than simply doing it without images, without music. I have much more difficulty entering hypnosis." (P5) Some noted that VRH was more soothing than hypnosis alone (4/15). Additionally, it might be easier for beginners and those fearful of hypnosis to use VRH (4/15). "It would be much easier because self-hypnosis at home is difficult. You need a lot of discipline to get there. Someone using a headset like this would find it much easier because there would be the voice, the images. (P6) "I think that people who might fear hypnosis, having relaxing images, […] could divert attention and help them relax." (P8) VRH might also make it easier to enter a hypnosis state (3/10). Music was also seen as a plus (3/15). "I find it easier to start, to forget, and, you know, because self-hypnosis is somewhat meant to, like, soothe our pain, but by thinking about something else, and letting go, you know. And I find it easier with this to let go. It was more obvious, it was easier to enter this relaxation, and to let go." (P1) Despite all the positive aspects of VRH, one person found it less easy to enter hypnosis because there was no fixed point for the induction and the images were moving (P12). Theme 3: Future usability of VRH Relevance at Home. Most participants would find it relevant to use VRH at home (12/15). One person was unsure if it was worth it (P8), another felt that just a hypnosis audio track would be sufficient (P14). Appropriate Moments. Many participants would use VRH daily at home (9/15), while some would use it only during pain peaks (5/15). A few people would like to use it before bed (2/15), while another person would use it in the morning to “start the day with less pain” (P5). Session Duration. More than a third of participants mentioned that 20 minutes was a bit short and would prefer a session of at least 30 minutes (6/15). Theme 4: Recommendations Improvements . The most common recommendation was to increase the volume of the voice or decrease the sound of the audio so both can be heard clearly (10/15). Additionally, several participants suggested improving the comfort of the seat (8/15). Another frequent comment was to have the camera move slowly in the videos like a stroll (7/15). Some would have also appreciated choosing their own scenario (6/15) to “secure patients in more personal images and make the experience more enjoyable and comforting” (P13) and background music (1/15). Furthermore, participants suggested to explain more at the beginning of the session how to use VR and the possibility to turn one’s head to see continuous landscapes (2/15). A more targeted hypnosis script focusing on pain would also be beneficial (2/15), like having images of the body part where the pain is located (P12). Other thought it could be interesting to add scents or add animals in the sceneries, such as birds (P6) or large animals like giraffes and horses, “elegant animals” (P5). Scenario Choices. The most preferred scenario includes natural landscapes (5/15), such as forests (6/15), beaches (5/15), mountains (3/15), and icy landscapes (P4). Theme 5: Preconceptions and expectations about the tool Regarding expectations for this tool, some were just curious to try a new experience (3/15), other had positive expectation or reducing pain and anxiety (3/15). Some already knew what to expect with VR (2/15), and one person even made peace with VR. “The other VR experience we had, we were on roller coasters, and it wasn’t relaxing. […] This experience reconciled me with the virtual reality headset. I think it’s very positive.” (P3) “Ah, I was curious. I talked to my occupational therapist. I said, I’m excited, I’m excited. It’s much more than I expected. I didn’t expect such a great comfort effect afterward.” (P9) Discussion This study aimed at investigating the efficacy of a VRH intervention with patients with chronic pain and evaluate their experience with the device. Overall, findings showed that participants have a good experience with VRH intervention. Indeed, they reported a high level of satisfaction, a positive user experience, and low symptoms of cybersickness. The VRH intervention was shown to be efficient to significantly decrease levels of anxiety and pain and increase the level of relaxation. Findings from the interviews showed the relevance of using VRH intervention for people with chronic pain. However, it is also worth noting that some would like to use it preventively to counter potential pain throughout the day. Benefits of the present VRH intervention The observed efficacy of the present VRH intervention is in line with the literature. Indeed, the benefits of using virtual reality is well-known in clinical context, particularly in reducing clinical pain in different clinical settings (16,17), with promising effects on pain and stress reduction (18). However, contrary to the present intervention, most studies investigating VR or VRH used various games (15,29). The present study constitutes an innovative approach by applying contemplative landscape images, aiming to escape from the hospital environment, allowing immersion in pleasant and high-quality images, and thus promoting greater immersion. Additionally, this study opted for a 360° contemplative virtual reality rather than a 3D contemplative virtual reality, to avoid graphical defects and inconsistencies in size, color, and movement fluidity of objects found in 3D animations (16) 360° videos also offer better image resolution to prevent visual discomfort and potential cybersickness such as nausea (30). Finally, developing a 360° video is easier and less expensive than creating a computer-simulated 3D environment. Those motivations in applying 360° contemplative images (vs. 3D contemplative VR) in a simple use design are confirmed by the findings of this study. Negative aspects of the intervention such as the relative discomfort reported by participants can be explained more by environmental arguments (i.e., the chair used during the session was neither suited for patients with pain nor designed for a session involving a VR headset) than by the intervention itself. Perspectives for the development of future VRH interventions The findings of this study lead to recommendations for the improvement of the present intervention and the development of future VRH interventions. First, content of the intervention should be refined by adding various landscapes available on the app, better transitions between videos, reducing the video/music loop, and adding some animals or moving objects such as boats to enhance realism, all aiming towards a fully customizable tool that can adjust image speed, color, and sound rhythm. The second area of improvement relates to the VRH session itself by adapting the hypnosis script to the illness in view of integrating audio into the VR headset and paying more attention to installation comfort for an optimal experience. Finally, olfactory suggestions could be added to achieve a full sensory immersion in the experience. Beyond this study, further investigations are needed to differentiate respective effect of hypnosis, virtual reality alone, and VRH. In that sense, comparative studies are essential to explore the similarities and differences between these techniques. Moreover, beside behavioral investigations, more fundamental studies are needed to understand which mechanisms are implied in the effect of the intervention in terms of physiological variables known to be involved in pain perception (e.g., heart rate, electrodermal activity) (31,32). The findings highlight the high expectations some participants have regarding VRH in terms of reducing their pain, anxiety, fatigue, distress, while improving their quality of life and mood. These expectations underscore the necessity of properly informing participants about what VRH can realistically offer. Despite the efficacy of VRH in various clinical settings, clear and realistic communication about the potential benefits and limitations of VRH is essential to avoid disappointment in patients. Strengths and weaknesses of this study By completing the quantitative investigation of efficacy of the intervention by qualitative interviews, this study adopts a user-centered design, emphasizing a focus on the patient. By doing so, research can ensure that the needs of users remain central to the design process (33). However, this study has several limitations. First, an unbalanced sex-ratio is present in the sample with 25 females and 5 men. Given pain perception can be impacted by sex (34), further studies should recruit samples with a balanced sex-ratio. Then, some participants did not report all the medical treatments they were undergoing that could influence the levels of pain and anxiety, nor were evaluated for potential confounding variables (e.g., previous experience with VR or hypnosis, expectations toward the intervention). Given the researcher was present during the use of VRH device, it is