Virtual reality reduces pain in children with cerebral palsy during Botox injections

Virtual reality, along with nitrous oxide, can reduce pain and successfully be used as a distraction for children with cerebral palsy and other developmental disabilities who are undergoing injections of botulinum toxin injections, according to new research published in the August 2026 Pain Reports.

Cerebral palsy is a neurological disorder that affects movement, coordination, muscle tone, reflexes and balance. It is one of the most common motor disabilities in childhood. About 1 million people have cerebral palsy in the United States.

Botox is often used to treat muscle spasticity of the lower limbs in children with cerebral palsy, helping to relax muscles, increase range of motion, and improve gait. But these injections last just a few months, requiring repeat injections, and the injections can be painful. Children often receive nitrous oxide alone, topical anesthesia, the benzodiazepine midazolam or sedation.

“On average, when VR was used, pain levels were lower while also using lower nitrous oxide concentrations,” researchers in the Pain Reports study wrote. “The pairing of VR and nitrous oxide… may reduce the need for strategies like physical holds, which adversely affects the child, parent, and healthcare workers.”

Researchers at Gillette Children’s and the University of Minnesota in Minneapolis wanted to determine if virtual reality paired with nitrous oxide could help manage pain for children with developmental disabilities who were undergoing injections of botulinum toxin. Led by Maykala J. Williams, MPH, a clinical research specialist at Gillette Children’s, researchers conducted a randomized, open-label study compared with standard of care with virtual reality and nitrous oxide.

The study assessed 31 children between the ages of 5 and 17 years. Most of the children had cerebral palsy; six children had traumatic brain injury, spinal cord injury or other neurological conditions.

In the study, pain was assessed by child and parent reports, as well as child life specialists who helped to distract patients, using the Faces Pain Scale‐Revised. Pain was assessed three times during each treatment session: once before the Botox injection and twice after the injection. Anxiety of both the children and the parents was also assessed at the same three time points. Twenty-three children used virtual reality for the entirety of the Botox procedure.

Researchers found that children using virtual reality reported significantly lower levels at all time points during treatment sessions compared with standard of care. Children’s self-reported pain scores during injections were 28% lower, on average, when using virtual reality. Parents also reported that the children experienced less pain. Parents also rated children's pain during injections 28% lower. Child life specialists rated pain 42% lower when virtual reality was used. Anxiety scores were also lower for both children and parents for those using virtual reality.

Additionally, children had significantly lower maximum nitrous oxide concentrations when virtual reality was used compared with standard of care. Nitrous oxide concentrations at the end of the procedure were, on average, 5% lower; however, some children had concentration reductions up to 20%. The lower concentrations may help with side effects associated with nitrous oxide, such as nausea, vomiting, and hallucinations.

Of the eight children who discontinued virtual reality, three preferred a different distraction strategy. Five children discontinued virtual reality use because of minor side effects including mild feelings of being overwhelmed or claustrophobic, mild dizziness or motion sickness and mild nausea.

Limitations of the study, researchers said, include its small sample size and that it used self-reporting tools, which may introduce bias. Additionally, the reasons for the reduction of nitrous oxide were not specified in the medical record.