Virtual reality on pain and anxiety after modified radical mastectomy in menopause


Hussein G. Mogahed1, Reham E. Hamoda2,3, Reham A. Elkalla4

1Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt.

2Department of Physical Therapy for Woman's Health, Faculty of Physical Therapy,

Cairo University, Giza, Egypt.

3Department of Physical Therapy for Obstetrics and Gynecology,

Faculty of Physical Therapy, October 6 University, Giza, Egypt.

4Department of Physical Therapy for Surgery, School of Physical Therapy, Badr University in Cairo, Egypt.

*Corresponding Author E-mail:



Objective: To examine the influence of virtual reality (VR) on pain and anxiety among post mastectomy menopause patients. Materials and Methods: Thirty females experiencing unilateral post-mastectomy shoulder pain and anxiety were randomly assigned into two equally sized groups. Group (A) which received a combination of VRand traditional physical therapy care. Group (B) which received traditional physical therapy care. A smart phone-based version of the visual analogue scale (VAS) was employed for pain assessment, while the anxiety rating scale was utilized to evaluate anxiety levels. Each group received three treatment sessions per week for three weeks.Patients were recruited from Om Elmasreen hospital and age ranged between 45-55 years. Results: Study results showed that there were no significant differences in ages between both groups statistically. Pain severity in study group had a lower mean score than those in control group, with a significant difference between two groups after the treatment statistically. Most of patients undergoing unilateral post-mastectomy reported being contended with virtual reality treatment, and there was a significant difference in anxiety between both groups statistically. Conclusion: Virtual reality demonstrates efficacy in alleviating pain and anxiety among post mastectomy menopausal patients.


KEYWORDS: Virtual reality, VAS, Anxiety, Mastectomy, Menopause.




Cancer is described as a condition marked by the unregulated proliferation and dissemination of aberrant cells. Breast cancer exerts an adverse influence on well-being and life quality, affecting cardiovascular health and inducing feelings of depression. Numerous investigations have explored the incidence of pain, anxiety, and depression in individuals suffering from cancer, all of which significantly influence their overall quality of life 1. An enhancement in the quality of life has been observed, potentially attributed to the rise in income within developing nations.



This rise in income has coincided with a heightened occurrence of breast cancer. The upsurge in breast cancer prevalence can be attributed to several factors, including extended life expectancy, heightened exposure to risk factors, greater consumption of fatty foods, increased obesity rates, and decreased rates of pregnancy2. The high-risk factors linked to this condition include a familial history of the condition, early menarche, nulliparity, advancing age, and delayed initial pregnancy 3. Every year, about 1.2 million women across the world are diagnosed with breast cancer, causing significant morbidity and mortality in both developed and developing nations3,4. During 2018, approximately 18.1 million new instances of cancer were reported, resulting in 9.6 million fatalities associated with cancer. These numbers were adjusted to exclude non-melanoma skin cancer, yielding 17.0 million new instances and 9.5 million deaths. The exact cause of breast cancer is not fully understood. Although some evidence points to lifestyle factors like alcohol consumption, diet, and exposure to stressors as potential contributors, there is ongoing debate and uncertainty. Analyzing the available data indicates that the quantity of stressful life situations might not directly forecast the risk of developing or surviving breast cancer. Interestingly, a specific stress level seems to offer protection against cancer 5.


Menopause itself doesn't cause cancer; however, the susceptibility to cancer emergence rises with age. Women who go through menopause after the age of 55 face a higher susceptibility to cancers in the breasts, ovaries, and uterus. This susceptibility is heightened if they commenced menstruation before the age of 12. Extended estrogen exposure elevates breast cancer           risk 6.


Research indicates that chemotherapy can be associated with an independent risk for developing anxiety and depression among breast cancer patients. This may lead to elevated levels of depression scores due to heightened unmet psychological support needs 4.


