Effects of virtual reality on pain,disability and kinesiophobia in patients with chronic low back pain: A systematic review with meta-analysis

Abstract

BACKGROUND:

Chronic low back pain (CLBP) significantly impairs function and productivity, emphasizing the need for effective solutions, with virtual reality (VR) emerging as a novel alternative for management.

OBJECTIVE:

The aim of this systematic review and meta-analysis was to examine the effects of VR interventions on pain, disability and kinesiophobia, compared with other therapeutic interventions in CLBP patients.

METHODS:

In July 2023, we searched PubMed and PEDro databases for studies that examined the effects of VR interventions on pain, disability or kinesiophobia in adults with CLBP. Using a meta-analysis with a random-effects model, we derived the standardized mean difference as the pooled effect.

RESULTS:

We found 33 studies, 22 of which were eligible for meta-analysis. Most studies were of good quality, with 12/22 reaching a score between 6 and 8 points on the PEDro scale. VR demonstrated superior results compared to placebo (SMD = –1.90; 95% CI = –3.60 to –0.20; p = 0.03), no intervention (SMD = –1.66; 95% CI = –2.49 to –0.83; p < 0.001), exercise (SMD = –0.61; 95% CI = –1.06 to –0.16; p = 0.008), and VR combined with physical therapy showed greater efficacy than exercise combined with physical therapy (SMD = –1.42; 95% CI = –2.33 to –0.52; p = 0.002) in pain intensity outcome. However, no significant differences were found for disability outcome.

CONCLUSION:

VR interventions are superior to non-VR interventions in terms of improving pain intensity in CLBP patients, but not also for disability outcomes. Further research is needed for conclusive insights into VR’s efficacy.

Keywords

Low back pain persistent pain virtual reality video games chronic pain

1 Introduction

Low back pain (LBP) is one of the most common reasons for which patients seek medical attention [1] and is defined as chronic when lasting longer than three months or exceeds the expected duration of tissue healing [2]. In most cases, it is not possible to identify the specific nociceptive cause of CLBP, which is why it is classified as nonspecific [4]. The economic impact of CLBP results from the gradual loss of function that leads to decreased work productivity, treatment costs, and disability payments [5]. Given this high burden of care, it is important to develop effective treatment options for patients with CLBP. There are numerous conservative treatment options for the management of CLBP, including: cognitive behavioural therapy, patient education, McKenzie exercises, yoga, aerobic exercise, manual therapy, and analgesic drugs [6, 7]. However, because of the multifactorial aetiology of CLBP, treatment of this condition is difficult, and many interventions have limited efficacy [8]. In addition to these non-surgical options, virtual reality (VR) is a new alternative for the management of CLBP [7].

VR technology allows the user to feel a sense of presence in a computer-generated three-dimensional virtual world in such a way that the user feels as if he is a part of that world [9 –11]. The simulated environments created by VR can give a varying illusion of presence and realism. The more real the virtual environment appears to the user, the greater the so-called immersive experience. The immersive experience is proportional to the number of stimulated physiological senses, the extent of interaction with the virtual environment and the isolation from external stimuli (e.g., light) [12]. In healthcare, VR has been shown as an effective treatment option for managing acute pain, while the body of research for chronic pain is still in the early stages [13]. For chronic patients, VR technology can be used both for cognitive rehabilitation, providing a medium for transferring the principles of cognitive behavioral therapy or pain neuroscience education [62], and for physical rehabilitation, where the patient performs exercises in a virtual environment [63]. Patients can benefit from VR technology, due to its distraction mechanism which is leaving less cognitive capacity available to process pain signals [14]. Furthermore, with involving patients in their recovery in a fun, attractive, and interactive way, VR contributes to motivation and adherence in the rehabilitation process [15 –17].

In the field of CLBP, previous systematic reviews showed promising results for the use of VR technology in CLBP rehabilitation. Brea-Gómez et al. [6] found that VR interventions can significantly reduce pain intensity and kinesiophobia (i.e., excessive and irrational fear of physical activity, caused by fear of re-injury) in patients with CLBP in the short and long term compared to no VR interventions. However, they found no significant differences in disability outcome [6]. A more recent systematic review of randomized and quasirandomized controlled trials conducted by Choi et al. [60] focused only on pain outcomes and found that VR-based interventions had moderate to strong evidence for pain reduction compared with conventional interventions. However, research on VR in CLBP is growing rapidly, and recent reviews have not included the latest research or did not analyse the effects of VR on a broader range of outcomes such as disability and kinesiophobia. Therefore, the novelty of our systematic review with meta-analysis lies in its inclusion of the latest studies and its comprehensive analysis of VR effects on pain, disability, and kinesiophobia. In accordance with previous studies, we hypothesised that VR would show a positive effect on pain intensity and kinesiophobia compared with other interventions, while we anticipated no significant differences in disability outcomes. This review aims to build upon previous papers by providing a current and extensive evaluation of VR’s efficacy, thereby contributing to the body of evidence supporting its use in CLBP management.

