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The modern management of chronic pain is largely focused on improving functional capacity (often despite ongoing pain) by using graded activation and exposure paradigms. However, many people with chronic pain find functional activation programs aversive, and dropout rates are high. Modern technologies such as virtual reality (VR) could provide a more enjoyable and less threatening way for people with chronic pain to engage in physical activity. Although VR has been successfully used for pain relief in acute and chronic pain settings, as well as to facilitate rehabilitation in conditions such as stroke and cerebral palsy, it is not known whether VR can also be used to improve functional outcomes in people with chronic pain.
This study aimed to assess the feasibility of conducting an adequately powered randomized controlled trial (RCT) to test the efficacy of VR in a chronic pain treatment center and assess the acceptability of an active VR treatment program for patients in this setting.
For this mixed methods pilot study, which was designed to test the feasibility and acceptability of the proposed study methods, 29 people seeking treatment for chronic pain were randomized to an active VR intervention or physiotherapy treatment as usual (TAU). The TAU group completed a 6-week waitlist before receiving standard treatment to act as a no-treatment control group. The VR intervention comprised twice-weekly immersive and embodied VR sessions using commercially available gaming software, which was selected to encourage movement. A total of 7 VR participants completed semistructured interviews to assess their perception of the intervention.
Of the 99 patients referred to physiotherapy, 53 (54%) were eligible, 29 (29%) enrolled, and 17 (17%) completed the trial, indicating that running an adequately powered RCT in this setting would not be feasible. Despite this, those in the VR group showed greater improvements in activity levels, pain intensity, and pain interference and reported greater treatment satisfaction and perceived improvement than both the waitlist and TAU groups. Relative effect sizes were larger when VR was compared with the waitlist (range small to very large) and smaller when VR was compared with TAU (range none to medium). The qualitative analysis produced the following three themes: VR is an enjoyable alternative to traditional physiotherapy, VR has functional and psychological benefits despite continued pain, and a well-designed VR setup is important.
The active VR intervention in this study was highly acceptable to participants, produced favorable effects when compared with the waitlist, and showed similar outcomes as those of TAU. These findings suggest that a confirmatory RCT is warranted; however, substantial barriers to recruitment indicate that incentivizing participation and using a different treatment setting or running a multicenter trial are needed.
Chronic pain is a leading cause of disability worldwide and represents a significant burden to individuals, societies, and health care systems [
Within the field of pain, VR has been predominantly used in acute pain settings as a nonpharmacological approach to pain relief in people undergoing painful medical procedures such as needle insertion and burn care [
The successful management of chronic pain relies on maintaining or improving physical activity, often despite ongoing pain [
In related work exploring whether VR can be used in chronic pain settings to encourage activity, 2 recent RCTs compared VR with physiotherapy treatment as usual (TAU) among people with chronic neck pain [
These studies suggest that VR can be used to encourage healthy movement using conditioning and exposure paradigms; however, to date, studies have typically focused on specific pain sites using targeted exercises [
Overall, it seems likely that commercially available, immersive, and embodied games that encourage full-body movement may be a less threatening and more enjoyable way for people with diverse pain conditions to improve their general function. However, the authors are only aware of 1 pilot study that has tested this possibility. In this study, 16 veterans with chronic pain participated in daily VR sessions using commercially available VR games over a 3-week period. The authors reported improvements in kinesiophobia, pain intensity, pain catastrophizing, and pain-specific functioning in some participants [
This mixed methods pilot study aimed to test the planned methods and approach by identifying whether it would be feasible to conduct an active VR RCT in a hospital-based chronic pain treatment center and whether active VR treatment would be considered acceptable to patients in this setting. The criteria for feasibility were as follows: (1) 30 participants recruited within a 6-month time frame; (2) ≥70% retention rate; and (3) effect sizes (ESs) for primary outcomes (pain intensity and interference) of ≥0.5, indicating that a sample of approximately 60 participants per treatment arm would be sufficient to detect an effect [
Ethics approval was granted by the Health and Disability Ethics Committee (New Zealand Ministry of Health; HDEC ref 19/CEN/106), and locality approval was granted by the Auckland District Health Board in July 2019. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619001170112; universal trial number U1111-1234-0487). Eligible patients were given a written information sheet, an informed consent form, and instructions for accessing the study website. Those interested in participating were advised to access the study website where the information sheet and consent form were replicated, and informed consent was indicated by clicking a link at the end of the web-based consent form. This action opened the baseline questionnaire, and the completion of this questionnaire enrolled participants in the study. Eligible participants who expressed interest in the clinic but did not complete the baseline questionnaire were contacted via telephone to address any questions or concerns they may have had about the study. Participants were able to complete informed consent procedures and baseline questionnaires in the clinic in a separate appointment if they preferred.