important to note a potential desirability bias in this study. Moreover, participants could have been pre-motivated to take part in the VRH session by being offered evaluating their experience. Those points relate to an absence of a blinding process in the intervention. Further studies should use a methodologically sounded blinding procedure to address this issue. Another limitation lays in the novelty of the intervention. Given innovative approaches are generally seen as positive, it could be worth to investigate user experience in a longer-term to evaluation if the attitudes remain positive across the time. Then, further studies should use standardized measures to evaluate outcomes of interest to allow comparisons between studies. Finally, it should be noted that the duration of sessions and the landscapes used remained the same throughout the study. Thus, future studies could investigate the impact of such parameters (e.g., comparing beach vs. mountain; investigating the effect of the duration of the intervention) on the outcomes. Conclusion This study evaluated the user experience of a virtual reality hypnosis intervention in patients with chronic pain. The findings lead to recommendations for the improvement the present tool and future interventions use in pain clinics. The intervention demonstrated its effectiveness in reducing pain and anxiety while increasing relaxation levels among this population. Future studies should be dedicated to implementing larger scale intervention using VRH in order to test its efficacy in more representative clinical settings. Declarations Author contributions The authors refer to CRediT (Contributor Roles Taxonomy). Conceptualization : Florianne Rousseaux, Mathieu Landry, Pierre Rainville, David Ogez Data curation : Alexandra Chevestrier-Lefeuvre, Joséphine Guiné, Valentyn Fournier Formal analysis : Alexandra Chevestrier-Lefeuvre, Joséphine Guiné, Valentyn Fournier Funding acquisition : Pierre Rainville and David Ogez Investigation : Alexandra Chevestrier-Lefeuvre, Jade Véronneau, Julie Labeau, Audrey Laurin, Marie-Fania Simard, David Ogez Methodology : Mathieu Landry, Pierre Rainville, David Ogez. Project administration : David Ogez Resources : Julie Labeau, Nadia Godin, Philippe Richebé, David Ogez Software : Alexandra Chevestrier-Lefeuvre, Joséphine Guiné, Valentyn Fournier Supervision : Valentyn Fournier, David Ogez Validation : Valentyn Fournier, David Ogez Visualization : Joséphine Guiné, Valentyn Fournier Writing - original draft : Alexandra Chevestrier-Lefeuvre, Joséphine Guiné, Valentyn Fournier, David Ogez Writing - review & editing : Alexandra Chevestrier-Lefeuvre, Joséphine Guiné, Karim Jerbi, Philippe Richebé, Valentyn Fournier, David Ogez Competing Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgments This work was supported by the Ministère de l’économie et de l’Innovation du Québec (2022-2027-63761). We thank Jean-François Malouin, CEO of Super Splendide, and patients of pain clinic from Maisonneuve-Rosemont Hospital. Data availability statements The data that support the findings of this study are available on an OSF repository via the following link: https://osf.io/vbh72/?view_only=af1597d4cc5c4850a513d2fc9b3cc7de then in the “1- User experience and proof-of-concept” study folder. References ICD-11 for Mortality and Morbidity Statistics [Internet]. [cited 2024 Oct 16]. Available from: https://icd.who.int/browse/2024-01/mms/en#1326332835 Canada H. Canadian Pain Task Force Report: March 2021 [Internet]. 2021 [cited 2024 Oct 15]. Available from: https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2021.html Choinière M, Peng P, Gilron I, Buckley N, Williamson O, Janelle-Montcalm A, et al. Accessing care in multidisciplinary pain treatment facilities continues to be a challenge in Canada. Reg Anesth Pain Med. 2020 Dec 1;45(12):943–8. Schwan J, Sclafani J, Tawfik VL. Chronic Pain Management in the Elderly. Anesthesiol Clin. 2019 Sep;37(3):547–60. Browse by h – APA Dictionary of Psychology [Internet]. [cited 2024 Oct 16]. Available from: https://dictionary.apa.org/ Jones HG, Rizzo RRN, Pulling BW, Braithwaite FA, Grant AR, McAuley JH, et al. Adjunctive use of hypnosis for clinical pain: a systematic review and meta-analysis. Pain Rep. 2024 Oct;9(5):e1185. Hinterberger T, Schöner J, Halsband U. Analysis of Electrophysiological State Patterns and Changes During Hypnosis Induction: Thilo Hinterberger, Julian Schöner und Ulrike Halsband. Int J Clin Exp Hypn. 2011 Feb 28;59(2):165–79. Rainville P, Duncan GH, Price DD, Carrier B, Bushnell MC. Pain Affect Encoded in Human Anterior Cingulate But Not Somatosensory Cortex. Science. 1997 Aug 15;277(5328):968–71. Rainville P, Hofbauer RK, Paus T, Duncan GH, Bushnell MC, Price DD. Cerebral Mechanisms of Hypnotic Induction and Suggestion. J Cogn Neurosci. 1999 Jan 1;11(1):110–25. Pike A, Hearn L, de C Williams AC. Effectiveness of psychological interventions for chronic pain on health care use and work absence: systematic review and meta-analysis. PAIN. 2016 Apr;157(4):777. Abbas JR, O’Connor A, Ganapathy E, Isba R, Payton A, McGrath B, et al. What is Virtual Reality? A healthcare-focused systematic review of definitions. Health Policy Technol. 2023 Jun 1;12(2):100741. Gutierrez-Martinez O, Gutierrez-Maldonado J, Cabas-Hoyos K, Loreto D. The illusion of presence influences VR distraction: effects on cold-pressor pain. Stud Health Technol Inform. 2010;154:155–9. Tse MMY, Ng JKF, Chung JWY, Wong TKS. The effect of visual stimuli on pain threshold and tolerance. J Clin Nurs. 2002;11(4):462–9. Gold JI, Kim SH, Kant AJ, Joseph MH, Rizzo A “Skip.” Effectiveness of Virtual Reality for Pediatric Pain Distraction during IV Placement. Cyberpsychol Behav. 2006 Apr;9(2):207–12. Patterson DR, Tininenko JR, Schmidt AE, Sharar SR. Virtual Reality Hypnosis: A Case Report. Int J Clin Exp Hypn. 2004 Jan 1;52(1):27–38. Rousseaux F, Bicego A, Ledoux D, Massion P, Nyssen AS, Faymonville ME, et al. Hypnosis Associated with 3D Immersive Virtual Reality Technology in the Management of Pain: A Review of the Literature. J Pain Res. 2020 May 21;13:1129–38. Schmitt YS, Hoffman HG, Blough DK, Patterson DR, Jensen MP, Soltani M, et al. A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns. Burns. 2011 Feb 1;37(1):61–8. Ong TL, Ruppert MM, Akbar M, Rashidi P, Ozrazgat-Baslanti T, Bihorac A, et al. Improving the Intensive Care Patient Experience With Virtual Reality—A Feasibility Study. Crit Care Explor. 2020 Jun;2(6):e0122. Fussell SG, Truong D. Using virtual reality for dynamic learning: an extended technology acceptance model. Virtual Real. 2022 Mar 1;26(1):249–67. Czajkowski SM, Powell LH, Adler N, Naar-King S, Reynolds KD, Hunter CM, et al. 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In: Design, User Experience, and Usability Theories, Methods, and Tools for Designing the User Experience. Springer International Publishing.; 2014. p. 383–92. Kennedy RS, Lane NE, Berbaum KS, Lilienthal MG. Simulator Sickness Questionnaire: An Enhanced Method for Quantifying Simulator Sickness. Int J Aviat Psychol. 1993 Jul 1;3(3):203–20. Lawson BD, Graeber DA, Mead AM, Muth ER. Signs and symptoms of human syndromes associated with synthetic experiences. In: Handbook of virtual environments: Design, implementation, and applications. Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; 2002. p. 589–618. (Human factors and ergonomics). Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006 Jan 1;3(2):77–101. Braun V, Clarke V. Thematic Analysis: A Practical Guide. SAGE Publications; 2021. 377 p. Hoffman HG, Richards T, Coda B, Richards A, Sharar SR. The Illusion of Presence in Immersive Virtual Reality during an fMRI Brain Scan. 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Sex differences in pain: a brief review of clinical and experimental findings. Br J Anaesth. 