2 Methods

2.1 Search strategy and inclusion criteria

The literature search was performed in July 2023. Three authors independently performed all search steps, and any disagreements were resolved by discussion, with D.M.I. (supervising researcher) having the final say. We searched the PubMed and PEDro databases. For PubMed, we used the following search strategy: (“virtual reality” OR “video games” OR “wii” OR “horse simulator”) AND (“back pain” OR “lumbar pain”). For PEDro, individual combinations of words, such as “virtual reality back pain”, “video games back pain”, “horse simulator back pain” and “wii back pain” were used. In addition, we reviewed the reference lists of identified systematic reviews on the topic and performed an additional non-systematic search of the GoogleScholar database. The records were imported into Mendeley (version 1.19.8) to remove the duplicates, and then exported into Microsoft Excel software for further examination.

The inclusion criteria, structured according to the PICOS tool [18], were determined as follows.

P (population): Adults (≥18 years) with CLBP, which was considered as LBP with pain duration >12 weeks.

I (Intervention): Exercise or physical therapy (PT) intervention using VR technology (duration of intervention≥four weeks).

C (Comparison): Conventional exercise, PT, placebo VR or no intervention.

O (Outcome): Outcomes describing pain (Visual Analogue Scale (VAS), Numeric Rating Scale (NRS), The Defence and Veterans Pain Rating Scale (DVPRS), McGill Pain Questionnaire), disability (Owestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ)) or kinesiophobia (Tampa Scale for Kinesiphobia (TSK)).

S (Study design): Any kind of interventional clinical trials, published in English language, with at least two groups (VR and control groups) were included in the meta-analysis. Single-group clinical studies were included in the narrative synthesis only. Clinical studies were considered regardless of the year of publication.

2.2 Data extraction

The data extraction was carried out independently by all authors and disagreements were resolved through additional discussion. The extracted data included: (a) baseline, post-intervention and follow-up data (means and standard deviations (SD)) for all eligible outcome measures for both VR and control groups (percent changes were considered instead of pre-post data when available) (b) baseline demographics of patients (gender, age, body height, body mass, body mass index); (c) intervention characteristics (VR intervention description, duration of the intervention, weekly frequency, volume (number of exercises, sets, and repetitions), breaks, and supervision). Data were collected into Microsoft Excel 2016 (Microsoft, Redmond, WA, USA). If the data were presented in a graphical form, we used GetGraphDataDigitalizer software (version 2.26.0.20) to obtain the means and SD. In case of missing data, the authors of the articles were contacted via e-mail and/or ResearchGate. A reminder was sent after 14 days, and if no reply was received after the second inquiry, the data was considered irretrievable.

2.3 Assessment of the quality of the included studies

All authors evaluated the quality of the studies included in the meta-analysis using the PEDro scale which assesses study quality based on ten items [19] and potential disagreements were resolved by discussion. Studies scoring from 9 to 10 were considered as “excellent,” 6 to 8 as “good,” 4 to 5 as “fair,” and <4 as “poor” quality. The PEDro scale was selected as it was specifically developed to evaluate the quality of clinical trial studies investigating PT interventions [20].

2.4 Data analysis

The meta-analysis was carried out in Review Manager (Version 5.3, Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, London, UK). Since there is still no consensus on the minimal number of studies required for a meta-analysis [21], we performed the analyses when two or more studies could be included. Before the results were entered into the meta-analytical model, the pre-post differences and pooled SD were calculated according to the following formula $SD = [{SD}_{pre}^{2} + {SD}_{post}^{2}] - (2 \times r \times {SD}_{pre} \times {SD}_{post})$ . The correction value (r), which represents the pre-test– post-test correlation of outcome measures, was conservatively set at 0.75. We used continuous outcomes meta-analysis with a random-effects model and inverse variance method to obtained the pooled effects. The effect sizes were expressed as standardized mean difference (SMD). Statistical heterogeneity among studies was determined with the I² statistics. According to Cochrane guidelines, the I² statistics of 0% to 30% might not be important, 30% to 60% may represent moderate heterogeneity, 50% to 90% may represent substantial heterogeneity, and 75% to 100% indicates considerable heterogeneity. The threshold for statistical significance was set at p≤0.05 for the pooled effect size.

3 Results

3.1 General overview of the search results

We found 33 studies that were included in the review, 22 of which were eligible for the meta-analysis. The detailed summary of the search process is shown in PRISMA flow diagram in Fig. 1. Due to the lack of studies that observed changes in kinesiophobia that had comparable study design (i.e., the same intervention or combination of interventions in experimental and control groups) meta-analyses were performed only for disability and pain intensity outcomes. However, the effects of VR interventions on kinesiophobia were included in the narrative review.

Fig. 1

Overview of article search and study selection.

3.1.1 Patient demographics

Both men and women participated in most studies included in our review. However, eight studies [22 –29] included male patients only, while four studies [30 –33] included exclusively female patients. Two studies [34, 35] did not specify the gender of the patients, and for one [36] only abstract was available in which gender was also not mentioned. Although all studies examined adult patients, some included younger adults (under 30 years of age) [22–27 , 34] and some older adults (older than 60 years) [30–32 , 37]. Due to unavailability of the full text, the age range of patients in the study by MacIntyre et al. [36] is considered to be unknown.

