VR-based meditation reduced anxiety before voice therapy in a small exploratory RCT, with lower attrition in the VR arm
How this was rated
Small randomized parallel-group trial (n = 26 randomized, n = 21 analyzed across two arms after scheduling/logistics exclusions), explicitly framed by the authors as exploratory and intended to inform the design of a future RCT. Statistical power is limited and the trial was not blinded (potential expectancy effects). Substantial baseline imbalance in MPT (MVR mean pre = 8.17 s vs M mean pre = 19.42 s) despite randomization; the authors addressed this via ANCOVA with baseline as covariate. Mixed and largely non-significant voice outcomes. Random assignment lifts this above pure pilot work, but conclusions on effect direction or magnitude are not warranted.
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Twenty-six dysphonia patients with elevated state anxiety were randomized to a brief 10-12 minute meditation either with immersive VR (TRIPP app on Quest 2) or audio-only, delivered before each of four voice therapy sessions; 21 were analyzed. Both groups significantly reduced state anxiety with no Group x Time interaction (p=.207) - the modalities were comparable on the primary outcome.
A small exploratory RCT (26 randomized, 21 analyzed) suggesting that brief immersive VR meditation prior to voice therapy is feasible and produces short-term anxiety reductions comparable to audio-only meditation, with possibly better engagement/adherence. Voice-quality outcomes were mixed (CPPS improved significantly in the audio-only arm but not in the VR arm); the authors are explicit that findings are hypothesis-generating rather than definitive, and that clinical significance was not established for any measure.
Key findings
- State anxiety (STAI-Y1): significant Time effect (Estimate 7.39, t(20.55) = 6.95, p < 0.001) reflecting robust reduction in both groups (M group pre 46.90 → post 34.89; MVR group pre 49.27 → post 31.73); Group main effect non-significant (p = 0.913); Group × Time interaction NOT significant (Estimate = -1.38, p = 0.207) - the modalities were comparable for anxiety reduction
- Cepstral peak prominence (CPPS): significant Time effect (p < 0.001) AND significant Group × Time interaction (Estimate = -0.35, t(14.68) = -2.45, p = 0.027); within-group post-hoc: Non-VR (audio-only) increased significantly pre-post (estimate -1.91, t(14.83) = -4.28, p = 0.003); MVR pre-post change was NOT significant (estimate -0.50, p = 0.392). The audio-only group showed the CPPS improvement, not the VR group
- Maximum phonation time (MPT): substantial baseline imbalance (MVR pre M = 8.17 s SD = 3.15 vs M group pre M = 19.42 s SD = 10.68); ANCOVA with baseline as covariate showed significant main effect of Time (F(1,36) = 7.53, p = 0.009) but no significant Group main effect (F(1,36) = 3.34, p = 0.076) - i.e., MPT improved overall but the apparent VR advantage at the raw level was attributable to baseline differences, not the intervention
- Attrition was higher in the M (audio-only) group: one participant discontinued after one session, another after two, a third after three (preferring to use remaining time for voice work), and a fourth was lost to follow-up. The MVR group had more regular participation with subjectively increasing motivation - adherence was not pre-specified, so this is a methodologically softer finding
- 5 participants were excluded post-randomization for scheduling/logistics reasons (3 from MVR, 2 from M), leaving 21 analyzed (11 MVR + 10 M) from 26 randomized
- Clinical significance was not established for any of the measures - the authors are explicit that findings are exploratory and hypothesis-generating
Background
Voice work is increasingly approached within a biopsychosocial framework, with growing recognition that anxiety and physiological arousal influence vocal function. Research consistently links voice disorders with elevated rates of anxiety and depression - one large-scale study (n = 283,137) found that individuals with dysphonia had 1.34 times the odds of depression and 1.44 times the odds of anxiety compared with non-dysphonia counterparts. Brief mindfulness-based interventions have demonstrated short-term reductions in state anxiety and improvements in self-perceived voice quality in dysphonic patients. Whether delivering meditation through immersive virtual reality (IVR) offers any advantage over audio-only meditation had not been previously established in voice therapy.
What the researchers did
Hoff, Palmer, and Daşdöğen (all at the Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai) randomized 26 patients with confirmed dysphonia from Mount Sinai’s Grabscheid Voice and Swallowing Center to one of two conditions: meditation with immersive virtual reality (MVR) or meditation without immersive virtual reality (M, audio-only). Inclusion required STAI-Y1 state anxiety > 37 (‘moderate’ threshold). Randomization was via Random.org. After scheduling and logistics issues, 5 participants were excluded (3 from MVR, 2 from M), leaving 21 analyzed: 11 in the MVR arm and 10 in the M arm.