A mixed methods randomized pilot study was conducted with assessment points before and after 3 treatment arms to assess the feasibility and acceptability of a planned RCT, comparing an active VR intervention with a waitlist control and physiotherapy TAU.
The study took place at a hospital-based interdisciplinary chronic pain center, The Auckland Regional Pain Service (TARPS), Auckland District Health Board, New Zealand. Patients attending TARPS and referred to physiotherapy between October 1, 2019, and November 30, 2020, were invited to participate. Inclusion criteria were having musculoskeletal pain, being aged 18 to 70 years, and being able to communicate in English. Participants were excluded if they had a severe medical or psychiatric condition, were receiving treatment for pain elsewhere, or if their health care was being funded by the Accident Compensation Corporation (New Zealand’s accident compensation provider).
Participants completed baseline questionnaires before being randomized using a web-based random number generator to either VR or waitlist followed by TAU. All participants wore activPAL activity monitors (PAL Technologies Ltd) and completed questionnaires at the start and end of each 6-week treatment period. Participants in the VR group completed session evaluations at each appointment, and 7 attended the semistructured interviews.
Participants attended twice-weekly VR appointments for 6 weeks, supervised by a physiotherapist with 4 years of experience in using VR for chronic pain. The HTC Vive immersive VR system (HTC Corporation) was used with a head-mounted display and accompanying hand sensors. The VR software programs were run via a wall-mounted desktop display that allowed the physiotherapist to view the participant’s visual field. Games that encouraged full-body movements were selected, and participants were guided to perform physically active tasks within the virtual environment and progressed through VR games at the discretion of the treating physiotherapist (
Patients assigned to TAU completed a 6-week no-intervention waitlist to act as a no-treatment control before receiving standard physiotherapy treatment. Outcome measures were completed before and after the waitlist period.
Following the 6-week waitlist, the participants attended 6 weeks of physiotherapy treatment with 1 of 2 physiotherapists, each with >10 years of experience working in this chronic pain treatment setting. Therapy included education related to pain neuroscience, fear avoidance, and deconditioning, and participants were given home-based exercise regimens and tailored gym-based activity programs focused on graded activation and exposure therapy.
The Brief Pain Inventory (BPI) [
The Tampa Scale of Kinesiophobia-13 (TSK-13) is a measure of fear of movement, injury, and reinjury [
Daily activity and step counts were collected using activPAL activity monitors during weeks 1 and 6 of VR, waitlist, and TAU. ActivPAL monitors have been validated in samples with chronic pain [
The Patient Global Impression of Change scale [
Participants completed questionnaires at each VR treatment session to assess changes in pain intensity from the pre- to postsession time points, as well as the degree to which they found the VR session enjoyable and immersive, using 10-point Likert scales.
The qualitative component of this study was designed in accordance with the Critical Appraisal Skills Program (CASP) guidelines [
Quantitative data were analyzed using SPSS (version 27). Baseline demographics and clinical characteristics were summarized using descriptive statistics (
For qualitative data, interviews were transcribed and analyzed using reflexive thematic analysis [
Demographic and baseline clinical characteristics (N=20).
Characteristics | Total (n=20) | Treatment | |||||
VRa (n=10) | Waitlist and TAUb (n=10) | ||||||
Age (years), mean (SD) | 40.1 (16.2) | 41.3 (17.7) | 38.7 (15.3) | ||||
Sex (female), n (%) | 13 (65) | 8 (80) | 5 (50) | ||||
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New Zealand European | 12 (60) | 6 (60) | 6 (60) | |||
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Māori | 2 (10) | 1 (10) | 1 (10) | |||
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Indian | 3 (15) | 2 (20) | 1 (10) | |||
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Fijian | 1 (5) | 0 (0) | 1 (10) | |||
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Other European | 2 (10) | 1 (10) | 1 (10) | |||
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Full-time | 5 (25) | 2 (20) | 3 (30) | |||
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Part-time | 3 (15) | 2 (20) | 1 (10) | |||
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Retired | 1 (5) | 1 (10) | 0 (0) | |||
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Unemployed | 9 (45) | 3 (30) | 6 (60) | |||
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Student | 2 (10) | 2 (20) | 0 (0) | |||
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<12 months | 0 (0) | 0 (0) | 0 (0) | |||
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12-24 months | 3 (15) | 2 (20) | 1 (10) | |||
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2-5 years | 5 (25) | 1 (10) | 4 (40) | |||
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>5 years | 12 (60) | 7 (70) | 5 (50) | |||
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Neck | 2 (10) | 0 (0) | 2 (20) | |||
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Back | 8 (40) | 4 (40) | 4 (40) | |||
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Stomach | 2 (10) | 1 (10) | 1 (10) | |||
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Chest | 1 (5) | 1 (10) | 0 (0) | |||
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Hips | 1 (5) | 1 (10) | 0 (0) | |||
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Pelvis or groin | 1 (5) | 1 (10) | 0 (0) | |||
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Knee | 3 (15) | 1 (10) | 2 (20) | |||
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Leg | 1 (5) | 1 (10) | 0 (0) | |||
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Foot | 1 (5) | 0 (0) | 1 (10) | |||
BPIc intensity, mean (SD) | 8.3 (1.5) | 8.4 (1.8) | 8.1 (1.2) | ||||
BPI interference, mean (SD) | 7.3 (1.6) | 7.5 (1.7) | 7.1 (1.5) | ||||
TSK-13d, mean (SD) | 33.5 (5.4) | 32.3 (5.4) | 34.6 (5.4) |
aVR: virtual reality.