2013 Jul;111(1):52–8. Tables Table 1 Participants’ socio-demographic and clinical information Variable Sample size Percentage Mean (SD), Range Sex Men 5 16.7 - Women 25 83.3 - Marital status Married 6 20.0 - Couple 15 50.0 - Single 7 23.3 - Divorce 1 3.3 - Widow 1 3.3 - Scholar level Secondary 3 10.0 - College 7 23.3 - University 20 66.7 - Professional status Full-Time 7 23.3 - Part-Time 1 3.3 - Retirement 8 26.7 - Temporary sick leave 9 30.0 - Disability 5 16.7 - Source/type of pain Arm or hand 3 10 - Arthritis 5 16.7 - Back pain 3 10 - Cervicalgia 1 3.33 - Complex regional pain syndrome 7 23.3 - Fibromyalgia 5 16.7 - Gonalgia 2 6.67 - Iliac pain 1 3.33 - Neck pain 1 3.33 - Postoperative pain 2 6.67 - Age - - 53.9 (11.7), 29-74 Table 2 Scores of symptoms of cybersickness induced by VRH GD Fatigue Headache Eye strain DF IS Sweating Nausea DC HH Blurring DEO DEC Vertigo SA Burping N 30 30 30 30 30 30 30 30 29 30 30 30 30 30 30 30 Mean 0.67 0.83 0.33 0.30 0.47 0.067 0.10 0.20 0.38 0.60 0.27 0.20 0.07 0.07 0.20 0.07 Median 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 SD 0.88 0.91 0.66 0.65 0.73 0.25 0.40 0.48 0.68 0.77 0.64 0.48 0.25 0.25 0.55 0.37 Min 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 3 3 2 3 3 1 2 2 3 2 3 2 1 1 2 2 Note. GD: General Discomfort; DF: Difficulty of Focusing; IS: Increase Salivation; DC: Difficulty to Concentrate; HH: Head Heaviness; DEO: Dizziness with Eyes Open; DEC: Dizziness with Eyes Closes; SA: Stomach Awareness Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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4","display":"","copyAsset":false,"role":"figure","size":6522,"visible":true,"origin":"","legend":"\u003cp\u003eScores of relaxation level before/after RVH\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6278623/v1/198e229d9a1b875ae9141ac7.png"},{"id":86670572,"identity":"b821e838-5e09-4aa6-86c2-be09dca0b391","added_by":"auto","created_at":"2025-07-14 11:30:19","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":115812,"visible":true,"origin":"","legend":"\u003cp\u003ePicture 1a. Various hypnosis induction windows on the application interface (Super Splendide)\u003c/p\u003e\n\u003cp\u003ePicture 1b. Windows containing 360° landscapes on the application interface (Super Splendide).\u003c/p\u003e","description":"","filename":"Picture1.png","url":"https://assets-eu.researchsquare.com/files/rs-6278623/v1/7617c28fab5cf3f32fd77272.png"},{"id":86671723,"identity":"172db000-968b-4e0f-9a45-0fdd42d6b46f","added_by":"auto","created_at":"2025-07-14 11:38:19","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":218166,"visible":true,"origin":"","legend":"\u003cp\u003ePicture 2. Example of environment shown during the session \"Beach at Rivière-au-Tonnerre, Québec\" (Super Splendide).\u003c/p\u003e","description":"","filename":"pic2.png","url":"https://assets-eu.researchsquare.com/files/rs-6278623/v1/558aa97e403256c874cd4bfe.png"},{"id":86675072,"identity":"37d931ab-1f1f-46b6-acea-4bd65402a1b2","added_by":"auto","created_at":"2025-07-14 11:54:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1550535,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6278623/v1/a3ef5405-3c8a-408a-93c9-3ffcc9abdb4c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of a Virtual Reality Hypnosis Intervention on Chronic Pain: A User Experience and Proof-of-concept Study","fulltext":[{"header":"Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eChronic Pain\u003c/h2\u003e\u003cp\u003ePain can be defined as an unpleasant sensory and emotional experience associated with, or resembling, actual or potential tissue damage. Among pain category, chronic pain is a pain that persists or recurs for more than three months. It involves multiple factors (i.e., biological, psychological, and social) contributing to the pain syndrome (1). In 2019, approximately 7.63\u0026nbsp;million people, or one in four Canadians aged 15 or older, lived with chronic pain. Chronic pain has significant impacts on physical and mental health, family and community life, society, and the economy, with a total direct and indirect cost of 38.3 to 40.4\u0026nbsp;billion dollars in 2019 in Canada (2).\u003c/p\u003e\u003cp\u003eChronic pain treatment can encompass several modalities such as pharmacological (e.g., non-steroidal anti-inflammatory drugs, opioids, cannabinoids, antidepressants), physical (e.g., rehabilitation therapy, low-power laser therapy, shockwave therapy, deep brain stimulation), or psychological therapies (e.g., cognitive and behavioral therapy, acceptance and commitment therapy, mindfulness-based interventions, hypnosis) (Public Health Agency of Canada, 2023).\u003c/p\u003e\u003cp\u003eHealthcare pathway of patients with chronic pain includes several pitfalls. First, despite being effective in management of pain, some pharmacological treatments were shown to carry some risks. For instance, opioids can lead to side effects or overdose-related deaths which became a major public health issue in North America during the last years. Furthermore, the median wait time for an appointment at a public clinic offering specialized multidisciplinary services for diagnosing and managing chronic pain patients is at least six months, and in some regions of Canada, it can take up to five years to access appropriate pain treatment (3). Access to care is subject to inequality depending on the source of funding of the institutions, for instance the wait time for public clinics is about 12 times longer than for non-public clinics (3).\u003c/p\u003e\u003cp\u003eFor those reasons, it is now recognized that pain prevention and management must be addressed more broadly, not only as part of substance use measures but also as a parallel public health priority (2). Using a multidisciplinary approach to treat chronic pain is expected to be effective, and treatment plans should include multimodal medication options, physiotherapy, pain psychology, and selected interventions as needed (4). Among interventions that could be used to treat chronic pain, hypnosis appears to be a promising solution.\u003c/p\u003e\u003cp\u003eHypnosis is defined as \u0026ldquo;a procedure, or the state induced by that procedure, in which suggestion is used to evoke changes in sensation, perception, cognition, emotion, or motor behavior control\u0026rdquo; (5). The efficacy of hypnosis was demonstrated in several studies, showing improvements in appraisal of pain (6)but on a physiological level (7\u0026ndash;9). Despite seeming a fruitful therapeutic solution, hypnosis requires specialized professionals and can be time-consuming in regard of administrative constraints. For those reasons, it seems necessary to develop innovative complementary interventions that could be widely disseminated (10).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eVirtual Reality Analgesia and Virtual Reality Hypnosis (VRH)\u003c/h2\u003e\u003cp\u003eVirtual reality (VR) developed tremendously in healthcare settings during the last decades (11). VR-based analgesia can be implemented at different levels of complexity. Sometimes, distraction is achieved through strange, evocative, and beautiful images in the virtual environment (12,13), or by programming fast-paced interactive activities similar to video games (14).\u003c/p\u003e\u003cp\u003eVirtual Reality Hypnosis (VRH) represents a combination of virtual reality and hypnosis and first appeared in a clinical research context in 2004 for a patient suffering from a severe burn (15). Among existing programs, some VRH interventions have shown to reduce clinical and experimental pain in randomized controlled trials (16,17). VRH has also shown promising effects in reducing pain and stress (18). Nevertheless, there remains a lack of studies on VRH in specifically supporting people with chronic pain. Moreover, the ability of these studies to account for predictive factors for the effective use of this technology (i.e., adherence, feasibility, user experience) hasn\u0026rsquo;t been widely evaluated. Additionally, current VR programs do not offer real-time adaptability of the audiovisual environment based on the patient's experience (19). Thus, there is a need to develop and evaluate new dynamic VRH paradigms in the field of chronic pain. Following the recommendations of the ORBIT model for the development of non-pharmacological interventions (20\u0026ndash;22), after having defined the interventions (Phase 1a), studies should aim at refining those if needed (Phase 1b) and preliminary test their efficacy on intended outcomes through a proof-of-concept study (Phase 2a). In that sense, according to the ORBIT model, this study constitutes a Phase 1b and Phase 2a study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eObjectives\u003c/h3\u003e\n\u003cp\u003eThe main objective of this study is to investigate the efficacy of an intervention integrating procedures that combine hypnosis and virtual reality in supporting patients with chronic pain, as well as the user experience of such an intervention.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThe data supporting the findings of this study are available on an OSF repository via the following link: https://osf.io/vbh72/?view_only=af1597d4cc5c4850a513d2fc9b3cc7de then in the \u0026ldquo;1- User experience and proof-of-concept\u0026rdquo; study folder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePopulation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was proposed to patients with miscellaneous chronic pain. The inclusion criteria were being 18 years or older, being French-speaking, having a diagnosis of chronic pain, and having previously experienced hypnosis. Exclusion criteria included declared deafness, blindness, confusion, or other conditions that may impair communication (e.g., psychosis, dementia).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProcedure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants recruitment began on February 23, 2024, and concluded on April 22, 2024.