Virtual reality and classical music help to reduce BP in patients in emergency department, suggests study

A virtual reality landscape of a flowing river and trees, accompanied by classical music, can help to reduce patients' blood pressure significantly within 15 minutes of their being seen in an emergency department.

In a randomised controlled trial of 130 adult patients who arrived in an emergency department with hypertensive urgency – blood pressure that is significantly high but without any symptoms or signs indicating acute organ damage – researchers found that viewing natural landscapes with a virtual reality (VR) headset while listening to the soothing music of composers such as Bach, Mozart, Debussy, Vivaldi and Tchaikovsky also reduced patients’ anxiety. The research was presented at the European Emergency Medicine Congress today (Saturday) [1].

Speaking before the congress, the first author and principle investigator of the study, Dr Safa Dönmez, an associate professor of emergency medicine at the University of Health Sciences, Ankara City Health Application and Research Center, Ankara, Turkey, said that as far as he knew, this was the first study to investigate combining VR and classical music to help patients with severely elevated blood pressure in emergency departments.

“Patients who arrive in the emergency department with markedly elevated blood pressure — readings of 180 mmHg or higher on the top number, or 110 mmHg or higher on the bottom number — are extremely common. We treat them with blood pressure medication, but what I kept noticing was how anxious and frightened many of these patients are. That matters medically, not just emotionally, because anxiety causes the body to release stress hormones that tighten the blood vessels and push blood pressure even higher. The emergency department environment itself — the noise, the bright lights, the uncertainty — can make that worse. This made me wonder: if we could help patients feel calmer, could we also help their blood pressure come down faster?” he said.

Dr Dönmez and colleagues, including Dr Kadir Yenal, an emergency medicine specialist at Ankara Bilkent City Hospital, Ankara, randomised patients with hypertensive urgency into an intervention group (65 patients) and a control group (65 patients). All patients received standard medication to reduce blood pressure. Patients in the control group had no other intervention, but the patients in the intervention group put on VR headsets, similar to those used in gaming, that transported them to a peaceful nature scene showing a river flowing through a forest, tall trees and a wooden suspension bridge [2].

At the same time, these patients listened on a smartphone to a playlist of classical music that the researchers had selected because of the calming, structured qualities of music by the composers mentioned above, as well as others such as Saint-Saens, Hadyn and Corelli [3].

The researchers measured the patients’ blood pressure at 15, 30, 60, 90 and 120 minutes. They looked at the mean arterial pressure (MAP), which combines the top (systolic) number with the bottom (diastolic) number to give a single figure representing the average pressure in the arteries during one heartbeat. A normal MAP is roughly 70–100 millimetres of mercury (mmHg). The patients in this study arrived in the emergency department with much higher MAP readings of around 130–138 mmHg.

Researchers assessed anxiety levels using a questionnaire called the State Anxiety Inventory (STAI). STAI-I measures how anxious a patient feels in that moment, which is called "state anxiety”. STAI-II measures how anxious the patient tends to be as a general personality trait and this is called "trait anxiety". Both are scored from 20 to 80, where higher numbers mean more anxiety.

Even though the patients were randomly assigned to the two groups, the researchers found that those in the VR group had slightly lower blood pressure when they started in the study. To account for this, the researchers not only compared the blood pressure readings between the two groups at all the time points, but also analysed the size of the reduction.

At 15 and 30 minutes, MAP values in the control group fell from 138 mmHg to 126 mmHg and then 119 mmHg, respectively. In the VR group, the MAP values fell from 132 mmHg to 116 mmHg and 112 mmHg, respectively. After 30 minutes there was no longer a significant difference between the groups. At 15 and 30 minutes, the percentage reductions in MAP in the control group were 8% and 14%, respectively, whereas the VR group had greater percentage reductions of 12% and 15%, respectively.

Dr Yenal told the congress: “After 15 minutes, patients in the VR group had both a lower absolute blood pressure reading and a greater reduction from their starting point, compared to the control group. This was a statistically significant finding, meaning it was unlikely to be due to chance. The VR group's blood pressure dropped approximately 4–5 mmHg more than the control group. After that, the gap then narrowed, and from 60 minutes onwards the two groups were essentially equivalent.”

At the beginning, the VR patients were significantly more anxious than the control group with trait anxiety scores (STAI-II) of about 46 compared to about 38 in the control group. During the observation period, there was a statistically significant difference in the reduction in trait anxiety between the two groups: an average reduction of eight points in the VR group versus four points in the control group.

Dr Yenal said: “By the end of the two-hour observation, both groups had reached similar post-intervention anxiety levels, but the VR group got there from a higher starting point of anxious temperament, which makes their greater improvement all the more notable.”

He said more research should be carried out in larger groups in several other hospitals but, as the technology was inexpensive and easy to use, without any side effects, “I believe it can reasonably be considered as a supportive, patient-centred addition to standard care, especially for patients who are visibly anxious or distressed.”

Dr Dönmez said the study provided early, meaningful evidence that the approach was safe, feasible and beneficial in reducing anxiety and blood pressure.

“The suggestion of faster early blood pressure reduction in the first 15 minutes is clinically interesting. In a busy emergency department, getting blood pressure under control quickly is important — both for patient safety and for the efficient use of resources. If a non-drug intervention can accelerate that process even modestly, it has practical value,” he said. “However, the diminishing effect over time suggests that intervention supports early stabilisation rather than long-term control of blood pressure.

“For patients, the significance of the study is that if you were brought into an emergency department with markedly elevated blood pressure, frightened and in pain, then being offered a few minutes in a peaceful virtual forest while listening to Mozart would likely be welcomed.”

Strengths of the study are that it was a randomised controlled trial that used the same standardised equipment for measuring blood pressure in both groups, and no patient dropped out of the study. Limitations include the difference in average blood pressures between the two groups at the start of the study; it was a single centre study; follow-up was only for two hours; the VR headset and music were always used together so it was not possible to determine which was responsible for the observed effects, or whether both were needed; and patients and medical staff could see who was using the VR headsets, so there could be a placebo effect.

The researchers now plan to conduct further studies in more hospitals with longer follow-up, looking at the effects of VR and classical music separately, and also investigating whether enabling patients to choose their own music makes any difference.

Dr Felix Lorang is a member of the EUSEM abstract selection committee. He is head of the emergency department at Klinikum Lippe, North Rhine-Westfalia, Germany, and was not involved with the research. He said: “Although this is a single-centre study, the results are interesting and deserve further investigation. They raise the possibility that this approach is not only safe and feasible, but offers meaningful benefits, particularly in reducing anxiety and helping to achieve faster blood pressure control during the early stages of treatment, and might avoid unnecessary medication. It is important to note that this approach was used in addition to, and not instead of, adaptation of the medication to reduce blood pressure.”