bTAU: treatment as usual.
cBPI: Brief Pain Inventory.
dTSK-13: Tampa Scale of Kinesiophobia-13.
Between October 1, 2019, and November 30, 2020, a total of 99 non–Accident Compensation Corporation patients were assessed at TARPS and referred to physiotherapy. Of these 99 patients, 53 (54%) met the inclusion criteria, and 29 (29%) were enrolled in the study. Of the 29 patients, 13 withdrew (n=5 from the VR group, and n = 4 from each of the waitlist and TAU groups), resulting in a final sample of 20 participants, of whom 10 were in the VR group, 10 in the waitlist group, and 6 in the TAU group. The recruitment rate of 2 participants per month, as well as the dropout rate of 45%, indicated that it would not be feasible to recruit approximately 60 participants per trial arm in this clinical setting.
All participants in the VR arm completed ≥7 appointments, and 30% (3/10) completed 12 appointments. There were no adverse events or increases in pain specific to the VR intervention. Immersion scores ranged from 8.4 to 9.6, and enjoyment scores ranged from 8.0 to 9.9, thereby meeting the acceptability criteria.
There were medium ESs favoring VR over the waitlist for a reduction in BPI pain intensity (ES=0.52) and BPI pain interference (ES=0.50). This suggests that for an α of .05, and a power of 0.80, a sample of 60 and 64 per group would be sufficient to detect significant effects for pain intensity and interference, respectively (
Mean change scores and relative effect sizes for pain-relevant outcomes, perceived improvement, and satisfaction with treatment.
Outcomes | Waitlist (n=10) | TAUa (n=6) | VRb (n=10) | VR versus waitlist, effect size (95% CI) | VR versus TAU, effect size (95% CI) | |||
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Participants, n (%)c | Values, mean (SD) | Participants, n (%)c | Values, mean (SD) | Participants, n (%)c | Values, mean (SD) |
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ΔBPId intensity | 10 (100) | –0.30 (1.57) | 6 (100) | –0.17 (2.32) | 9 (90) | –1.00 (0.87) | –0.52 (–1.39 to 0.67) | –0.49 (–1.47 to 0.51) |
ΔBPI interference | 10 (100) | –1.10 (2.13) | 6 (100) | –1.00 (1.39) | 9 (90) | –2.06 (1.46) | –0.50 (–1.37 to 0.39) | –0.70 (–1.70 to 0.32) |
ΔTSK-13e | 10 (100) | –2.90 (5.17) | 6 (100) | –4.00 (4.56) | 9 (90) | –1.56 (5.57) | 0.24 (–0.63 to 1.10) | 0.44 (–0.55 to 1.42) |
Change in daily steps | 7 (70) | 212 (2394) | 6 (100) | 1127 (2784) | 8 (80) | 852 (2934) | 0.22 (–0.74 to 1.18) | –0.09 (–1.08 to 0.90) |
Change in daily activity (minutes) | 7 (70) | 2.15 (59.03) | 6 (100) | –21.05 (91.49) | 8 (80) | 19.45 (64.50) | 0.26 (–0.70 to 1.22) | 0.49 (–0.52 to 1.49) |
Satisfaction (score: range 1-7) | 9 (90) | 4.78 (1.20) | 6 (100) | 5.83 (0.98) | 9 (90) | 6.11 (0.93) | 1.18 (0.20 to 2.14) | 0.28 (–0.71 to 1.25) |
Improvement (score: range 1-7) | 9 (90) | 4.78 (0.83) | 6 (100) | 5.67 (1.03) | 9 (90) | 5.89 (0.78) | 1.31 (0.31 to 2.28) | 0.24 (–0.75 to 1.21) |
aTAU: treatment as usual.
bVR: virtual reality.
cNumber of valid participants with complete data.
dBPI: Brief Pain Inventory.
eTSK-13: Tampa Scale of Kinesiophobia-13.
