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Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald

4 Issues per year

CiteScore 2017: 0.84

SCImago Journal Rank (SJR) 2017: 0.401
Source Normalized Impact per Paper (SNIP) 2017: 0.452

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The effects of auditory background noise and virtual reality technology on video game distraction analgesia

Julia A. Zeroth
  • Corresponding author
  • Department of Psychology, University of Maryland, Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250, USA
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  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Lynnda M. Dahlquist / Emily C. Foxen-Craft
  • Department of Psychology, University of Maryland, Baltimore County, Baltimore, MD, USA
  • Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
  • Other articles by this author:
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Published Online: 2018-11-13 | DOI: https://doi.org/10.1515/sjpain-2018-0123


Background and aims

The present study was designed to evaluate the relative efficacy of two video game display modalities – virtual reality (VR) assisted video game distraction, in which the game is presented via a VR head-mounted display (HMD) helmet, versus standard video game distraction, in which the game is projected on a television – and to determine whether environmental context (quiet versus noisy) moderates the relative efficacy of the two display modalities in reducing cold pressor pain in healthy college students.


Undergraduate students (n=164) were stratified by sex and self-reported video game skill and were randomly assigned to a quiet or a noisy environment. Participants then underwent three cold pressor trials consisting of one baseline followed by two distraction trials differing in display modality (i.e. VR-assisted or standard distraction) in counter-balanced order.


Participants experienced improvement in pain tolerance from baseline to distraction in both display modality conditions (p<0.001, partial η2=0.41), and there was a trend toward greater improvement in pain tolerance from baseline to distraction when using the VR HMD helmet than during standard video game distraction (p=0.057, partial η2=0.02). Participants rated pain as more intense when experienced with concurrent experimental background noise (p=0.047, partial η2=0.02). Pain tolerance was not influenced by the presence or absence of background noise, and there was not a significant interaction between display modality and noise condition. Though exploratory sex analyses demonstrated a significant three-way interaction between noise condition, sex, and display modality on pain intensity (p=0.040, partial η2=0.040), follow-up post-hoc analyses conducted for males and females separately did not reveal significant differences in pain intensity based on the interaction between noise condition and display modality.


As expected, video game distraction both with and without an HMD helmet increased pain tolerance; however, the two display modalities only marginally differed in efficacy within the population under study. The effect of auditory background noise on pain was mixed; while pain tolerance did not vary as a function of the presence or absence of background noise, the addition of noise increased pain intensity ratings. The interaction between participant sex, noise condition, and distraction modality on pain intensity trended toward significance but would require replication in future research.


Results suggest that video game distraction via HMD helmet may be superior to standard video game distraction for increasing pain tolerance, though further research is required to replicate the trending findings observed in this study. Though it does not appear that background noise significantly impacted the relative efficacy of the two different video game display modalities, the presence of noise does appear to alter the pain response through amplified pain intensity ratings. Further research utilizing more sophisticated VR technology and clinically relevant background auditory stimuli is necessary in order to better understand the impact of these findings in real-world settings and to test the clinical utility of VR technology for pain management relative to standard video game distraction.

Keywords: pain management; distraction; virtual reality; environmental noise; non-pharmacological analgesia

1 Introduction

Distraction is a pain management technique that has been employed effectively in medical settings in order to manage acute pain and distress [1], [2]. Distraction is thought to reduce pain by allocating capacity-limited attentional resources toward the distractor, therefore reducing the attentional resources available to cognitively process the painful stimulus [3].

According to cognitive-affective and neurocognitive models of attention and pain, distraction is most effective when attention is voluntarily directed toward an interactive task involving “top-down” processing and engagement of central attentional resources in order to interfere with the involuntary, “bottom-up” processing of painful stimuli [4], [5], [6]. Video game distraction meets this requirement in that it is interactive, goal-oriented, and requires executive skills, such as planning, anticipation, and ongoing active direction of attention to the game [7], [8], [9]. When used in conjunction with virtual reality (VR) technology, such as a head-mounted display (HMD) helmet, video game distraction may be more effective, as the HMD helmet may dampen perceptions of external stimuli and facilitate direction of central attentional resources toward the distractor [7], [10], [11]. However, few studies have tested this premise and findings have been inconclusive [e.g. 12], [13], [14].