With the progress of virtual reality (VR) technology, it has become possible to utilize VR for treating anxiety in patients undergoing modified radical mastectomy. VR uses computer software and hardware to create interactive simulations, allowing people to experience environments that feel like real-life situations. VR employs interactive stimulation that responds to the patient's moment, enabling them to engage with a virtual environment during functional activities. This approach facilitates the creation of an exercise setting where patients can enhance their practice frequency, exercise duration, and intensity. Through these features, VR can notably enhance range of motion (ROM), overall body function, and muscle strength. Additionally, it has the potential to impact personal factors like motivation and confidence, leading to improved outcomes 5.



The study enrolled thirty menopause patients who underwent unilateral modified radical mastectomywith removal of axillary lymph nodes, in the presence or absence of radiation therapy. Participants were recruited from Om Elmasreen Hospital, aged between 45 and 55 years. Prior to the study, a thorough examination was conducted by a physician. The research received approval from the research ethics committee of Faculty of Physical Therapy of Badr University (No:BUC-IACUC-230507-27).The followed procedures were in accordance with Helsinki declaration of 1975.



Females were ineligible if they presented with remote metastasis, ongoing infections, lymphedema affecting both upper limbs, renal issues, cardiac conditions, diabetic conditions, cognitive disorder and respiratory distress. The study followed a prospective, single-blinded, controlled clinical trial design withconvenient sampling.


Participants were evenly split into two groups (A and B) through a random assignment process. Group A, the study group, consisted of 15 participants who underwent a combination of VR and traditional physiotherapy care (including lymphatic drainage massage, circulatory exercises with elevated limbs, pneumatic compression, and ROM exercises for the shoulder) three times a week for three weeks. Group B, the control group, consisted of 15 participants who underwent the traditional physiotherapy care (lymphatic drainage massage, circulatory exercises with elevated limbs, pneumatic compression, and ROM exercises for the shoulder) at the same frequency and duration.


2.1. Ethical consideration:

Comprehensive explanations for each evaluative and therapeutic process were provided to the participants, and each participant signed an informed consent before commencement. The participants received a concise overview of the study's purpose, intervention duration, and details, presented in a language tailored to their understanding. Any questions they had regarding the study were openly addressed and clarified.


2.2 Measurements:

Patient’s demographic information, including age, weight, dominant upper limb, kind of breast surgical procedure, and initiation of arm volume alteration due to post-mastectomy lymphedema, was documented on each participant’s evaluation sheet.


The measurement procedures commenced prior to the initiation of treatment (initial record) and were repeated after the 3-week treatment period (second record).


2.2.1 Shoulder pain measurement procedures:

Visual analogue scale (VAS) smart phone version for assessing pain:

The VAS-100 smart phone versions were adapted for a 3.5-inch iPod diagonal touch screen (Apple Inc, USA) and displayed against light blue backgrounds for improved disparity. The Panda version of the VAS-100 scale measures 6.7 cm in length. A marker in the form of an "X" emerges where the individual interacts with the line, indicating the pain severity level. A numerical score ranged from 0 to 100 is generated based on the marker's position relative to the line's endpoints. The marker aligns with a number corresponding to the participant’s pain intensity. Participant data were directly downloaded from the iPod 7.


2.2.2 Anxiety measurement procedures:

Anxiety rating scale for evaluating anxiety:

To examine women's anxiety level. It is a straight line whose ends are the extreme limits of sensation measured from 0 (equilibrium mood) to 10 (loss of control). Anxiety rating scale is divided into six main parts: the first section rated 0 represents balanced mood, the second section 1-2 reflects slight fear and anxiety, the third section 3-4 represents mild fear, the fourth section rated 5 representing moderate fear, the fifth section 6-7 represents strong agitation and the six section 8- 10 represents uncontrollable behavior 8.