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter having provided their informed written consent, study participants were welcomed at Maisonneuve-Rosemont Hospital (Montr\u0026eacute;al, Quebec, Canada) by a psychology doctoral student or psychologist, and then guided to a consultation room dedicated to the experiment. In this hospital setting, the atmosphere was conducive to concentration, with a comfortable chair and adequate lighting to facilitate the experience, the interview, and the completion of questionnaires.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnce they were installed, participants were asked to provide socio-demographic and clinical variables, and their feelings of pain, anxiety, and relaxation were assessed before the VRH session. Then, they used the VRH intervention in the presence of a member of the research team. After the VRH session, participants completed a questionnaire evaluating their satisfaction, user experience with VRH, cyber-sickness, and a questionnaire assessing their feelings of pain, anxiety, and relaxation after the VRH session. Eventually, the first 15 participants participated in a semi-structured individual interview to provide further explanations regarding the scores given in the questionnaires.\u003c/p\u003e\n\u003cp\u003eA graphical representation of the procedure is displayed in Figure 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInsert Figure 1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMeasured Variables \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSociodemographic and clinical variables questionnaire consisted of gender, age, marital status, scholar level, professional status, and medication for chronic pain.\u003c/p\u003e\n\u003cp\u003eBefore and after the VRH session, participants were asked to evaluate their levels of pain, anxiety, and relaxation on 11-points numerical rating scale from 0 to 10. For pain, 0 meant \u0026ldquo;no pain at all\u0026rdquo; and 10 \u0026ldquo;Very important pain\u0026rdquo;. For anxiety, 0 meant \u0026ldquo;No anxiety at all\u0026rdquo; and 10 \u0026ldquo;Very important anxiety\u0026rdquo;. For relaxation, 0 meant \u0026ldquo;Not relaxed at all\u0026rdquo; and 10 \u0026ldquo;Very important relaxation\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants satisfaction was assessed using 10 questions from the Kazdin (1977) questionnaire(23). Those questions were rated on an 11-point Likert scale (0 = \u0026quot;strongly disagree\u0026quot; to 10 = \u0026quot;strongly agree\u0026quot;).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe user experience was assessed with the User Experience Questionnaire (UEQ, 26 items, bipolar 7-point Likert scale)(24) evaluating six components: attractiveness, perspicacity, efficiency, dependability, stimulation and novelty. Answers can range from -3 to +3. Values between -0.8 and 0.8 represent a neutral evaluation, values above 0,8 represent a positive evaluation and, values below -0,8 represent a negative evaluation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCybersickness, referring to symptoms induced by virtual reality immersion, was evaluated with a 16-items questionnaire (25). Answers are comprised between 0 and 3 (0 = Not at all to 3 = Severely). It should be noted that cybersickness is a normal physiological response to an unusual stimulus (26).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInterviews\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviews were conducted with the first 15 participants of the study. The interviews allowed participants to expand on their responses, exploring questions regarding the sensations they experienced during the session (i.e., physical, emotional, impressions), their opinions on the VRH prototype (i.e., visuals, hypnosis, audio, headset comfort), strengths and weaknesses of the prototype, recommendations, and the feasibility of using it at home.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eVirtual Reality Material\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA virtual reality headset with an integrated audio system, the Meta Quest Pro, released in 2022, was used. A tablet connected to the headset hosted the \u0026quot;Hypnosis\u0026quot; app developed by Super Splendide. Super Splendide (www.supersplendide.com) specializes in virtual reality application development. In collaboration with researchers in the field of medical hypnosis and patient partners, Super Splendide developed an intervention program (VRH) that combines VR and medical hypnosis (H) leading patients to immerse themselves in a caring and safe imaginary world where they are invited to experience something that distracts them from their negative emotions and pain.\u003c/p\u003e\n\u003cp\u003eThe interface includes various hypnosis induction options used during this study, such as oxygen-mimicking bubbles (see Picture 1a). Additionally, it features different landscapes accompanied by nature sounds (i.e., wind, rain, birds, river, waves, campfire) and music (i.e., piano, minimalist orchestral music) (see Picture 1b). The VRH session lasts 20 minutes and ends by the seaside. Participants do not interact with the environment and are simply invited to watch the 3D animation of three different beaches and relax during the session. The sounds include the ocean, birds, wind, crackling campfire, and relaxing music. Moreover, the hypnosis script includes relaxation suggestions, bodily sensations, and a final suggestion so that participants can replicate the pleasant sensation experienced during the VRH session at any time.\u003c/p\u003e\n\u003cp\u003eInsert Picture 1a\u003c/p\u003e\n\u003cp\u003eInsert Picture 1b\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eVRH Intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention was structured as a hypnosis session: (1) A calming immersion was provided to anchor absorption (progression controlled by the therapist) through soothing audiovisual stimuli (oxygen bubbles); (2) The experience featured a calming natural environment (see Picture 2); (3) A hypnosis script was provided to facilitate dissociation from the body and escape into the secure environment; (4) Participants were led to a wakeful state, with progression controlled by the therapist.\u003c/p\u003e\n\u003cp\u003eInsert Picture 2\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuantitative analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSociodemographic and clinical data, satisfaction, user experiences, and cybersickness were analyzed descriptively, displaying mean and standard deviation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEfficacy of the VRH intervention was tested by comparing scores of pain, anxiety, and relaxation before and after the intervention. Given the small sample size, non-parametric test (Wilcoxon signed-rank) was used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStatistical testing was done at a two-tailed \u0026alpha; level of 0.05. Data were analyzed using jamovi 2.3.18 software package.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVerbatim analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInterview were recorded and transcribed by ACL and JV. Recurrent themes were identified in the discourse of participants through a general inductive approach (27,28). Themes are defined as significantly recurring patterns in the discourse. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe qualitative data analysis was conducted in several stages using Google Colab, a coding software that transcribe audio recordings into written text. The interview transcriptions were then validated against the digital audio recordings. Subsequently, using QDAMiner, a qualitative analysis software; (1) Important elements were coded, and relevant data for each codewer identified; (2) Themes were searched by examining the constructed codes and identifying broader patterns; (3) Themes and data were cross-examined and coherence measured (redefine, combine, split, or remove themes); (4) Detailed descriptions and naming of each theme were conducted; (5) Thematic tables were created in Google Colab; (6) A report was written, containing examples of data and contextualizing the results (27).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt should be noted that some statements were modified to ensure appropriate syntax without altering the meaning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was provided by the Ethics Committee of the Centre Int\u0026eacute;gr\u0026eacute; Universitaire de Sant\u0026eacute; et de Services Sociaux de l\u0026apos;Est-de-l\u0026rsquo;\u0026Icirc;le-de-Montr\u0026eacute;al at Maisonneuve-Rosemont Hospital, located at 5415 Boulevard de l\u0026apos;Assomption, Montreal, Canada, on December 15, 2023 (Ethics Committee Project Number: 2024-3539). Thus, the study was conducted in accordance with ethical guidelines and recommendations, the 1964 Helsinki declaration and its later amendments, and the 2016 APA Ethical Principles of Psychologists and Code of Conduct.