Moreover, most studies fail to consider the impact of the environmental context in which distraction is employed. The settings in which patients require analgesia are often noisy, which stands in contrast to quiet, controlled laboratory environments [15]. Noise that is loud, unpredictable, or uncontrollable is associated with decrements in performance on cognitive tasks [16], [17], suggesting that background noise could interfere with an individual’s ability to maintain engagement with a video game. The use of an HMD helmet may facilitate video game distraction by making it easier to ignore competing environmental stimuli.

Additionally, Rhud and Meagher [18] found that exposure to unpredictable noise bursts led to decreased pain reactivity in women and increased pain reactivity in men. Thus, there may be sex differences in the impact of background noise on the experience of pain.

1.1 Aims and objectives

The present study was designed to compare the effects of video game distraction delivered via HMD helmet (VR-assisted distraction) with video game distraction in which the game was projected on a television screen (standard distraction) under noisy versus quiet environmental conditions. The primary aim was to determine if either display modality provided enhanced analgesia through increased pain tolerance or decreased pain intensity. The secondary aim was to evaluate the impact of experimental noise on pain tolerance and intensity, as well as to analyze the interaction between display modality and background noise. An exploratory aim was to determine if the effects of display modality or noise condition differed based on participant sex.

We hypothesized that both VR-assisted and standard video game distraction would improve pain tolerance and pain intensity relative to baseline. However, we expected VR-assisted distraction to have the greatest analgesic effect. Additionally, we hypothesized that the relative benefits of VR-assisted distraction would be greatest in the noisy environment. We did not have an a priori hypothesis regarding specific sex effects.

2 Methods

2.1 Participants

A total of 179 undergraduate students over the age of 17 were recruited from undergraduate psychology courses at the University of Maryland, Baltimore County. Exclusion criteria included Raynaud’s disorder, heart conditions, sickle cell anemia, chronic pain disorders, or other blood circulation problems. Additionally, students who had taken pain medication or narcotics within the previous 12 h were ineligible. Students who were enrolled in participating courses received extra credit in the course in exchange for participation.

In total, 15 participants were excluded from study analyses. One person voluntarily withdrew from the study following the baseline cold pressor trial; two people left in the middle of the experimental procedure due to unexpected scheduling conflicts. Two participants reported prior hearing impairments and were subsequently excluded from further analyses. Seven participants were excluded because they reached the 180 s cold pressor pain tolerance ceiling during baseline. Finally, three participants were excluded due to errors in the administration of the study protocol.

The final sample consisted of 164 participants ranging in age from 17 to 43 years (M=20.49, SD=3.03), 102 (62.2%) of whom were females. Despite five outliers due to age (over 27 years), analyses with and without these yielded equivalent results, and thus they were retained in the final study sample. Ethnic representation was as follows: 57 (34.8%) Caucasian, 50 (30.5%) Asian American, 25 (15.2%) African American, 6 (3.7%) Hispanic, and 26 (15.9%) “Other.”

2.2 Equipment

2.2.1 Cold pressor

A NesLab RTE17 refrigerated bath circulator (Thermo Electron Corporation, Newington, NH, USA) was used to maintain a water temperature of 1°C (±0.1°C). This temperature was selected in order to minimize the likelihood of ceiling effects that are more common with warmer temperatures [19].

2.2.2 Virtual reality helmet

A 5DT model 800-26 3D adjustable HMD helmet with integrated headphones (Fifth Dimension Technologies, Irvine, CA, USA), was used for the VR-assisted distraction condition. The HMD has 1.44 million pixels of resolution and a 26° diagonal viewing angle.

2.2.3 Finger temperature measurement

A Thermal Feedback System (Model DT-100; Power ID-91) manufactured by Bio-feedback Systems, Inc. (Boulder, CO, USA) was used to measure participants’ finger temperature before and after each trial.

2.2.4 Television

During the traditional video game trial, participants viewed the video game on a Sony Trinitron television (Model KV-20V80; Sony, New York, NY, USA).