3.1.2 Interventions

The duration of interventions in the studies ranged from four to 18 weeks and the weekly frequency of sessions from two to seven. In most studies, patients were included in a non-immersive VR training intervention. VR has been used in various forms: Nintendo programs and consoles [30 , 39], horse simulator riding [27 , 40], VR programs with VR glasses [28 , 41–44], other systems similar to VR, but without video games, based on biofeedback [45] and other types of video games with sensors and a monitor [22 , 46–49]. When the intervention was carried out on a horse simulator, participants sat on an indoor riding machine, that simulated riding a real horse and looked at a screen displaying the visual information of riding a real horse. In studies where exercises were performed with a VR, the VR game was usually controlled by moving the trunk in all possible movements. When VR involved cognitive behavioural therapy, pain neuroscience education or biopsychosocial education was delivered through VR glasses or a monitor. In experimental groups, VR was either a sole intervention or combined with standard PT or exercise interventions. Standard PT included a combination of some of the following methods: hot pack therapy, therapeutic ultrasound, interferential electrotherapy, exercise program, manual therapy and pain neuroscience education. In studies where VR was compared to placebo VR, placebo meant either a non-immersive 2D VR or, if the experimental intervention was training on the horse simulator, placebo meant that the participants sat on the horse and just watched the video without training. In all studies, patients had to report the presence of LBP for at least 12 weeks. However, to provide a comprehensive review, we also included studies in which the duration of LBP was described as chronic only [30 , 46]. The details of each study are shown in Table 1.

Table 1
Characteristics of included studies

Author (year) Participants Interventions Relevant results/conclusions

Sample size Age (years) mean±SD Duration of pain (months) mean±SD

Garcia, Birckhead, Krishnamurthy, Mackey, Sackman, Salmasi, Louis, Castro, et al. (2022) / Garcia, Birckhead, Krishnamurthy, Mackey, Sackman, Salmasi, Louis, Maddox, et al. (2022) / Garcia et al. (2021) / Maddox et al. (2022) / Maddox et al. (2023) n = 179EG = 89CG = 90 EG = 51.5±13.5CG = 51.4±12.9 At least six months EG: Home-based immersive VR programImmersive, multimodal, skills-based, pain self-management VR program Ease VRx (AppliedVR), that incorporated evidence-based principles of cognitive behavioral therapy, mindfulness and pain-neuroscience education. Program combined biopsychosocial education, diaphragmatic breathing training, relaxation response exercises that activate the parasympathetic nervous system, and executive functioning games.CG: Home-based sham VRNon-immersive 2D content (nature footage with neutral music) delivered in a VR headset.Program duration and frequency8 weeks (1 session / day for 6 min on average) Average pain intensity significantly decreased over time for both treatment groups. The decrease was greater for EG versus CG. Pain intensity reduced by an average of 42.8% for the EG and 25.1% for the CG. Sustained reductions for pain intensity were observed three and six months after immersive VR program, that were superior to Sham VR program. At 18- and 24-months post-treatment, the average pain reduction for EG was still significantly larger than that for CG.

Nambi, Abdelbasset, Alrawaili, et al. (2021) n = 60EG = 20CG₁ = 20 CG₂ = 20 EG = 23.2±1.5CG₁ = 22.8±1.6CG₂ = 23.3±1.5 EG = 5.8±0.8CG₁ = 5.2±0.7CG₂ = 5.4±0.9 EG: Non-immersive VR training + PTExercises in sitting position with VR device which focused on the balance of stability of the core muscles. The game was executed and controlled by moving the trunk back and forth and left and right according to the signs. Patients performed all possible spinal movements within their pain limits. One session of VR program lasted for 30 min. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min.CG₁: Isokinetic training + PTThe trunk was trained from 10° of extension to 80° of flexion and 0° was considered neutral. Patients were allowed to perform the exercise at an angular speed of 60°/second, 90°/second, and 120°/second with 15 repetitions of three sets. Between each set 30 seconds rest and between each pace 60 seconds rest was given. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₂: Conventional training + PTConventional training of the core muscles of the trunk. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (5 days / week) Training through VR and isokinetic training is a more effective strategy than a conventional exercise program in terms of improving pain and kinesiophobia.