2.3. Virtual reality (VR) treatment procedures:

Participants were instructed to find a comfortable position, either seated or lying down. The VR equipment was then applied to the patient for an initial duration of 10 minutes on the first day. Participants were encouraged to remove the equipment if they experienced any discomfort, such as headaches or dizziness. Subsequently, the duration was gradually extended up to 30 minutes as tolerated. Utilizing VR equipment, the intervention aimed to assist participants in reducing their anxiety levels. VR is a technology that uses computer hardware and software to make individuals engage in an environment that closely resembles real-world objects and events. This helped participants connect with the simulated environment, contributing to the reduction of their anxiety and depression. Participants received VR training three times a week for a span of three weeks, with each session extending to duration of 30 minutes. Throughout the program, active communication with the patients was maintained to ensure their comfort and alleviate any potential discomfort. Pain levels were evaluated using the smart phone version of the VAS, while anxiety was evaluated utilizing the anxiety rating scale.


Data analysis:

Data were analyzed through Statistical Package for the Social Sciences (SPSS) version 23 (IBM Corp, United States), and an independent investigator performed the analysis. Paired t-test was employed to measure changes from pre-intervention to post-intervention within both groups. Furthermore, to ascertain any differences in the post-intervention scores, an independent t-test was computed based on post-intervention changes in both groups. A significance level of p < 0.05 was utilized.



Descriptive characteristics of the two groups are presented in (Table 1). No significant differences were observed between both groups related to age statistically.

Table 1: Descriptive statistics for age in the two groups.


Group (A)

Group (B)

Mean of age (years)






Standard error



Mean difference


t. value


p. value


Significance level



3.1. Results of shoulder pain:

Table (2): Showed mean of pain scores in both groups post mastectomy. Results represented that there was no significant difference between both groups pre-treatment statistically. There was a decrease in pain scores post treatment with a significant difference between both groups statistically (P <0.001).


Table 2: Data presentation of visual analogue scale (VAS).


Study group

Control group

Independent t-test


Mean ±SD

Mean ±SD

Pre treatment





Post treatment






3.2. Results of Anxiety rating scale:

Table (3): showed mean of anxiety scores in both groups after mastectomy. Results represented that there was no significant difference between both groups pre-treatment statistically. There was a decrease in anxiety scores post treatment with significant difference between both groups statistically (P<0.001).


Table 3: Data presentation of anxiety rating scale.


Independent t-test

Control group

Study group


Mean ±SD

Mean ±SD





Pre treatment





Post treatment



This study demonstrated the high efficacy of VR equipment in diminishing pain and anxiety levels among menopause patients who had undergone unilateral modified radical mastectomy after 3-weeks of intervention.


Results were agreed with Lambert et al., 9 who highlighted that immersive VR is a valuable tool for distraction, effectively alleviating pain, stress, and negative emotional consequences during various medical treatments, such as chemotherapy for individuals with cancer. Emotional instability could contribute to prolonged hospital stays or increased sedation needs during painful procedures. Furthermore, a patient experiencing stress might struggle to effectively undergo treatment and could face challenges in cooperating with healthcare services, potentially complicating therapy. The researchers proposed that immersive VR holds potential as a promising strategy to alleviate pain and anxiety in individuals suffering from breast cancer.


As Janelsins et al. 10 suggest, incorporating Kinect-based VR rehabilitation programs into standard physical therapy is advisable, or they could even be considered as an alternative to traditional physical exercises for breast cancer patients, particularly those who experience high levels of anxiety or pain related to movement after surgery.


In their study involving forty women with breast cancer, Feyzioğlu et al. 11 observed significant improvements in pain, muscle power, ROM, hand grip strength, functional capacity, and scores of Tampa kinesiophobia scale following therapy (p<0.01). The movement fear showed significant improvement in the group of Kinect-based rehabilitation, while the group of standardized physical therapy showed greater enhancement in functional capacity (p<0.05). After treatment, no significant differences were noted in pain, muscle strength, ROM, and grip strength between both groups (p>0.05).