2.2.5 Video game console

The Nintendo Wii® (Kyoto, Japan), a gaming console operated by a wireless handheld controller, was used during all video game trials.

2.2.6 Video game

Participants played the NK64 DK Jungle Parkway level of the game Mario Kart for Nintendo® Wii during both distraction trials. Mario Kart is a racing game, in which players race a go-kart against 11 other computer-controlled characters and must dodge obstacles and collect power-ups distributed randomly throughout the course to improve their place in the game. This game was selected because it is fast-paced and goal-oriented, lasts longer than 3 min, and is not too difficult to navigate with one hand (while the other was immersed in the cold pressor). Additionally, the game automatically resumes at the location where an avatar falls or drives off the course, thus increasing the likelihood that players will remain engaged in the game even if their characters “die” during game play.

2.2.7 Environmental noise stimuli

Three 3.5-min sound tracks were produced to provide background noise and were designed to make it difficult to focus on the video game distractor. Elements of the sound tracks were based on parameters that have been identified as highly distracting in previous research on noise and performance [16], [17], [20]. Emberson and colleagues [17] found “halfalogues” (i.e. conversations in which the listener can only hear one side of the conversation) to be more distracting and disruptive to task performance than dialogs or monologues, neither of which resulted in poorer task performance. Matthews and colleagues [20] found unpredictable noise containing impulses or “bursts” and alternating with periods of silence to be more distracting than predictable patterns of sound.

In keeping with these findings, a schema was created for the three sound tracks that included the following three types of noise: segments of a halfalogue, various constant and moderately loud noises (e.g. birds chirping, traffic sounds), and various brief and loud noise bursts (e.g. phone ringing, baby crying, air horn). Within the schema, each type of noise lasted for 2–14 s in duration and alternated with periods of silence.

Using methodology similar to that developed by Emberson et al. [17], each sound track contained segments of a different halfalogue. In order to obtain the halfalogue, two female adults (aged 25–26) talked to each other on the phone and one side of the conversation was recorded. Each conversation was focused on a different topic (party, beach, or talent show) that was not expected to be strongly affectively valenced. In each of the three tracks, segments from one of the halfalogues were presented in chronological order.

The sound stimuli used for the various constant/moderately loud noises and various brief/loud noise bursts were obtained from soundbible.com, and were assigned randomly to each of the three sound tracks in accordance with the predetermined schema. Additionally, each of the three sound tracks contained one unique constant/moderately loud noise that did not occur on either of the two other tracks, and two unique brief/loud noise bursts. Each sound track was standardized on several parameters: the ratio of noise to silence (161–50 s), the average total duration of each of the four components [i.e. halfalogue segments (116 s), constant noises (78 s), noise bursts (24 s), and silence (50 s)], and decibel level, which alternated randomly between 80 and 100 decibels throughout each track. The entire sound track was standardized according to these parameters, as were the first 30 s of the track (the time at which it was expected that many participants would withdraw their hand from the cold pressor). The final sound tracks were professionally produced with the Apple Inc. editing program Final Cut Pro, Version 7 (Apple Inc., Cupertino, CA, USA).

2.3 Measures

2.3.1 Demographics

Each participant completed a questionnaire with basic demographic information, including age, sex, and ethnicity.

2.3.2 Video game skill

Video game skill was assessed with a single-item self-report measure: “On a scale of 1–7, with 1 being “not skilled” and 7 being “very skilled”, how would you characterize yourself as a gamer?” Ratings were dichotomized based on frequency distributions for each sex to form the categories of “low” (i.e. below the median) and “high” (i.e. above the median) video game skill. In the final sample, 51% of females rated their level of video game skill as either 1 or 2 (“low” video game skill) while 49% rated themselves as 3–7 (“high” video game skill). In contrast, 41.9% of males rated themselves as 1–4 (“low” video game skill), whereas 58.1% rated themselves as 5–7 (“high” video game skill).

2.3.3 Pain tolerance

Pain tolerance was defined as the total elapsed time that the participant’s hand remained submerged in the cold water, and was measured with stopwatches by two research assistants and recorded to one-tenth of a second. Interrater reliability was excellent, with intraclass correlation coefficients ranging from r=0.99–1.00 across all trials.