Small ESs favored the waitlist over VR (ES=0.24) and TAU over VR (ES=0.44). None of the groups met the criteria for MCID in kinesiophobia change scores (≥18% reduction;
There were small ESs favoring VR over the waitlist for both step count (ES=0.22) and activity scores (ES=0.26). Both VR and TAU met the criteria for an MCID in daily step counts (≥600-1100 step increase;
There were very large ESs favoring VR over the waitlist for treatment satisfaction (ES=1.18) and perceived improvement (ES=1.31) and small ESs favoring VR over TAU for treatment satisfaction (ES=0.28) and perceived improvement (ES=0.24;
Analysis of the transcribed interviews generated three themes: (1) VR is an enjoyable alternative to traditional physiotherapy, (2) VR leads to functional and psychological benefits despite continued pain, and (3) the importance of a well-designed VR setup.
Participants were enthusiastic about trying VR rehabilitation and had positive expectations of treatment; for example, one of the participants said the following:
I had really high hopes...I thought it might actually take my pain away
Participants also described VR as more enjoyable, accessible, and achievable than their previous experiences of physiotherapy and described VR as
It’s a really good way to incorporate fun activity into your life on a regular basis. And for someone who struggles to find the mental and physical energy to do anything like that, it’s a really good pull to get you up.
Participants also described VR as improving activity levels by distracting them from pain. Several participants described VR as
By doing a movement and not having that immediate thought that it’s going to hurt, it’s already training my brain so that it doesn’t go—nope you’re not doing that!—and then sending pain signals everywhere.
Despite the perceived benefits, some participants expressed uncertainty about whether VR could be considered a legitimate treatment. They explained that the enjoyable nature of VR was inconsistent with their expectations of physiotherapy:
With VR you don’t really feel like it’s treatment...you have an expectation that when you go to [physical therapy] they give you exercises or manual treatment so when you leave it feels like you’ve done something. But when you’re doing VR, I don’t feel like I’ve necessarily achieved any treatment.
Overall, the participants had positive expectations about VR, the rationale for VR treatment was clear to them, and they found VR to be highly agreeable. For some participants, the enjoyable nature of VR meant that it did not feel like a legitimate treatment approach.
Participants said that they experienced pain relief during the VR sessions; however, this was not sustained after treatment. Despite ongoing pain, participants reported an overall increase in daily physical activity, improved strength, reduced stiffness, improvements in sitting and standing tolerances, and greater confidence in engaging in activities of daily living. Participants said that VR changed their perspectives of activity from something unpleasant and difficult to something that could be enjoyable:
It helped me understand that I can move and do more activity. I can go for a walk outside and enjoy it and not have to focus on being in pain all the time. So, I think it just made me realise that that was actually an option.
The participants also felt that the VR sessions improved their moods. They described feeling happier and more content following the sessions and explained that VR provided relief from daily stressors and an opportunity to do something enjoyable:
Mentality wise, it made a big difference. I looked forward to coming to the VR sessions. I’d be like—yeah, I’ve got this pain but at least something’s happening, and I have fun when I’m there.
Overall, participants described the intervention as having a positive impact on their mood and function and reported increased confidence in participating in physical activities despite continued pain.
Most participants found the VR equipment easy to use and the games straightforward to understand and play. The exceptions were those whose first language was not English and who described difficulties in understanding game instructions. Participants emphasized the importance of a comfortable and adjustable headset, and the physical space was considered important, with all participants feeling constrained by the size of the room. There were a range of opinions regarding the importance of having a trained physiotherapist deliver the VR; however, all participants highlighted the importance of being supervised by someone with whom they could form a therapeutic alliance:
I think it makes you feel better that it’s a trained physiotherapist. You knew they had that background and it just fills you with confidence a bit more.
Overall, this theme demonstrates the importance of investing in a good-quality VR setup that participants can use easily and comfortably in a safe and supervised environment and the value of developing a strong therapeutic relationship.
This mixed methods pilot study assessed the acceptability and feasibility of a VR RCT in a hospital-based chronic pain treatment center. The findings indicated that the VR intervention was highly acceptable to patients, with session rating scores, treatment satisfaction, and perceived improvement all surpassing the a priori acceptability criteria. Those in the VR treatment showed improvements in pain intensity, pain interference, step counts, and activity scores, with preliminary findings suggesting that VR may be superior to no treatment and equivalent to TAU. Qualitative data supported the quantitative findings and indicated that participants enjoyed the VR treatment and found it beneficial.