Nambi et al. (2022) n = 58 EG = 19CG₁ = 19CG₂ = 20 EG = 23.2±1.6 CG₁ = 22.9±1.7CG₂ = 22.8±1.8 EG = 4.8±1.1CG₁ = 5.2±0.9CG₂ = 5.5±0.8 EG: Non-immersive VR training + PTExercises for strengthening trunk muscles while using VR device. The exercises were performed in the upright position. Patient was asked to sit on the moving game chair and instructed to watch the game on the desktop monitor. Joystick actions were performed by changing the trunk positions, such as moving backwards, forward, to the left or right, based on the position of the target on the display screen. During the training, patients were permitted to move their trunk in all directions within their pain-free limit. One session of VR program lasted for 30 min. PT consisted of hydro collateral packs for 20 min and ultrasound for 5 min. CG₁: Isokinetic training + PTThe trunk flexor and extensor muscles were trained from 10–15° of extension to 70–80° of flexion and 0° was considered neutral. Patients were instructed to do these movements at an angular velocity of 45, 60, and 90°/s with ten repetitions of three sets. Thirty seconds rest was given between each set, and sixty seconds rest was given between each pace. PT consisted of hydro collateral packs for 20 min and ultrasound for 5 min. CG₂: Conventional training + PTRoutine balance exercises to train the lower trunk muscles (abdominal, deep abdominal, and back muscles). PT consisted of hydro collateral packs for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (five days / week) After four weeks of different exercise protocols, there was a significant improvement in pain intensity level when comparing the VR training vs. isokinetic training program and VR vs. conventional groups. Virtual reality and isokinetic training had equal effects on reducing pain intensity.

Stamm et al. (2022) n = 22 EG = 11 CG = 11 EG = 75±5.8CG = 75.5±4.39 EG = 15.8±18.67CG = 26.4±16.57 (In years) EG: Immersive VRVR (ViRST application) consisted of movement therapy and psychoeducation. The training session, consisting of 12 exercises, was structured as follows: (1) warm up (training of the upper and lower extremities with “marching and rowing” exercises); (2) main part (strengthening of the abdominal and back muscles, core stability); (3) cool down (stretching, progressive muscle relaxation exercise); (4) psycho-educative units (topics: physiology of pain, pain management, stress management, everyday training). CG: Conventional multimodal pain therapyMovement therapy (seated exercises) and psychoeducation in a group setting. The intervention phase in the CG differed from EG mainly in the use of VR technology. Program duration and frequency4 weeks (30 min per session, three sessions / week) Although the VR therapy did not reach the pain intensity reduction of the CG, the results of the present study showed that a pain intensity reduction can be reached with the current VR exergame prototype, albeit not significantly. In terms of fear-avoidance behaviour, both groups showed a reduction compared to the data before the four-week intervention, however, without significance.

Nambi et al. (2020) n = 45 EG = 15 CG₁ = 15 CG₂ = 15 EG = 21.25±1.2 CG₁ = 20.23±1.6CG₂ = 20.78±1.6 EG = 4.1±0.5 CG₁ = 4.1±0.6 CG₂ = 4.3±0.4 EG: Non-immersive VR + PTEG received VR training with focusing on the balance of core stability muscles. Training was given in the sitting position. The game was shooting game, which consists of the subject sitting on the virtual platform and visualizing the game in the display screen. The game is executed and controlled by moving the trunk back and forth and left and right according to the signs. Patients performed all the six movements of their spine within their pain limits. One session of VR program lasted for 30 min. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₁: Isokinetic training + PTBefore isokinetic training, the subjects were asked to perform five-minute warm-up followed by slow stretching of back extensors and flexors. Subjects were allowed to perform the exercise at an angular speed of 60°/second, 90°/second, and 120°/ second with 15 repetitions of three sets. Rest between each set of 30 seconds and between each pace of 60 seconds has been given. The trunk was tested from –10° of extension to 80° of flexion and 0° was considered neutral. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₂: Conventional training + PTConventional balance training for core muscles: active isotonic and isometric exercise for abdominal muscles, deep abdominal muscles, and back muscles. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (5 days / week) After intervention, VR program led to more reduction in pain than isokinetic training and conventional training.

Nambi, Abdelbasset, Alsubaie, et al. (2021) n = 54 EG = 18 CG₁ = 18 CG₂ = 18 EG = 22.3±1.6 CG₁ = 21.4±1.8 CG₂ = 21.9±1.8 EG = 5.4±0.2 CG₁ = 5.3±0.6 CG₂ = 5.5±0.4 EG: Non-immersive VR training + PTVR balance training, focusing on the balance of core stability muscles. Training was given in the sitting position. The game used in the current study was a shooting game, which consists of the subject sitting on the virtual platform and visualizing the game on the computer display screen. The game was executed and controlled by moving the trunk back and forth and left and right according to the signs. Patients performed all the movements of their spine within their pain limits. One session of VR program lasted for 30 min. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₁: Combined physical rehabilitation + PTPatients received balance training through a Swiss ball for core muscles. The exercises performed were wall squat, Russian twist, leg lift, plank saw, cobra, and hip raise on the Swiss ball (15 times per set for three sets). Patients were asked to maintain each position for 10 seconds, with a 3-second break between the repetitions. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₂: Conventional training + PTConventional balance training for core muscles: active isotonic and isometric exercisea for abdominal muscles, deep abdominal muscles, and back muscles. They performed these exercises ten to 15 repetitions per day. Stretching was focused on each muscle group for three repetitions for 10 seconds per muscle group (hamstring, hip flexors, and lumbar extensors). PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (5 days / week) The results showed a greater percentage of improvement in pain intensity and kinesiophobia level in the VR training group than in the combined physical rehabilitation or conventional training groups.