2.3.4 Pain intensity

Pain intensity was measured with a Numerical Rating Scale. Immediately following each cold pressor trial, a researcher recorded the participant’s answer to the following prompt: “On a scale of 0–100, with 0 being “no pain” and 100 being “the worst pain you’ve ever felt”, how much pain did you feel while your hand was in the cold water?” The Numerical Rating Scale has been recommended for use as a pain intensity outcome measure in adult pain research by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials [21].

2.4 Procedure

2.4.1 Research design overview

Participants were stratified by sex and self-reported video game skill and were randomly assigned to a quiet or a noisy environment. Participants then underwent three cold pressor trials consisting of one baseline followed by two distraction trials differing in display modality (i.e. VR-assisted or standard distraction) in counter-balanced order.

2.4.2 Randomization procedures

Prior to participation, participants were randomly assigned to one of four groups produced as a function of crossing environment (noisy vs. quiet) and order of distraction presentation (standard distraction first vs. second). Randomization was initially accomplished with two coin flips, the first of which determined distraction order and the second which determined noise condition. However, the randomization procedure was altered midway through the study in order to stratify by sex and video game skill. Groups were then assigned by randomly drawing a sealed envelope containing environment and order assignment from a larger envelope pertaining to stratification by sex and video game skill (e.g. “High Skill Female”) in order to more evenly balance participant sex and videogame experience across the four groups.

2.4.3 Experimenters

Undergraduate research assistants served as experimenters in the roles of “reader” and “recorder.” Research assistants were trained extensively on the protocol and observed by graduate student supervisors. The research assistants followed a detailed script to ensure that the instructions communicated to each participant were identical.

2.4.4 Consent and baseline procedures

This study was approved by UMBC’s Institutional Review Board. Informed consent was obtained from all participants. Participants then placed their non-dominant hand in a bucket of tepid (34°C) water for 1 min in order to ensure their initial hand temperature was not excessively hot or cold. The “recorder” then documented their baseline finger temperature.

Before beginning the baseline trial, the “reader” instructed participants not to make a fist or move their hand around in the water, and to remove it when the pain became so strong that they could no longer tolerate it. The “recorder” then placed the participants’ hand in the water and the two research assistants timed pain tolerance with stopwatches. Immediately after participants removed their hand from the cold pressor, the “reader” administered the Numerical Rating Scale while the “recorder” measured finger temperature and warmed the participants’ hand in the warm water bath until within 1°C of their initial baseline finger temperature. Following each cold pressor trial, the “reader” asked participants if they saw or heard anything while their hand was in the cold pressor to serve as a manipulation check.

2.4.5 Distraction trials

Prior to the distraction trials, participants were taught how to play the video game and practiced playing the game both with and without the HMD helmet. Each practice trial consisted of one race from start to finish. The distraction trials were then conducted in the order indicated by random assignment. The general structure of the distraction trials was the same as the baseline trial with the addition of the video game. Participants in both distraction conditions played the video game for 15 s before the “recorder” placed their hand in the cold pressor. After their final trial, participants were allowed to warm their hand until it was comfortable. A short handout containing general information about the purpose of the study was provided to each participant at the conclusion of the study session.

2.4.6 Environmental manipulation

Participants assigned to the quiet environment completed the baseline and distraction trials without extraneous background noise. For participants in the noisy environment, the auditory stimulus was turned on as the participant’s hand was immersed in the cold pressor during the baseline trial and at the start of video game play in the distraction trials, and was turned off as soon as the participants removed their hand from the cold water.

2.5 Analysis plan

Preliminary analyses revealed a significantly positively skewed distribution of the pain tolerance scores. Accordingly, pain tolerance scores were transformed with a log10 transformation, resulting in skewness and kurtosis values within normal limits (i.e. z-score nearest to zero) [22]. All subsequent analyses of pain tolerance scores were conducted using the transformed scores. Because skew and kurtosis metrics for pain intensity scores were acceptable [22], untransformed pain intensity scores were used for all subsequent analyses (see Table 2).