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocio-Demographic and Clinical\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population consisted of 30 patients with an average age of 53.9 ± 11.7 years; with a majority of women (n = 25) compared to men (n = 5). Regarding employment status, seven participants are employed full-time, one is part time, eight are retired, nine are on temporary sick leave, and five are on disability due to their condition. An extended description of sociodemographic and clinical characteristics of participants is displayed in Table 1.\u003c/p\u003e\n\u003cp\u003eInsert Table 1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSatisfaction\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results show that participants rated \"The VRH program is adequate for supporting a patient with chronic pain\" with a mean score of 8.87 ± 1.55, and \"The VRH program can be implemented in a pain clinic\" with a mean score of 9.33 ± 1.18.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults related to perceived efficacity of VRH showed that participants rated the VRH as improving quality of life (8.77 ± 1.28), reducing distress (8.70 ± 1.32), reducing anxiety (9.03 ± 1.16), improving mood (8.90 ± 1.06), reducing pain (8.07 ± 1.44), fatigue (7.92 ± 1.90), and nausea (6.25 ± 3.15), as well as decreasing side effects from treatments (6.65 ± 2.71).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eUser Experience\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAttractiveness received a score of 2.56 ± 0.39, perspicuity was rated with a score of 2.42 ± 0.45, efficiency was scored 1.35 ± 0.75, dependability received a score of 1.66 ± 0.55, stimulation was rated with a score of 2.18 ± 0.62, and novelty scored 2.13 ± 0.76.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCybersickness\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results showed that general discomfort had a mean score of 0.67 ± 0.88. Fatigue was rated with a mean of 0.83 ± 0.91. Participants reported relatively low levels of headache (0.33 ± 0.66), eye strain (0.30 ± 0.65), and difficulty of focusing (0.47 ± 0.73). Increased salivation was very low at 0.07 ± 0.25, while sweating (0.10 ± 0.40) and nausea (0.20 ± 0.48) were also low. Difficulty concentrating had a mean score of 0.38 ± 0.68, and head heaviness was slightly higher at 0.60 ± 0.77. Blurring was rated at 0.27 ± 0.64, and dizziness with eyes open had a mean of 0.20 ± 0.48. Dizziness with eyes closed, and vertigo, all had similarly low mean values (0.07 ± 0.25 for each). Finally, stomach awareness scored 0.20 ± 0.55, and burping was rated low with a mean of 0.07 ± 0.37 (see Table 2).\u003c/p\u003e\n\u003cp\u003eInsert Table 2\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLevels of pain, anxiety, and relaxation, before and after intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results showed that the pre- and post- VRH differed significantly regarding pain level (W = 253.5; p \u0026lt;.001; rank biserial correlation = 0.837) (Figure. 2), anxiety level (W = 173.5; p =.002; rank biserial correlation = 0.826) (Figure. 3), and relaxation level (W = 9.00; p \u0026lt;.001; rank biserial correlation = -0.949). (Figure. 4)\u003c/p\u003e\n\u003cp\u003eInsert Figure 2\u003c/p\u003e\n\u003cp\u003eInsert Figure 3\u003c/p\u003e\n\u003cp\u003eInsert Figure 4\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThematic analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this section, 5 themes are presented. Theme 1 addresses the participants' feelings following the RVH session, Theme 2 deals with the users' experience with this tool. Theme 3 includes the relevance of using this tool at home for individuals with chronic pain. Theme 4 discusses recommendations regarding the prototype and the RVH session. Theme 5 explores preconceived notions and expectations regarding this tool.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Feelings after the RVH session\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePsychological aspects\u003c/em\u003e. After the experience, most of participants mentioned feeling relaxed and at ease (13/15), others experienced a sense of well-being (6/15) and described it as a peaceful, calm, and soothing moment (4/15). Some felt transported to another world (4/15), two participants reported feelings of joy and fun (2/15), and some participants mentioned that this was the occasion to take a moment for themselves.\u003c/p\u003e\n\u003cp\u003e\"For me, in my anxiety issues, it’s often loneliness that weighs on me. But here, I was fine being alone with myself. It was a moment, like an inner peace.\" (P1)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\"I even found it soothing to feel enveloped. I really felt like I was in a bubble.\" (P2)\u003c/p\u003e\n\u003cp\u003eHowever, one participant experienced a panic attack during the session.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\"Since I was young, I’ve had significant anxiety and panic attacks. […] I’m disappointed in a sense because, you know, I think it works, but well, it’s like that. We try to identify a little bit what’s going on in that head. I don’t quite understand.\" (P8)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhysical sensation.\u0026nbsp;\u003c/em\u003eMost participants said that VRH helped forgetting the pain during the sessions, reducing it afterward (9/15), and decreasing any physical tension they had prior to the sessions (3/15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\"I feel so good in my body. I have less pain. I’m floating.\" (P11)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\"I feel less tension here, less tension in my neck. So, it’s like, a soothing effect.\" (P7)\u003c/p\u003e\n\u003cp\u003eSome also described a sense of floating and detachment from their body (2/15).\u003c/p\u003e\n\u003cp\u003e\"I feel so good in my body. I have less pain. I’m floating. During the experience, I felt like I was floating in my body. So, I feel like I no longer have pain\" (P11)\u003c/p\u003e\n\u003cp\u003eHowever, three participants noted an unpleasant sensation due to discomfort from the seating, which exacerbated their pain (3/15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\"On the physical side, I think it’s maybe the chair, which might not be the most comfortable for me in the long run. In fact, it's one of the areas where I have the most pain underneath, and it’s because I’m short. The fact of sitting made the pain in my thigh worse, whereas initially, it was in my toe. So, these are the two areas with the most significant pain.\"(P2)\u003c/p\u003e\n\u003cp\u003eMost of participants reported no side effects following the session (11/15). Two people mentioned neck pain (2/15). One participant experienced discomfort and nausea due to the bubble induction (1/15).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: User experience\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePositive aspects: audio-visual content\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost participants noted the realism and quality of the images (13/15).\u003c/p\u003e\n\u003cp\u003e\"Image quality was number one. Really. It was very beautiful, I felt like I was really there”. (P2)\u003c/p\u003e\n\u003cp\u003e\"It was realistic. It was really beautiful, and what was fun was that when you turned or went down, you saw even more things.\" (P5)\u003c/p\u003e\n\u003cp\u003eAdditionally, the images and the bubble induction were deemed appropriate for relaxation. (7/15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\"I really liked the bubbles. The bubbles made it even more real when we started the hypnosis. I sometimes imagined bubbles. Whereas here, it was different. It felt like I was really at the bottom of the sea. I saw everything rising. I was holding my breath. I felt free. I felt like I was breathing underwater.” (P9)\u003c/p\u003e\n\u003cp\u003eMoreover, being the only person in the scenery was appropriate to reconnect with oneself (2/15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA large part of the participants stated that the sound and images was appropriate and synchronized which create a good immersive experience. (9/15). Other noticed that the music was also good for the relaxation (2/15).\u003c/p\u003e\n\u003cp\u003e\"The sound with the image is perfect. It adds to it, it’s like we are really present, because if there wasn’t the sound, I’m not sure the relaxation would have been the same.\" (P10)\u003c/p\u003e\n\u003cp\u003eSome participants reported that the visuals were very consistent with the hypnotic script (5/15). Furthermore, the pace of the voice appreciated (4/10), and it was also evaluated as suitable and relaxing (4/10).\u003c/p\u003e\n\u003cp\u003e\"It was calm enough, I felt good because it was a good voice. It was reassuring\" (P11).