Eccleston et al. (2022) n = 42 EG = 14 CG₁ = 17 CG₂ = 11 EG = 55.14±10.53 CG₁ = 52.76±11.19 CG₂ = 57.09±8.34 At least three months EG: Immersive VR trainingThe intervention was guided by an “embodied” model of the psychology of pain aimed to reduce fear of movement and reinjury by creating a safe virtual environment to encourage exploration and repeated movement. The virtual mentor invited the patient to the outside space where they engaged in a gamified “fruit-picking” activity. Fruits from trees appeared in all four quadrants of their peripersonal space. The activities were designed to promote fine and gross motor movements typically avoided by low back pain patients fearful of movement and reinjury. Patients were encouraged to move within their peripersonal space, owning and being agents within that space, and engaging in a full range of motion physical activities, repeatedly. Education on avoidance behavior was delivered. Techniques offered to promote problem solving, reflection on change, and increased self-efficacy for change were presented. CG₁: Immersive sham VRThe virtual environment showed a similar seashore environment to the DTxP program. None of the content provided in the DTxP was presented. Instead, the patients viewed text that instructed them to relax and enjoy the environment as used in the DTxP. CG₂: Standard careNo intervention, instructions, or education. Just standard care as usual. Program duration and frequency6–8 weeks (5 sessions / week) Patients in the EG reported greater reductions in fear of movement when compared with sham placebo and standard care post treatment. When compared with baseline, patients in the EG reported lower disability at 5-month follow-up, lower fear of movement post treatment and follow-up, and lower pain intensity at posttreatment. The sham placebo group also reported lower disability and fear of movement at 5-month follow-up compared with baseline. Standard care did not report any significant changes.

Park et al. (2013) n = 24 EG = 8 CG₁ = 8 CG₂ = 8 EG = 44.12±5.48 CG₁ = 43.37±5.42 CG₂ = 45.5±5.34 Over three months EG: Nintendo Wii exercises + PTThe Nintendo Wii sports program was used for the Nintendo Wii exercise program, including the wakeboard, Frisbee dog, jet ski, and canoe games. Patients controlled a virtual character on the screen by swinging, rowing, and tilting remote controllers with motion sensors. One session of Wii program lasted for 30 min. PT (50 min / session) consisted of: hot pack, interferential therapy, ultrasound. CG₁: Lumbar stabilization exercise + PTStabilization exercises (30 min / session) included seven positions based on the back bridge, hands and knees, and side bridge. Patients maintained each position for 15 seconds for three sets. PT (50 min / session) consisted of: hot pack, interferential therapy, ultrasound. CG₂: PTPT (50 min / session) consisted of: hot pack, interferential therapy, ultrasound. Program duration and frequency8 weeks (3 sessions / week) Pain decreased significantly in EG and lumbar stabilization exercise group, but not in PT only group.

Oh et al. (2014) n = 37EG₁ = 9EG₂ = 9EG₃ = 10CG = 9 EG₁ = 20.44±0.27EG₂ = 20.33±0.52EG₃ = 20.56±0.69CG = 20.7±0.37 EG₁ = 6.75±2.01EG₂ =7.57±1.06EG₃ =6.21±2.11CG =6.38±2.14 EG1: Horse simulator (30 min) Horse simulator riding VR system: Horse simulator machine (HJL Co. Ltd., Korea). VR program: warmup (stretching 5 min + ordinary walking on the horse simulator 5 min) + work-out (sitting trotting and rising trotting 30 min) + cool-down (supine stretching 10 min). Time using videogame: 35 min. EG2: Horse simulator (20 min)Horse simulator riding VR system: Horse simulator machine (HJL Co. Ltd., Korea). VR program: warmup (stretching 5 min + ordinary walking on the horse simulator 5 min) + work-out (sitting trotting and rising trotting 20 min) + cool-down (supine stretching 10 min). Time using videogame: 25 min. EG3: Horse simulator (10 min)Horse simulator riding (10 min) VR system: Horse simulator machine (HJL Co. Ltd., Korea). VR program: warmup (stretching 5 min + ordinary walking on the horse simulator 5 min) + work-out (sitting trotting and rising trotting 10 min) + cool-down (supine stretching 10 min). Time using videogame: 15 min. CG: No intervention Program duration and frequency8 weeks (5 days / week) Patients back pain reduced after an 8-week program of riding a horse simulator. Especially, 20 min horseback riding in the simulator was associated with the best results.

Yoo et al. (2014) n = 47 EG = 24CG = 23 EG = 20.44±1.33CG = 20.7±1.45 EG = 9.41±3.64CG = 8.35±2.62 EG: Horse riding simulatorHorse simulator riding VR system: Horse simulator machine (HJL Co. Ltd., Korea). VR program: warmup (stretching 10 min) + work-out + cool-down (stretching 10 min). Workout consisted of: ordinary walking and sitting trotting (week 1), increase riding time and riding trotting (weeks 2–3), increase riding time and intensity (weeks 4–5), and increase riding time and intensity (weeks 6–8). Time using videogame: 10 min (week 1), 20 min (weeks 2–3), 30 min (weeks 4–5) and 40 min (weeks 6–8). CG: No intervention Program duration and frequency8 weeks (3 days / week) Horse simulator exercises significantly reduced pain intensity scores after intervention. The reduced levels observed in EG were significantly higher than those in CG.