To test whether the order in which each display modality was administered had an effect on pain tolerance, two 2×2 [trial (baseline vs. distraction)×order of administration (first vs. second)] repeated measures analyses of variance (ANOVA) were conducted. The first ANOVA tested whether the order in which the VR-assisted distraction condition was administered impacted pain tolerance while the second ANOVA tested whether the order in which the standard distraction condition was administered impacted pain tolerance. Given that the order was significant for the standard distraction condition, the impact of display modality and noise condition on pain tolerance was analyzed with a 2×2×2 [trial (baseline vs. distraction) × distraction condition (VR vs. standard)×noise condition] mixed design ANOVA.

Similar analyses were also conducted to examine whether the order in which each distraction modality was administered had an effect on pain intensity ratings. No significant order effects were identified; as such, the impact of distraction modality and noise condition on pain intensity was analyzed with a 2×3 [noise condition×trial (baseline vs. VR-assisted vs. standard)] mixed design ANOVA.

Significant ANOVA effects were explored post hoc through evaluation of change scores. Finally, an exploratory 2×2×3 (sex×noise condition×trial) ANOVA was conducted to test for sex differences in the sample; significant effects were probed with paired sample t-tests. α was set at 0.05 for all analyses.

3 Results

3.1 Preliminary analyses

Descriptive statistics for pain tolerance and pain intensity scores across trials are presented in Table 1, with descriptive statistics for pain tolerance and pain intensity scores by sex presented in Table 2. One male in the noisy environment had missing baseline pain intensity data and was therefore excluded for all pain intensity analyses.

Table 1:

Raw and log10 transformed pain tolerance scores and raw pain intensity scores.

Table 2:

Means and standard deviations for raw pain tolerance and pain intensity scores by trial and sex.

3.2 Order effects

Results indicated that there were no significant differences in pain tolerance scores as a function of the order in which the VR-assisted distraction condition was presented [F(1, 162)=1.21, p=0.273, partial η2=0.01]. However, there was a significant effect of the order in which the standard distraction condition was presented on pain tolerance scores, F(1, 162)=4.45, p=0.037, partial η2=0.03.

In order to understand the nature of this interaction, change scores were computed by subtracting each participant’s baseline pain tolerance from his or her pain tolerance during the standard distraction condition. Results revealed that participants who received standard distraction second demonstrated greater improvements in pain tolerance (M=0.21, SD=0.22; Median=0.22) than participants who received it first (M=0.14, SD=0.21; Median=0.09).

Results indicated no significant differences in pain intensity scores as a function of the order for either VR-assisted distraction, F(1, 161)=0.05, p=0.819, partial η2<0.01, or standard distraction, F(1, 161)=1.16, p=0.284, partial η2=0.01.

3.3 Primary analyses

3.3.1 Pain tolerance

Because of the significant effect of distraction modality presentation order, each participant’s baseline pain tolerance score was compared with his or her pain tolerance score during the first administered distraction trial only. A 2×2×2 mixed design ANOVA with trial (baseline vs. distraction) as the within subjects factor and distraction modality (VR vs. standard) and noise condition (noisy vs. quiet) as the between subjects factors was conducted with pain tolerance as the dependent variable.

As predicted, the main effect of trial was significant, F(1, 160)=109.70, p<0.001, partial η2=0.41; pain tolerance scores increased significantly from baseline (M=1.45, SD=0.26) to distraction (M=1.62, SD=0.34). Additionally, the interaction between trial and distraction condition trended toward, but did not reach, significance, F(1, 160)=3.69, p=0.057, partial η2=0.02. In order to explore this trend, t-tests comparing the pain tolerance change scores were conducted. Results revealed that participants who received VR-assisted distraction averaged greater change scores (M=0.20, SD=0.20; Median=0.17) than participants who received standard distraction (M=0.14, SD=0.21; Median=0.09), t(162)=1.95, p=0.053. The predicted three-way interaction was not significant, [F(1, 160)=0.01, p=0.941, partial η2<0.01], suggesting that distraction condition did not differentially affect pain tolerance as a function of environmental noise.