Intervention protocol: A 10-12 minute meditation immediately before each of four weekly 45-minute voice therapy sessions. The MVR condition used the TRIPP application on a Meta Quest 2 headset, with four carefully selected calming ‘worldscapes’ - Aurora (hilltop forest under Northern Lights), Cosmic Mists (floating through space), Serenity Meadow (seated in a dimly lit forest), and Mountain Lake (canoe on still water facing an ice-capped peak). Voice type and amount of verbal guidance were patient-selected. The M condition used freely sourced guided meditation videos from two clinician-vetted YouTube channels - Sounds True - Many Voices (including content from Jon Kabat-Zinn: ‘10-Minute Guided Mindfulness Meditation’, ‘Mindfulness of the Breath and Body’, ‘Body Scan Meditation’) and The Priory UK (short clinically oriented meditations for stress and anxiety). For the audio-only arm, the screen was outside the participant’s field of vision; participants rested with eyes closed or in a relaxed semi-downward gaze.
Voice therapy followed the meditation in a 25-30 minute block drawing on Lessac-Madsen Resonant Voice Therapy, Exuberant Voice Exercise with LSVT LOUD-style tasks, Vocal Function Exercises, and Manual Circumlaryngeal Therapy. Outcomes were measured pre/post each session (MPT and STAI-Y1 short form) and pre/post the full study (STAI-Y1 long form, MPT, CPPS). Smoothed cepstral peak prominence (CPPS) was analyzed via the Phonanium plug-in in Praat from sustained vowels.
Statistical approach: Linear mixed-effects models in JASP 0.95.4 for STAI-Y1 and CPPS (fixed effects: Group, Time, Group × Time; random intercept for Subject). For MPT, a mixed ANCOVA was used with baseline MPT as a covariate due to substantial baseline imbalance. Holm correction for multiple comparisons.
What they found
State anxiety (STAI-Y1). Both groups showed substantial pre-post reductions (M: 46.90 → 34.89; MVR: 49.27 → 31.73). The model revealed a robust Time effect (Estimate 7.39, t(20.55) = 6.95, p < 0.001) but no Group main effect (p = 0.913) and no significant Group × Time interaction (Estimate = -1.38, p = 0.207). Meditation reduced state anxiety - in both modalities, comparably.
Cepstral peak prominence (CPPS). Significant Time effect (p < 0.001) and a significant Group × Time interaction (p = 0.027). Post-hoc within-group analyzes showed the audio-only (M) group improved significantly pre-post (estimate = -1.91, p = 0.003), while the MVR group did not (estimate = -0.50, p = 0.392). The CPPS gain in the audio-only arm was unexpected and the authors caution it may reflect baseline variability, nonspecific factors, or chance in a small sample - especially since the meditation intervention did not include concurrent voice practice.
Maximum phonation time (MPT). Substantial baseline imbalance despite randomization (MVR pre M = 8.17 s SD = 3.15; M group pre M = 19.42 s SD = 10.68). Raw MPT increased markedly in MVR (post M = 15.13 s) but only slightly in M (post M = 20.27 s). After controlling for baseline MPT in ANCOVA, the apparent group advantage disappeared: significant Time effect (F(1,36) = 7.53, p = 0.009), no significant Group main effect (F(1,36) = 3.34, p = 0.076). Baseline accounted for a large proportion of variance (F = 122.54, p < 0.001).
Attrition. Higher in the M (audio-only) group: one participant discontinued after one session, one after two sessions, one after three sessions (explicitly preferring to use the remaining time for voice work), and one was lost to follow-up. MVR participants had more regular and ‘subjectively, increasingly motivated participation, frequently reporting positive affective reactions.’ Adherence was not a pre-specified outcome.
Why this matters
This is one of the first published RCTs to test immersive VR meditation specifically as a preparatory phase before voice therapy. The findings are honest and appropriately hedged: the modality is feasible, anxiety reductions occurred in both groups, and any modality-specific advantages remain unconfirmed at this sample size. For speech-language professionals working in voice care, the practical takeaway is that brief meditation can be integrated into routine practice and that the VR-mediated form is at least as feasible as audio-only delivery, with possible engagement advantages that deserve formal evaluation.
The unexpected CPPS finding (audio-only > VR) is also worth thinking about clinically: in a study where meditation was isolated from voice practice, the VR-mediated condition did NOT produce the voice-quality improvement that the audio-only condition did. The authors view this as ‘best interpreted with considerable caution’ but worth investigating with a future protocol that pairs meditation with concurrent voice practice.
Limitations
The authors are explicit about limitations:
- Heterogeneous clinical profiles across muscle tension dysphonia, benign vocal fold lesions, vocal fold atrophy, spasmodic dysphonia, prior vocal procedures, and comorbidities (Parkinson’s, EDS, mTBI, chronic cough). Variability in time since procedure and degree of physiological adaptation may have confounded MPT and acoustic measures.