Monteiro-Junior et al. (2015) n = 30 EG = 16CG = 14 EG + CG = 68±4 Chronic pain EG: Wii based exercises + strength exercises and core trainingCore exercises and strength training + eight Wii Fit Plus workouts. VR system: Nintendo Wii Motion and Wii Balance Board Games (chair, tightrope walk, ski slalom, balance bubble, table tilt, sideways, rowing squat, lunge). Verbal stimulus was allowed, and rest periods (1–2 min) were administered. Time using videogame: 30 min. CG: Strength exercises and core trainingIn core exercises the postures adopted by subjects lasted 15–30 seconds or in according with the capacity of each one. The strength training emphasized lower limbs. In each exercise, ten repetitions were performed and the subjects were asked to do each exercise three times. The prescribed load of exercise was moderate (5-6; 0 to 10 values) according to rated perceived exertion.Program duration and frequency8 weeks (90 min / session, three days / week) Both groups were effective in reducing pain and showed similar perceived pain post-training.

Chen et al. (2016) n = 19 EG = 10CG = 9 Age range: 19–30 years More than three months EG: Horse riding simulatorIndoor riding machine, simulating riding a real horse through the visual information that appeared on the front screen by diving the virtual environment. One training consisted of 15 min horse riding + 15 min lumbar strengthening exercises (same as in CG). CG: Lumbar strengthening exercisesCore strengthening exercises (six movements for one set; each movement was hold for 5 sec with eight repetitions). Program duration and frequency4 weeks (3 times / week) EG and CG showed significant within-group differences after intervention for pain intensity and ODI outcome. There were no significant differences between the groups in VAS and ODI outcomes before and after intervention.

Zadro et al. (2019) n = 58 EG = 30CG = 28 EG = 68.8±5.5CG = 67.8±6 At least three months EG: Wii Fit UNintendo Wii U console with Wii Fit U software was used. Patients were given a booklet outlining a range of flexibility, body weight resistance, and aerobic exercises preselected by the research team. Wii Fit U exercises included video and audio instructions, gave patients feedback on their performance during and after exercises, and scored their performance.CG: No intervention Program duration and frequency8 weeks (3 times / week) Patients completing Wii Fit U exercises demonstrated significantly greater improvements in pain immediately postintervention compared with the control group. However, these effects were small and did not reach the minimal clinically important difference. There were no significant between-group differences in disability and fear of movement.

Kim et al. (2020) n = 48 EG = 24CG = 24 EG = 26±3.82CG = 28.79±9.05 EG = 58.22±37.37CG = 101.55±97.12 EG: Simulated horseback ridingThe simulated horseback riding system used in the present study produced similar patterns to a real horse gait by using anteroposterior, vertical, and oblique motion axes. The workout consisted of walking, slow trotting, and fast trotting of a real horse gait. Each pattern was provided with continuously specified velocity (walking = 80 m/min, slow trotting = 135 m/min, and fast trotting = 159 m/min). CG: Stabilization exercises with suspensionExercise with suspension consisted of a supine pelvic lift, supine and prone bridging exercise, and side-lying hip abduction. Time required to perform each movement was about 10 seconds. Program duration and frequency8 weeks (46 min / session, two sessions / week) Both groups presented significant within-group differences in NPRS (both EG and CG after four weeks), ODI (both EG and CG after six months), and RMDQ (EG after six months and CG after eight weeks) compared with baseline values.

Park et al. (2020) n = 80 EG = 40CG = 40 EG = 71.5±6.34CG = 72.05±6.82 EG = 23.61±8.47 CG = 22.10±7.47 EG: Equine riding simulatorThe equestrian simulator was designed to mechanically reproduce the movement of an actual horse. Program included: 8 min warm up, 15 min exercise, 7 min cool down. After boarding the simulator, patients walked for three min as a pre-exercise before the actual exercise. After the actual exercise, patients walked again for 2 two min and finished with stretching on the ground. Work-out consisted of: walking (weeks 1–4), walking 10 min + trotting 5 min (weeks 5–8) and trotting 10 min + cantering 5 min (weeks 9–12). Time using videogame: 15 min. CG: Watching videoThey sat on the horse and watched the video from the monitor (no exercise). Program duration and frequency12 weeks (3 times / week) The EG showed a significant decrease in back pain compared to the CG. The effects of equine riding simulator exercise led to more significant relief of back pain for activities done on a daily basis.