3.3.2 Pain intensity

Because there was not a significant effect of distraction modality presentation order on the outcome of pain intensity scores, pain intensity scores were collapsed across order in a 2×3 (noise×trial) mixed design ANOVA with noise condition (noisy vs. quiet) as the between subjects factor and trial (baseline vs. VR distraction vs. standard distraction) as the within subjects factor and pain intensity as the dependent variable. Results revealed a significant main effect of noise condition, F(1, 161)=4.01, p=0.047, partial η2=0.02, such that participants in the noisy environment rated pain as significantly more intense (M=67.53, SD=19.26) than participants in the quiet environment (M=61.27, SD=20.59). Neither the main effect of trial, F(2, 160)=2.61, p=0.077, partial η2=0.03, nor the trial by noise condition interaction, F(2, 160)=0.30, p=0.739, partial η2<0.01, was significant.

3.3.3 Exploratory post-hoc analyses

Previous research has identified a differential response to noise and pain as a function of participant sex [18]. In order to test for sex differences within the current sample, a 2×2×3 mixed design ANOVA with noise condition (noisy vs. quiet) and sex (male vs. female) as the between subjects factors and trial (baseline vs. VR-assisted distraction vs. standard distraction) as the within subjects factor was conducted with pain intensity as the dependent variable. There was a significant three-way interaction between noise condition, sex, and trial, F(2, 158)=3.28, p=0.040, partial η2=0.040, suggesting that the effect of noise environment on response to distraction differed as a function of participant sex. Follow-up 2×3 mixed design ANOVAs with noise condition (noisy vs. quiet) as the between subjects factor, trial (baseline vs. VR-assisted distraction vs. standard distraction) as the within subjects factor, and pain intensity as the dependent variable were conducted separately for each sex in order to understand the nature of the interaction. The noise condition by trial interaction did not reach significance for females (n=102) or males (n=61). However, there was a stronger trend toward significance for men in the sample, F(2, 58)=2.37, p=0.103. Though this trend was not statistically significant at the stated α level, the magnitude of the effect was moderate, partial η2=0.07, which suggests that males rated pain marginally differently in response to distraction depending on noise condition. This trend is depicted in Fig. 1.

Pain intensity rating by trial and noise condition for males and females.
Fig. 1:

Pain intensity rating by trial and noise condition for males and females.

Because the trend toward significance was stronger for males than for females in the sample, pain intensity change scores were computed in order to further analyze the magnitude of change from baseline to each distraction condition for males as a function of noise condition. Follow-up paired samples t-tests revealed that the change in pain intensity scores of male participants in the quiet environment did not significantly differ based on distraction modality, t(29)=1.12, p=0.273. However, male participants in the noisy environment evidenced a significantly greater magnitude of change from baseline in the VR-assisted distraction condition (pain intensity decreased an average of 3.50 points; SD=15.97), compared to the standard distraction condition, where average pain intensity actually increased by 1.79 points (SD=10.39), t(30)=2.18, p=0.037. This trend should be interpreted with extreme caution, given the initial noise condition by trial interaction for males did not achieve statistical significance.

4 Discussion

The results of the present study are consistent with previous research suggesting that pain can be made more tolerable through video game distraction [8], [13]. Participants experienced an average 23.2 s increase in pain tolerance from baseline to distraction and the magnitude of this effect was large (partial η2=0.41), suggesting that 41% of the variance in pain tolerance scores could be explained by the video game distraction interventions. This finding adds to the growing body of literature supporting the efficacy of distraction in general, and video game distraction specifically, for increasing tolerance of laboratory-induced cold-pressor pain.

Participants who received VR-assisted distraction appeared to experience slightly greater improvements in pain tolerance than those who experienced standard video game distraction without the addition of VR or the HMD helmet. However, the magnitude of the effect was small (partial η2=0.02), and it did not reach statistical significance; therefore, this finding should be interpreted with caution. It is not clear why the HMD helmet did not make a greater difference, though it could be speculated that a higher quality helmet would have enhanced this effect [23].