Chirico et al.12 enrolled thirty patients in VR group, thirty in music therapy group, and thirty-four in control group, which received standard care during the chemotherapy. The results demonstrated that both VR and music therapy were effective in lowering levels of anxiety and enhancing mood status of breast cancer patients receiving chemotherapy. Additionally, VR demonstrated greater effectiveness compared to music therapy in depression, mitigating anxiety, and level of fatigue.


Jimenez et al.,13 reported that VERT breast cancer-targeted education programs showed significant potential in enhancing patients' understanding of radiation therapy and potentially reducing anxiety levels.


In a study by Bani and Ahmad14, a randomized controlled trial involving 80 female breast cancer patients at a cancer treatment center in Kindom of Jordan was conducted. The results revealed that the combination of a single immersive VR session with morphine significantly reduced self-reported pain and anxiety scores, in individuals suffering from breast cancer, in comparison to the use of morphine only.



In a pilot study by House et al.15, position of the arm and strength of the hand grasp were examined in patients playing three-dimensional custom integrative rehabilitation games. The study involved six women living in the community who underwent breast cancer operation and experienced pain in their upper arm. These participants engaged in training using the system two times weekly over a period of 8 weeks. The Bright Arm Duo Rehabilitation System's feasibility for addressing chronic upper body pain in cancer survivors was demonstrated. The study outcomes indicated enhancements in cognition, shoulder ROM, strength, functionality, and depression.


In study by Saravana and Padmavathi16, virtual reality therapy is a beneficial treatment in lowering anxiety through patients under spinal anesthesia.


In study by Rinu17, a guided imagery may be a beneficial adjunctive treatment in management of pediatrics with anxiety and painful disorders.


Anandhukrishnan et al.,18 found that there was significant reduction in anxiety score among hospitalized pediatric patients by virtual reality treatment.


Soniya et al.,19 showed that after virtual reality there was a significant decrease in mean post test level of anxiety of the study group in preschoolers.


Mohanasundari et al.,20 conducted experiment to investigate visual reality plus conventional care on pre-operative anxiety through 24 pediatrics undertaking surgeries. Results suggested use of that protocol.


Sampoornam21 showed that quantitative study of usage of intra-operative virtual video therapy was significant in reducing anxiety through patients undertaking spinal anesthesia.


Sasmita et al.,22 reported that virtual reality on upper GIT endoscopy improved awareness, decreased pre treatment anxiety  and patients satisfaction at end of treatment.


Sudheendra and Mutalikdesai 23 showed that the virtual reality therapy as a distraction way was beneficial in decrease pain within 40 pediatric patients undertaking Intravenous cannulation.


Oommen and Shetty24, studied 24 children with age group of 3 - 12 years. Pain and behavioral distress were assessed using Revised Faces Pain Scale and Behavioral Distress Scale respectively. Results of showed that distraction technique during invasive intravenous procedures reduces pain and pain associated behavioral distress among children caused due to invasive intravenous procedures.


Saravanagenesh and Padmavathi related to study carried out on 30 patients, virtual reality is a  beneficial way to reduce anxiety within patients undertaking spinal anesthesia.25


Eid et al.,26 studied sixty patients had  partial thickness anterior shoulder burn with pain and decrease in shoulder ROM and concluded that virtual reality was better in lowering pain and shoulder ROM.



Small sample size.



Eventually, after the discussion of results of the study and according to reports of previous investigators about virtual reality and its effect, it can be claimed that virtual reality equipment demonstrates remarkable efficacy in lowering anxiety levels among breast cancer menopause patients who have undergone modified radical mastectomy, following a 3-weeks of intervention.



Authors confirm that no connections or engagements with any organization or entity that holds financial interests.



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Received on 16.09.2023            Modified on 06.11.2023

Accepted on 22.12.2023           © RJPT All right reserved

Research J. Pharm. and Tech 2024; 17(4):1657-1661.

DOI: 10.52711/0974-360X.2024.00262