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNegative Aspects: Material\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe first negative aspect mentioned was the discomfort of the headset, either due to its weight or the strap at the back of it, which prevented a comfortable sitting position (6/15). The chair itself was also judged uncomfortable (4/15).\u003c/p\u003e\n\u003cp\u003e\"Maybe the fact that it touches, it gives an unpleasant feeling. It’s the neck that touches and if the chair wasn’t so high, it would be much more comfortable.\" (P13)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNegative Aspects: Interface\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegarding the visual aspects, the image could be blurred in the background, on the horizon (4/10). In addition, the transitions between videos were unpleasant, for some (4/10). Furthermore, the music and videos came back in a loop after a certain time, which could distract from staying in the experience.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the audio, one person mentioned that the sound and rhythm of the music were loud at the time of the induction (P5) and another person would have liked more in-depth musical research, such as putting a known pianist (P3).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHypnosis vs. VRH\u003c/em\u003e\u003cbr\u003e\u0026nbsp;Given that all participants had been introduced to hypnosis before this VRH session, they were asked about the differences between hypnosis alone and VRH. Almost half of the participants indicated that VR was an immersive experience that reduced distractions compared to hypnosis alone (7/15). And that it even facilitates hypnosis (7/15).\u003c/p\u003e\n\u003cp\u003e\"It’s really an immersion, we are really plunged into the experience. Because there’s nothing to distract us. Even if the eyes are open and we look around, we are really immersed in the experience. I find it creates a beautiful disconnection between body and mind.\" (P6)\u003c/p\u003e\n\u003cp\u003e\"I find it much more relaxing to do, to enter a moment you want when you see images and music, than simply doing it without images, without music. I have much more difficulty entering hypnosis.\" (P5)\u003c/p\u003e\n\u003cp\u003eSome noted that VRH was more soothing than hypnosis alone (4/15). Additionally, it might be easier for beginners and those fearful of hypnosis to use VRH (4/15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\"It would be much easier because self-hypnosis at home is difficult. You need a lot of discipline to get there. Someone using a headset like this would find it much easier because there would be the voice, the images. (P6)\u003c/p\u003e\n\u003cp\u003e\"I think that people who might fear hypnosis, having relaxing images, […] could divert attention and help them relax.\" (P8)\u003c/p\u003e\n\u003cp\u003eVRH might also make it easier to enter a hypnosis state (3/10). Music was also seen as a plus (3/15).\u003c/p\u003e\n\u003cp\u003e\"I find it easier to start, to forget, and, you know, because self-hypnosis is somewhat meant to, like, soothe our pain, but by thinking about something else, and letting go, you know. And I find it easier with this to let go. It was more obvious, it was easier to enter this relaxation, and to let go.\" (P1)\u003c/p\u003e\n\u003cp\u003eDespite all the positive aspects of VRH, one person found it less easy to enter hypnosis because there was no fixed point for the induction and the images were moving (P12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3: Future usability of VRH\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRelevance at Home.\u003c/em\u003e Most participants would find it relevant to use VRH at home (12/15). One person was unsure if it was worth it (P8), another felt that just a hypnosis audio track would be sufficient (P14).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAppropriate Moments.\u003c/em\u003e Many participants would use VRH daily at home (9/15), while some would use it only during pain peaks (5/15). A few people would like to use it before bed (2/15), while another person would use it in the morning to “start the day with less pain” (P5).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSession Duration.\u003c/em\u003e More than a third of participants mentioned that 20 minutes was a bit short and would prefer a session of at least 30 minutes (6/15).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 4: Recommendations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImprovements\u003c/em\u003e. The most common recommendation was to increase the volume of the voice or decrease the sound of the audio so both can be heard clearly (10/15). Additionally, several participants suggested improving the comfort of the seat (8/15). Another frequent comment was to have the camera move slowly in the videos like a stroll (7/15).\u003c/p\u003e\n\u003cp\u003eSome would have also appreciated choosing their own scenario (6/15) to “secure patients in more personal images and make the experience more enjoyable and comforting” (P13) and background music (1/15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, participants suggested to explain more at the beginning of the session how to use VR and the possibility to turn one’s head to see continuous landscapes (2/15). A more targeted hypnosis script focusing on pain would also be beneficial (2/15), like having images of the body part where the pain is located (P12). Other thought it could be interesting to add scents or add animals in the sceneries, such as birds (P6) or large animals like giraffes and horses, “elegant animals” (P5).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eScenario Choices.\u003c/em\u003e The most preferred scenario includes natural landscapes (5/15), such as forests (6/15), beaches (5/15), mountains (3/15), and icy landscapes (P4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 5: Preconceptions and expectations about the tool\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding expectations for this tool, some were just curious to try a new experience (3/15), other had positive expectation or reducing pain and anxiety (3/15). Some already knew what to expect with VR (2/15), and one person even made peace with VR.\u003c/p\u003e\n\u003cp\u003e“The other VR experience we had, we were on roller coasters, and it wasn’t relaxing. […] This experience reconciled me with the virtual reality headset. I think it’s very positive.” (P3)\u003c/p\u003e\n\u003cp\u003e“Ah, I was curious. I talked to my occupational therapist. I said, I’m excited, I’m excited. It’s much more than I expected. I didn’t expect such a great comfort effect afterward.” (P9)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed at investigating the efficacy of a VRH intervention with patients with chronic pain and evaluate their experience with the device. Overall, findings showed that participants have a good experience with VRH intervention. Indeed, they reported a high level of satisfaction, a positive user experience, and low symptoms of cybersickness. The VRH intervention was shown to be efficient to significantly decrease levels of anxiety and pain and increase the level of relaxation. Findings from the interviews showed the relevance of using VRH intervention for people with chronic pain. \u0026nbsp;However, it is also worth noting that some would like to use it preventively to counter potential pain throughout the day.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBenefits of the present VRH intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe observed efficacy of the present VRH intervention is in line with the literature. Indeed, the benefits of using virtual reality is well-known in clinical context, particularly in reducing clinical pain in different clinical settings (16,17), with promising effects on pain and stress reduction (18). However, contrary to the present intervention, most studies investigating VR or VRH used various games (15,29). The present study constitutes an innovative approach by applying contemplative landscape images, aiming to escape from the hospital environment, allowing immersion in pleasant and high-quality images, and thus promoting greater immersion. Additionally, this study opted for a 360° contemplative virtual reality rather than a 3D contemplative virtual reality, to avoid graphical defects and inconsistencies in size, color, and movement fluidity of objects found in 3D animations (16) 360° videos also offer better image resolution to prevent visual discomfort and potential cybersickness such as nausea (30). Finally, developing a 360° video is easier and less expensive than creating a computer-simulated 3D environment. Those motivations in applying 360° contemplative images (vs. 3D contemplative VR) in a simple use design are confirmed by the findings of this study. Negative aspects of the intervention such as the relative discomfort reported by participants can be explained more by environmental arguments (i.e., the chair used during the session was neither suited for patients with pain nor designed for a session involving a VR headset) than by the intervention itself.