Pain intensity was not similarly susceptible to the influence of distraction for the vast majority of participants, with participants reporting as much pain during distraction as they experienced during baseline. Though this finding is contrary to the intuitive notion that distraction would result in decreased pain intensity, it also follows logically from the structure of the cold pressor paradigm. As participants experienced significant increases in pain tolerance during distraction, their hands remained submerged in the cold water for greater lengths of time. It could be presumed that increased exposure to the painful stimulus would naturally lead to increases in pain intensity. Indeed, it is possible that the distraction interventions provided in the present study attenuated what would have been an increase in pain intensity had exposure time increased in the absence of behavioral intervention. Additionally, pain intensity was only measured at the point when pain had become too intense to bear any longer. Other researchers [e.g. 14] take the approach of measuring pain intensity at scheduled intervals throughout the trial. However, we did not adopt this methodology because the act of probing for pain ratings would necessarily interrupt attention to the video game distractor.

The hypothesized interaction between auditory background noise and distraction modality on pain tolerance was not supported. In fact, the presence of noise did not result in significant differences in pain tolerance even at baseline. It is possible that the lack of a main effect of noise on pain tolerance means that the presence of loud, unpredictable auditory background noise is not implicated in the ability to withstand laboratory-induced pain, or that the specific noise stimuli used in the current study were in some way inadequate to induce an overall effect on pain. Although previous research has identified auditory background noise as a factor contributing to pain reactivity [18] and decrements in performance on cognitive tasks [16], [17], less is known about the specific aspects of noise stimuli that affect the experience of pain.

Although the noise stimulus used in this study incorporated multiple auditory parameters (i.e. volume and predictability) that have been shown to influence distractibility, it is possible that we failed to produce a highly distracting sound stimulus. Future research should consider employing a control condition that examines the impact of background noise on non-pain tasks that are known to be susceptible to noise distraction (e.g. serial recall tasks [24]). It is also possible that the noise stimuli we employed did not influence pain tolerance because the noise stimuli were not unpleasant enough [25]. Increasing the stimulus volume may make the experience optimally unpleasant. Additionally, it is possible that the noise in medical settings (e.g. beeping, doctors and nurses talking about medical procedures, crying) would be more distressing than the affectively neutral auditory stimuli that were utilized in the present study, thus creating a greater need to block the external stimuli with the HMD helmet. Regardless, researchers utilizing noise stimuli in the future should consider measuring the perceived unpleasantness of the noise stimulus in order to more thoroughly assess the affective dimension of the experience.

Although pain tolerance was not impacted by the presence or absence of experimental noise, participants in the noisy condition reported significantly greater pain intensity than participants in the quiet condition. Exploratory analyses revealed that males in the noisy condition experienced a trend toward a greater magnitude of improvement in perceived pain intensity from baseline to VR-assisted distraction than from baseline to standard distraction, though this trend did not achieve statistical significance (p=0.103). Had this analysis reached statistical significance, the finding would lend support to the premise that the HMD helmet aided in blocking the auditory stimulus in order to alter the perception of pain for a subset of participants in the sample. No such attenuation of pain was reported in the standard distraction condition, thus implying that VR-assisted distraction may be superior to standard video game distraction for some people who experience pain in noisy conditions. However, it is also possible that the initial interaction between sex, environment, and distraction modality was a spurious finding; as such, this trend should be interpreted with extreme caution until it has been replicated in further research.

The relation between sex, distraction techniques, and environmental conditions warrants further investigation. The theory that drove this exploratory analysis was prompted by previous research suggesting that experimental noise has the potential to influence responses to pain and that these effects may differ by sex. Rhud and Meagher [18] speculated that men attend more closely to both environmental (e.g. noise) and somatic (e.g. pain) external stimuli, which may interfere with distraction interventions. It is also possible that men find background noise more aversive than women, which further highlights the importance of assessing for the affective unpleasantness of auditory background noise in future studies.

4.1 Strengths and limitations

The present study represents a novel attempt to examine the impact of environmental noise on the efficacy of two different methods of delivering video game distraction for acute pain management. As such, it begins to shed light on the impact of environmental factors on pain management interventions. A specific strength of the study lies in the randomized experimental design because it allowed for tight control over potentially confounding variables, such as sex and video game skill. Finally, the extensive training procedures that were used to ensure research assistant competency in administering the experimental protocol helped to ensure that the integrity of experimental procedures was maintained throughout three separate semesters of data collection.