Tomruk et al. (2020) n = 42 EG = 21CG = 21 (Median, IQR: (25–75%)) EG = 46.00 (40.05–50.50) CG = 45.00 (44.00–48.00) At least three months EG: Computer-based stability trainingComputer-based postural balance training using postural stability, limits of stability, weight shift and maze control training parameters on Biodex Balance System. One session duration: 30 min. CG: Traditional trainingTraditional postural control exercises by giving visual, vestibular, or proprioceptive stimulus under the cues of a physiotherapist. Program duration and frequency12 weeks (2 times / week) Both, computer-based and traditional training could be useful to decrease pain and disability in patients with chronic low back pain.

Afzal et al. (2022) n = 84 EG = 42CG = 42 EG = 37.5±12.5 CG = 38.2±11.8 Mentioned only as chronic pain EG: Non-immersive VR + PTVR using kinetic exergames, like the body ball game and reflex ridge, along with routine PT. The patients were subjected to trunk slide flexion, sitting to avoid obstacles, jumping and combined movement of arms for 5 min, as displayed on the mounted LCD. After 30 seconds of rest, the body ball game, including moving arm, head pushing and kicking of ball, for 5 min was introduced. VR exercises were combined with routine PT (same program as in CG). CG: PTRoutine PT with 10 minutes of heat therapy by a moist hot pack, hamstring stretching and back strengthening exercises. Program duration and frequency4 weeks (3 sessions / week) While both groups showed significant intra-group differences post-intervention, EG registered significantly better results than CG for both, pain intensity and disability outcome.

Fatoye et al. (2022) n = 46 EG = 22CG = 24 EG = 32.6±11.5CG = 48.8±10.2 More than three months EG: Non-immersive Back Extension VR gameBack extension VR game which involves a less invasive 3D graphic environment on computer/television screen. Each intervention comprised of warm up and the cool down phases (low intensity active stretching of the upper extremities, as well as the low back for about 5 min). The choice and design of the tasks in this group was based on the intention to achieve therapeutic activities that is comparable with the McKenzie ‘extension in standing’ protocol, as well as, the relevance of the tasks in rehabilitation of the patient. Patients carried out the activities in an upright standing position with the feet slightly apart, while holding the waist with both hands. Then, they were asked to head virtual balls seen on the screen as though coming towards them, while their feet were stationary but the trunk and head moves to accomplish heading of the ball. The main therapeutic movement that was intended is trunk extension while standing. However, side-glide of the spine to the left and also to the right were accompanied movements during the tasks. During game play, visual and textual feedback on the patient’s performance and results were displayed on the screen. CG: McKenzie TherapyMcKenzie ‘extension in standing’ protocol required that a patient stand upright with the feet slightly apart while placing his/her hands in the small of the back with the fingers pointing backwards. Then, the patient was asked to stretched the trunk backwards at the waist level as far as he/she could, using the hands as a fulcrum while keeping the knees straight. The protocol involved a course of specific lumbosacral repeated movements in extension that caused the symptoms to centralize, decrease or abolish. Each intervention comprised of warm up and the cool down phases (low intensity active stretching of the upper extremities, as well as the low back for about 5 min). Program duration and frequency8 weeks (3 times / week) There was a significant difference in the scores of ODI between EG and CG at baseline, weeks four and weeks 8.

Nambi, Abdelbasset, Elsayed, et al. (2021) n = 60 EG = 20CG₁ = 20CG₂ = 20 EG = 21.45±1.5CG₁ = 21.39±1.4 CG₂ = 20.97±1.5 EG = 4.8±0.5CG₁ = 5.2±0.6CG₂ 4.9±0.5 EG: Non-immersive VR + PTExercises for the core muscles of trunk with Pro-Kin system PK 252 N Techno body, Italy. The patient was asked to sit in the virtual platform which offers challenges to the trunk movement. The firing game was executed by trunk movements (flexion, extension and lateral flexion) within the limitations of pain. PT included: heat modality for 20 min and ultrasound for 5 min. CG₁: Core stabilization training + PTThe core stability training through therapeutic ball for the spinal stabilizers. Different set of exercises were performed on the ball such as: Quadruped arm rise, cat and camel, pelvic tilt, side plank and extension exercises. PT included: heat modality for 20 min and ultrasound for 5 min. CG₂: Conventional exercises + PTThe traditional active balance exercise for the abdominal muscles and back muscles. Self-stretching was done to all the group muscles of lower limb for 30 seconds. PT included: heat modality for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (5 times / week) There was a substantial improvement in each group in pain status. However, VR group showed more statistical improvement in pain status compared to other groups.

Mbada et al. (2019) n = 46 EG = 22 CG = 24 EG = 32.6±11.5CG = 48.8±10.2 EG = 8.00±4.2CG = 8.4±3.3 EG: Back Extension VR game + back care educationThe choice of tasks in the VR game was based on the intention that they had to be comparable with the McKenzie extension protocol, as well as relevant in rehabilitation of low back pain. Each patient was asked to maintain an upright standing position with the feet, while holding the waist with both hands. Stretching the trunk, the subject was asked to head balls coming to them as seen on the screen. The intended therapeutic motion was extension of the spine while standing. However, side-glides of the spine to the left and also to the right were observed as accompanying motions in that position. Back care education: instructions comprising a 9-item instructional guide on standing, sitting, lifting, and other activities of daily living for home. CG: McKenzie Therapy + back care educationThe McKenzie extension in standing protocol involved a course of specific lumbosacral repeated movements in extension that caused the symptoms to centralize, decrease, or abolish. Back care education: instructions comprising a 9-item instructional guide on standing, sitting, lifting, and other activities of daily living for home. Program duration and frequency8 weeks (3 times / week) For kinesiophobia, VR group led to significantly higher decline in mean rank at week four and 8. Back extension VR game was comparable with the McKenzie extension therapy in its effects on pain, pain-related characteristics and disability.