- Pre-intervention MPT was substantially lower in the MVR group despite randomization. Although baseline MPT was statistically controlled, residual confounding is possible, particularly given that individuals with progressive neurologic conditions may follow different rehabilitation trajectories.
- Partial data inclusion required decisions. Inclusion criteria: complete initial evaluation, at least 2 therapy sessions, and a voice recording for post-intervention analysis. The five participants who did not meet these criteria were counted as ‘opt-outs’ for attrition reporting.
- Small sample size and exploratory design - limits statistical power and generalizability.
- Lack of blinding - may have introduced expectancy effects, especially for the VR-novel arm.
- Brief intervention duration (four sessions) precludes conclusions about longer-term outcomes.
- CPPS findings should be interpreted cautiously - meditation did not include concurrent voice practice, and CPPS may not fully capture voice-quality changes related to attentional focus or subtle respiratory-phonatory adjustments.
- Novelty and usability factors inherent to VR could have influenced engagement, affective responses, and adherence, making it difficult to disentangle specific effects of meditation from the broader IVR experience.
- STAI-Y1 indexes state anxiety but not the multidimensional nature of stress. Future studies should add physiological markers and/or longer follow-up, and a voice-specific instrument (e.g., Vocal Fatigue Index, Voice Handicap Index) to correlate stress and anxiety with vocal fatigue and quality of life.
Implications for practice
Brief meditation prior to voice therapy is feasible to integrate into routine practice and may support patient readiness. The VR-mediated version was comparable to audio-only on anxiety reduction and may offer engagement/adherence advantages worth investigating, but direct voice-quality benefits over audio-only meditation were not demonstrated - in fact, the audio-only arm showed the CPPS improvement. The authors interpret this with significant caution given the small sample, baseline imbalances, and the fact that meditation in this protocol was isolated from concurrent voice practice.
Implications for research
A larger, blinded, longer-follow-up trial is needed to establish whether IVR meditation produces voice-related effects beyond anxiety reduction, and to disentangle effects of VR-mediated engagement, presence, and attentional focus. Adherence should be a pre-specified outcome rather than a subjective observation. Future studies should add stress-specific instruments (physiological markers and/or longer follow-up) and a voice-specific instrument (e.g., Vocal Fatigue Index, Voice Handicap Index) to correlate stress and anxiety with vocal fatigue and quality of life. The CPPS finding (audio-only > VR) should be investigated with a protocol that includes concurrent voice practice during/after meditation - the current study had meditation isolated from voice practice.
Where this connects to Therapy withVR
The study above is independent research and does not endorse any product. The notes below are commentary from withVR on how the themes in this research relate to features of Therapy withVR. The research findings are not claims about Therapy withVR.
Meditation Mode
Hoff and colleagues used immersive VR meditation as a preparatory phase before voice therapy - Therapy withVR's environments support similar pre-session work where the clinician can grade the surrounding context.
Without VR Mode
The audio-only comparator condition in this trial parallels the principle of starting outside immersive VR before progressing into it - Therapy withVR's screen-based mode supports the same kind of step.
Cite this study
If you reference this study in your work, the canonical citation formats are:
@article{hoff2026,
author = {Hoff, B. and Palmer, B. and Daşdöğen Ü},
title = {An Exploratory Study of Meditation With and Without Immersive Virtual Reality: Effects on Anxiety and Voice-Related Outcomes},
journal = {Journal of Voice},
year = {2026},
doi = {10.1016/j.jvoice.2026.03.033},
url = {https://withvr.app/evidence/studies/hoff-2026}
}TY - JOUR
AU - Hoff, B.
AU - Palmer, B.
AU - Daşdöğen Ü
TI - An Exploratory Study of Meditation With and Without Immersive Virtual Reality: Effects on Anxiety and Voice-Related Outcomes
JO - Journal of Voice
PY - 2026
DO - 10.1016/j.jvoice.2026.03.033
UR - https://withvr.app/evidence/studies/hoff-2026
ER - Know of research that should be in this hub? If a relevant peer-reviewed study is not listed here, send the reference to hello@withvr.app. The hub is kept up to date as the literature grows.
Funding & independence
From the paper's own Declaration of Competing Interest: 'Bradley Hoff MA, CCC-SLP reports administrative support was provided by Icahn School of Medicine at Mount Sinai. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.' All three authors are affiliated with the Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY. The study was approved by the Icahn School of Medicine Institutional Review Board (protocol #STUDY-24-01217). The authors also disclose use of Microsoft Dragon Co-Pilot in the writing process 'to make minimal adjustments to format for readability and flow, as well as to locate, search, or confirm some references' (Declaration of Generative AI). No withVR BV involvement in funding, study design, or authorship. Summary prepared independently by withVR using the published paper.