Despite the benefits, poor recruitment and high dropout rates suggest that it would not be feasible to conduct an adequately powered RCT in this setting. ESs for primary outcomes in this study indicate that a reasonable sample size of approximately 60 per group (power=0.80) would be adequate to detect effects. These ESs are consistent with recommended ESs for motor interventions [
Most prior studies exploring the role of VR in chronic pain have focused on specifically designed health applications [
When considering game design and selection, commercially available games were used for this pilot study because of their benefits in terms of access, convenience, and cost. Using commercially available games in chronic pain rehabilitation also makes theoretical sense, as when pain is attributed to nociplastic mechanisms, the key interventional targets are general physical activity, stress reduction, and pain self-management [
This study had several limitations. Primarily, comparing active VR with a no-treatment control and physiotherapy TAU allowed for comparisons between active VR and standard physiotherapy-led activity programs but did not provide insight into the most salient elements of VR or gaming interventions. Future work administering an active non-VR control, such as computer-based games using similar movements but without a head-mounted display, or comparing active VR with passive VR treatments that facilitate downregulation of autonomic arousal, would help to clarify the unique benefits specific to immersive, embodied, and active VR protocols over and above other VR and gaming platforms. Furthermore, this study deviates from a standard 3-arm trial design as, for practical purposes (given the small pool of participants), a single group covered 2 intervention arms (waitlist and TAU). Future work would benefit from recruiting separate groups of participants for the TAU and no-treatment arms. In addition, it is likely that patients interested in VR would have self-selected for the trial and potentially overreported the perceived benefits. Another limitation is that session rating scales were not collected in the TAU arm, meaning that between-group comparisons for session enjoyment and changes in pain scores immediately after treatment could not be made and that VR and TAU were delivered at different doses, with VR offered twice weekly and TAU delivered once weekly; thus, it is not known whether VR delivered at the same dose of TAU would have produced the benefits seen here. Finally, end users were not consulted in the study design phase, and future RCTs would benefit from engaging in a co-design process.
Despite these limitations, this mixed methods pilot study indicates that active VR is an acceptable treatment for patients attending a tertiary-level chronic pain treatment center. Qualitative data suggest that participants enjoyed the VR treatment, found it beneficial, and believed that it was an acceptable component of chronic pain rehabilitation. Although outcomes for VR in this pilot study were superior to no treatment, and appeared to be at least equivalent to standard physiotherapy, these findings should only be interpreted as a basis for designing future adequately powered clinical trials. In particular, the finding that the ESs comparing VR with standard treatment were generally small suggests that there may not be clinically meaningful differences between these groups in a larger trial. Despite this, an adequately powered RCT appears justified as, if equivalence is found, then VR may be a useful adjunct or alternative to standard treatment for some people with chronic pain. Although a future RCT is warranted, low recruitment and poor retention rates indicate that this would not be feasible in the present setting. Future RCTs would benefit from incentivizing study participation and actively reducing dropout rates while considering a broader range of outcome measures to identify likely mechanisms. VR technology is increasingly affordable and accessible and may improve chronic pain outcomes by encouraging participation in activities in a novel and enjoyable way. Adequately powered RCTs with long-term follow-ups examining the recommended pain-relevant outcomes and potential mechanisms of action are warranted.
Virtual reality software programs graded from levels 1 to 6.
Brief Pain Inventory
Critical Appraisal Skills Program
effect size
minimal clinically important difference
randomized controlled trial
The Auckland Regional Pain Service
treatment as usual
Tampa Scale of Kinesiophobia-13
virtual reality
Internal Auckland University of Technology research funding was used to purchase activPAL devices. No other funding sources were used for this study.
NT was involved in the conceptualization, methodology, formal analysis, project administration, and supervision of the study and in the writing of the original draft and review and editing of the manuscript. CP was involved in the methodology, formal analysis, and investigation of the study and in the writing of the original draft. CG was involved in the methodology and investigation of the study and in the review and editing of the manuscript. CW was involved in the formal analysis, investigation, and data curation of the study and in the writing of the original draft. GL was involved in the conceptualization, methodology, and supervision of the study and in the review and editing of the manuscript. MH was involved in the conceptualization and supervision of the study and in the review and editing of the manuscript. TA was involved in the conceptualization and supervision of the study and in the review and editing of the manuscript. DB was involved in the conceptualization, methodology, project administration, supervision, and funding acquisition of the study and in the review and editing of the manuscript.
None declared.