An additional strength of the study design was that each participant served as his or her own control, which allowed for the within-subjects comparison of baseline with distraction. Furthermore, the direct comparison of two different distraction modalities improved upon gaps in previous research by testing the premise that the HMD helmet is a crucial component in video game distraction and superior to standard video game distraction. It is widely accepted that distraction aids in pain management, but less is known about which specific distraction tasks lead to the greatest reductions in pain. By testing the HMD helmet against a standard video game distraction condition, we were able to separate the unique effects and added benefits of the HMD helmet rather than simply assume it contributed to success beyond what can be accomplished through the use of a cheaper, less cumbersome alternative (i.e. standard video game play). Finally, the inclusion of measures assessing both pain tolerance and pain intensity represents an important strength of the study, particularly in light of the differential pattern of effects that emerged for each outcome measure.

The primary limitation of this study is that laboratory-induced pain differs from pain as experienced in medical settings. Participants were assured that they could stop the procedure at any time by removing their hand, which resulted in pain that was predictable, controllable, and voluntary. As such, the results of this experimental study may not translate directly into recommendations for clinical practice. Additionally, individual executive function capacity was not assessed in the current study. Given that engagement with video games requires the use of executive functions, it is possible that executive functioning abilities had a measurable impact on distraction and pain outcomes. It is not clear to what extent executive functions are implicated in the ability to achieve analgesia; as such, this may be a promising avenue for future research.

Finally, the uneven ratio of males to females in the study reduces our ability to fully interpret the effect of sex on pain outcomes. However, the magnitude of the trend for males was moderate (partial η2=0.07) despite there being fewer males than females in the study. It could be that the trending sex differences were primarily driven by differences between males and females in video game skill or experience, or differences in other psychological variables that were not measured. A detailed examination of these phenomena is beyond the scope of this study but may be warranted in the future, particularly should this research be translated to clinical populations.

4.2 Future research directions

The present study represents an early step toward understanding the interaction between environmental variables (e.g. noise) and pain management outcomes. Though little can be said about clinical applications on the basis of this laboratory study, researchers should continue to examine the relative efficacy of different intervention techniques across different settings and conditions representative of those they might encounter in clinical practice as a means of further understanding how to improve pain outcomes in clinical populations. This research should then be translated and further piloted in clinical settings in order to test for effectiveness and to produce guidelines for best practice in the area of pain management.


The authors thank Nour Al Ghriwati, Brittney Allen, Sydney Baker, Maia Barber, Natasha Barlow, Katie Boutot, Samantha Braatz, Allyson Crehan, Mariana De Matos Medeiros, Shashanna Eaton, Rebecca Garrigues, Nicole Gosnell, Amy Hahn, Lauren Hicks, Jessica Hoehn, Nicole Hurd, Antonia Jankowiak, Sam Kott, Valerie Koury, Kristen Kreider, Laura Lewis, Elizabeth Lynott, Lauren McGee, Nicole Magin, Abigail Matthews, Chelsea Meh, Amy Mickhael, Rachel Nicholson, Andrea Owusu-Sekyere, Shyam Patel, Megan Pejsa, Wendy Pinder, Jacob Sechrest, Manroop Singh, Caitlin Thompson, Laura Viar, Emily Wald, Alexandra Woo, and Melissa Zarger for their help with literature reviews and data collection, and Christina Ferrera for producing the auditory stimuli used in the study.


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About the article

Received: 2018-08-02

Revised: 2018-10-08

Accepted: 2018-10-11

Published Online: 2018-11-13

Authors’ statements

Research funding: This study was funded in part by grant R01HD050385 from the National Institute for Child Health and Development, National Institutes of Health.

Conflict of interest: The authors of this manuscript have no conflicts of interest to report.

Informed consent: Informed consent was obtained from all participants.

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by UMBC’s Institutional Review Board.

Citation Information: Scandinavian Journal of Pain, 20180123, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1515/sjpain-2018-0123.

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