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerspectives for the development of future VRH interventions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study lead to recommendations for the improvement of the present intervention and the development of future VRH interventions. First, content of the intervention should be refined by adding various landscapes available on the app, better transitions between videos, reducing the video/music loop, and adding some animals or moving objects such as boats to enhance realism, all aiming towards a fully customizable tool that can adjust image speed, color, and sound rhythm. The second area of improvement relates to the VRH session itself by adapting the hypnosis script to the illness in view of integrating audio into the VR headset and paying more attention to installation comfort for an optimal experience. Finally, olfactory suggestions could be added to achieve a full sensory immersion in the experience. Beyond this study, further investigations are needed to differentiate respective effect of hypnosis, virtual reality alone, and VRH. In that sense, comparative studies are essential to explore the similarities and differences between these techniques. Moreover, beside behavioral investigations, more fundamental studies are needed to understand which mechanisms are implied in the effect of the intervention in terms of physiological variables known to be involved in pain perception (e.g., heart rate, electrodermal activity) (31,32).\u003c/p\u003e\n\u003cp\u003eThe findings highlight the high expectations some participants have regarding VRH in terms of reducing their pain, anxiety, fatigue, distress, while improving their quality of life and mood. These expectations underscore the necessity of properly informing participants about what VRH can realistically offer. Despite the efficacy of VRH in various clinical settings, clear and realistic communication about the potential benefits and limitations of VRH is essential to avoid disappointment in patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrengths and weaknesses of this study\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy completing the quantitative investigation of efficacy of the intervention by qualitative interviews, this study adopts a user-centered design, emphasizing a focus on the patient. By doing so, research can ensure that the needs of users remain central to the design process (33). However, this study has several limitations. First, an unbalanced sex-ratio is present in the sample with 25 females and 5 men. Given pain perception can be impacted by sex (34), further studies should recruit samples with a balanced sex-ratio. Then, some participants did not report all the medical treatments they were undergoing that could influence the levels of pain and anxiety, nor were evaluated for potential confounding variables (e.g., previous experience with VR or hypnosis, expectations toward the intervention). Given the researcher was present during the use of VRH device, it is important to note a potential desirability bias in this study. Moreover, participants could have been pre-motivated to take part in the VRH session by being offered evaluating their experience. Those points relate to an absence of a blinding process in the intervention. Further studies should use a methodologically sounded blinding procedure to address this issue. Another limitation lays in the novelty of the intervention. Given innovative approaches are generally seen as positive, it could be worth to investigate user experience in a longer-term to evaluation if the attitudes remain positive across the time. Then, further studies should use standardized measures to evaluate outcomes of interest to allow comparisons between studies. Finally, it should be noted that the duration of sessions and the landscapes used remained the same throughout the study. Thus, future studies could investigate the impact of such parameters (e.g., comparing beach \u003cem\u003evs.\u0026nbsp;\u003c/em\u003emountain; investigating the effect of the duration of the intervention) on the outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study evaluated the user experience of a virtual reality hypnosis intervention in patients with chronic pain. The findings lead to recommendations for the improvement the present tool and future interventions use in pain clinics. The intervention demonstrated its effectiveness in reducing pain and anxiety while increasing relaxation levels among this population. Future studies should be dedicated to implementing larger scale intervention using VRH in order to test its efficacy in more representative clinical settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors refer to CRediT (Contributor Roles Taxonomy).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization\u003c/strong\u003e: Florianne Rousseaux, Mathieu Landry, Pierre Rainville, David Ogez\u003cbr\u003e \u003cstrong\u003eData curation\u003c/strong\u003e: Alexandra Chevestrier-Lefeuvre, Jos\u0026eacute;phine Guin\u0026eacute;, Valentyn Fournier\u003cbr\u003e \u003cstrong\u003eFormal analysis\u003c/strong\u003e: Alexandra Chevestrier-Lefeuvre, Jos\u0026eacute;phine Guin\u0026eacute;, Valentyn Fournier\u003cbr\u003e \u003cstrong\u003eFunding acquisition\u003c/strong\u003e: Pierre Rainville and David Ogez\u003cbr\u003e \u003cstrong\u003eInvestigation\u003c/strong\u003e: Alexandra Chevestrier-Lefeuvre, Jade V\u0026eacute;ronneau, Julie Labeau, Audrey Laurin, Marie-Fania Simard, David Ogez\u003cbr\u003e \u003cstrong\u003eMethodology\u003c/strong\u003e: Mathieu Landry, Pierre Rainville, David Ogez.\u003cbr\u003e \u003cstrong\u003eProject administration\u003c/strong\u003e: David Ogez\u003cbr\u003e \u003cstrong\u003eResources\u003c/strong\u003e: Julie Labeau, Nadia Godin, Philippe Richeb\u0026eacute;, David Ogez\u003cbr\u003e \u003cstrong\u003eSoftware\u003c/strong\u003e: Alexandra Chevestrier-Lefeuvre, Jos\u0026eacute;phine Guin\u0026eacute;, Valentyn Fournier\u003cbr\u003e \u003cstrong\u003eSupervision\u003c/strong\u003e: Valentyn Fournier, David Ogez\u003cbr\u003e \u003cstrong\u003eValidation\u003c/strong\u003e: Valentyn Fournier, David Ogez\u003cbr\u003e \u003cstrong\u003eVisualization\u003c/strong\u003e: Jos\u0026eacute;phine Guin\u0026eacute;, Valentyn Fournier\u003cbr\u003e \u003cstrong\u003eWriting - original draft\u003c/strong\u003e: Alexandra Chevestrier-Lefeuvre, Jos\u0026eacute;phine Guin\u0026eacute;, Valentyn Fournier, David Ogez\u003cbr\u003e \u003cstrong\u003eWriting - review \u0026amp; editing\u003c/strong\u003e: Alexandra Chevestrier-Lefeuvre, Jos\u0026eacute;phine Guin\u0026eacute;, Karim Jerbi, Philippe Richeb\u0026eacute;, Valentyn Fournier, David Ogez\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Minist\u0026egrave;re de l\u0026rsquo;\u0026eacute;conomie et de l\u0026rsquo;Innovation du Qu\u0026eacute;bec (2022-2027-63761). We thank Jean-Fran\u0026ccedil;ois Malouin, CEO of Super Splendide, and patients of pain clinic from Maisonneuve-Rosemont Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on an OSF repository via the following link: https://osf.io/vbh72/?view_only=af1597d4cc5c4850a513d2fc9b3cc7de then in the \u0026ldquo;1- User experience and proof-of-concept\u0026rdquo; study folder.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eICD-11 for Mortality and Morbidity Statistics [Internet]. [cited 2024 Oct 16]. Available from: https://icd.who.int/browse/2024-01/mms/en#1326332835\u003c/li\u003e\n \u003cli\u003eCanada H. Canadian Pain Task Force Report: March 2021 [Internet]. 2021 [cited 2024 Oct 15]. 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PAIN. 2016 Apr;157(4):777.\u003c/li\u003e\n \u003cli\u003eAbbas JR, O\u0026rsquo;Connor A, Ganapathy E, Isba R, Payton A, McGrath B, et al. What is Virtual Reality? A healthcare-focused systematic review of definitions. Health Policy Technol. 2023 Jun 1;12(2):100741.\u003c/li\u003e\n \u003cli\u003eGutierrez-Martinez O, Gutierrez-Maldonado J, Cabas-Hoyos K, Loreto D. The illusion of presence influences VR distraction: effects on cold-pressor pain. Stud Health Technol Inform. 2010;154:155\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eTse MMY, Ng JKF, Chung JWY, Wong TKS. The effect of visual stimuli on pain threshold and tolerance. J Clin Nurs. 2002;11(4):462\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eGold JI, Kim SH, Kant AJ, Joseph MH, Rizzo A \u0026ldquo;Skip.\u0026rdquo; Effectiveness of Virtual Reality for Pediatric Pain Distraction during IV Placement. 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Improving the Intensive Care Patient Experience With Virtual Reality\u0026mdash;A Feasibility Study. Crit Care Explor. 2020 Jun;2(6):e0122.\u003c/li\u003e\n \u003cli\u003eFussell SG, Truong D. Using virtual reality for dynamic learning: an extended technology acceptance model. Virtual Real. 2022 Mar 1;26(1):249\u0026ndash;67.\u003c/li\u003e\n \u003cli\u003eCzajkowski SM, Powell LH, Adler N, Naar-King S, Reynolds KD, Hunter CM, et al. From ideas to efficacy: The ORBIT model for developing behavioral treatments for chronic diseases. Health Psychol Off J Div Health Psychol Am Psychol Assoc. 2015 Oct;34(10):971\u0026ndash;82.\u003c/li\u003e\n \u003cli\u003eCzajkowski SM. Using the ORBIT Model to Design an Intervention Promoting Healthy Weight Gain During Pregnancy: the Value of an Iterative and Incremental Approach to Intervention Development. Int J Behav Med. 2019 Oct 1;26(5):457\u0026ndash;60.\u003c/li\u003e\n \u003cli\u003eCzajkowski SM, Hunter CM. 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Int J Aviat Psychol. 1993 Jul 1;3(3):203\u0026ndash;20.\u003c/li\u003e\n \u003cli\u003eLawson BD, Graeber DA, Mead AM, Muth ER. Signs and symptoms of human syndromes associated with synthetic experiences. In: Handbook of virtual environments: Design, implementation, and applications. Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; 2002. p. 589\u0026ndash;618. (Human factors and ergonomics).\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006 Jan 1;3(2):77\u0026ndash;101.\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V. Thematic Analysis: A Practical Guide. SAGE Publications; 2021. 377 p.\u003c/li\u003e\n \u003cli\u003eHoffman HG, Richards T, Coda B, Richards A, Sharar SR. The Illusion of Presence in Immersive Virtual Reality during an fMRI Brain Scan. Cyberpsychol Behav. 2003 Apr;6(2):127\u0026ndash;31.\u003c/li\u003e\n \u003cli\u003eNarciso D, Bessa M, Melo M, Coelho A, Vasconcelos-Raposo J. Immersive $$360^{\\circ }$$video user experience: impact of different variables in the sense of presence and cybersickness. Univers Access Inf Soc. 2019 Mar 1;18(1):77\u0026ndash;87.\u003c/li\u003e\n \u003cli\u003eTracy LM, Ioannou L, Baker KS, Gibson SJ, Georgiou-Karistianis N, Giummarra MJ. Meta-analytic evidence for decreased heart rate variability in chronic pain implicating parasympathetic nervous system dysregulation. PAIN. 2016 Jan;157(1):7.\u003c/li\u003e\n \u003cli\u003eAqajari SAH, Cao R, Naeini EK, Calderon MD, Zheng K, Dutt N, et al. Pain Assessment Tool With Electrodermal Activity for Postoperative Patients: Method Validation Study. JMIR MHealth UHealth. 2021 May 5;9(5):e25258.\u003c/li\u003e\n \u003cli\u003eVagal A, Wahab S, Lecky S, Washburn E, Schwartz R, Vogel C, et al. Optimizing Patient Experience Using Human-Centered Design. J Am Coll Radiol JACR. 2020 May;17(5):668\u0026ndash;72.\u003c/li\u003e\n \u003cli\u003eBartley EJ, Fillingim RB. Sex differences in pain: a brief review of clinical and experimental findings. Br J Anaesth. 2013 Jul;111(1):52\u0026ndash;8.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e\u003cem\u003eParticipants\u0026rsquo; socio-demographic and clinical information\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eSample size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eMean (SD), Range\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e83.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eCouple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eDivorce\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eWidow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScholar level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eFull-Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003ePart-Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eRetirement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eTemporary sick leave\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eDisability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource/type of pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eArm or hand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eArthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eBack pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eCervicalgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e3.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eComplex regional pain syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eFibromyalgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eGonalgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e6.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eIliac pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e3.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eNeck pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e3.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003ePostoperative pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e6.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e53.9 (11.7), 29-74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003cem\u003eScores of symptoms of cybersickness induced by VRH\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003eGD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eHeadache\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eEye strain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003eDF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003eIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eSweating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eNausea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003eDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eHH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eBlurring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eDEO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eDEC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eVertigo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003eSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBurping\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eMin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eMax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote. \u0026nbsp; GD: General Discomfort; DF: Difficulty of Focusing; IS: Increase Salivation; DC: Difficulty to Concentrate; HH: Head Heaviness; DEO: Dizziness with Eyes Open; DEC: Dizziness with Eyes Closes; SA: Stomach Awareness\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chronic pain, Virtual Reality, Hypnosis, Intervention","lastPublishedDoi":"10.21203/rs.3.rs-6278623/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6278623/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eChronic pain is a significant public health issue in Canada, with approximately one in four Canadians over the age of 15 living with this condition. Due to its impact on individuals—both physically and psychologically—and its financial burden on the healthcare system, it is crucial to develop cost-effective and efficient treatment methods. Hypnosis and virtual reality have emerged as promising solutions in this context. This study aims to evaluate the preliminary efficacy and feasibility of an intervention combining virtual reality and hypnosis.\u003c/p\u003e\n\u003cp\u003eThe study involved 30 patients with chronic pain who were invited to test a hypnosis application delivered through a virtual reality device. Levels of pain, anxiety, and relaxation were measured before and after the intervention, while satisfaction, cybersickness, and user experience were evaluated post-intervention. At the end of the intervention, participants were invited to participate in a semi-structured interview to provide feedback on their satisfaction with the experience.\u003c/p\u003e\n\u003cp\u003eParticipants reported high levels of satisfaction with the intervention, a positive user experience, and minimal symptoms of cybersickness. The intervention was effective in reducing anxiety (W = 173.5, \u003cem\u003ep\u003c/em\u003e = .002) and pain (W = 253.5, \u003cem\u003ep\u003c/em\u003e\u0026lt; .001) while significantly enhancing relaxation levels (W = 9.00, \u003cem\u003ep\u003c/em\u003e\u0026lt; .001).\u003c/p\u003e\n\u003cp\u003eThis intervention demonstrated effectiveness in reducing pain and anxiety while improving relaxation levels among individuals with chronic pain, paving the way for further investigations of the involved mechanisms.\u003c/p\u003e","manuscriptTitle":"Effects of a Virtual Reality Hypnosis Intervention on Chronic Pain: A User Experience and Proof-of-concept Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 11:30:14","doi":"10.21203/rs.3.rs-6278623/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"deb50937-7c80-49f9-a4b3-44eb6c5d842f","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-22T19:53:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-14 11:30:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6278623","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6278623","identity":"rs-6278623","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}