Groenveld et al. (2023) n = 40 EG = 20CG = 20 EG = 51±2.9CG = 52±2.5 EG = 10.05±8.6 CG = 9.6±8.5 EG: Immersive VRBehavioral therapy-based VR application was used. The application is designed as a game, in which a patient “travels” through the nervous system sitting in a pod. During the journey, a calm voice explains the mechanisms of pain, which are made visual in the virtual environment. Along the way, patients are offered five different games, each containing exercises based on different psychological treatment principles (i.e., acceptance and commitment therapy, mindfulness, hypnotherapy, eye movement, and desensitization and reprocessing) incorporating an education element, explaining the maladaptive changes in the central nervous system, in every game. Patients were instructed to use the VR intervention for at least 10 minutes daily for four weeks with the restriction of 30 minutes per session and three sessions per day. CG: No intervention Program duration and frequency4 weeks (at least 10 min daily) VR seemed to positively affect worst and least experienced pain. A significant main treatment effect of VR was seen on the daily worst experienced pain score. A significant main treatment effect was seen on the daily least experienced pain score. No between-group differences were seen at four weeks and four months for the ODI outcome.

Yalfani et al. (2022) n = 25 EG = 13CG = 12 EG = 68±2.94CG = 67.08±2.9 Mentioned only as chronic EG: Immersive VRThe VRT exercises were implemented with the help of a HTC Vive virtual reality system. A patient was positioned 1.5 to 2 m away from the Vive sensor. The VRT exercises and games included Fisher, Boxing, Tennis, Football, Bowling, Beat Saber, Audio shield, and Skiing. Notably, the selected exercises involved a variety of movements, and they induced the simultaneous use of the upper and lower limbs and the trunk. CG: No intervention Program duration and frequency8 weeks (3 times / week) The pain intensity score of the EG significantly decreased after participation in the VR program.

Alemanno et al. (2019) n = 20 47.5±15.3 35.0±42.4 VR sensorimotor rehabilitationThe aim of the exercises was to regain a correct body image by improving the control of single movements of the trunk. Patients underwent a series of exercises consisting mainly in trunk rotation, flexion and extension realized in various positions (standing, sitting, and kneeling). Program duration and frequency4–6 weeks (12 sessions total, one hour per session) Both, pain and disability significantly reduced after intervention.

Vries et al. (2023) n = 8 A minimum age of 18 years More than six months Immersive VR gameGame consisted of five different phases: Nerves, Spinal cord, Brain, Alarm center and Control room. Phase Nerves was conceptualized as a strong visual metaphor for taking control over the threat-related stimuli in the nervous system. Phase Spinal cord aimed at educating patients how a state of relaxation may positively influence perceived pain. The game Brains explained how to let your brain react less strongly to pain stimuli. Phase Alarm center focused on how feelings, thoughts and actions affect sensitivity of the brain for pain stimuli. The Control room was the final exercise of the training and visualized the inside of alarm center (the part of the brain that processes pain stimuli and determines to what extent pain stimuli are transmitted to the brain). Program duration and frequency21–26 days (45 min per session, three times / week) None of the patients showed a reliable change in TSK total score from the baseline phase compared to post intervention. A significant decrease in pain intensity was shown across all the eight patients.

Trujilo et al. (2020) n = 2 Patient A: 37 year-old Patient B: 64 year-old Patient A: more than seven yearsPatient B: twenty years Immersive VR gameExercises were designed based on the principles of graded motor imagery and include motor imagery (virtual sit-to-stand exercise), graded exposure (soccer exercise, target shooting exercise, and a dish stacking exercise), and corrective exercises (virtual ball rolling task). Each exercise increased in duration as patients became more successful at completing the tasks. One session duration increased from 20 min to 45 min. Program duration and frequency7 sessions total (2 times / week) There was a significant improvement in pain intensity after single sessions of VR intervention for both patients. Pain intensity improved in six of seven sessions for Patient A and all seven sessions for Patient B.

Birchem et al. (2020) n = 2 Patient A: 59 year-oldPatient B: 55 year-old Patient A: five monthsPatient B: four months VR game + PTPT included: manual therapy, pain neuroscience education, and core activation/stabilization exercises. At the conclusion of each treatment, the patient completed 15 min of VR training that encouraged functional movements such as: punching, squatting, ducking, and twisting. VR was implemented using a PlayStation^®VR that promoted movement and pain distraction. Program duration and frequencyPatient A: nine sessions total; patient B: 14 sessions total (2 visits per week for two months) The study showed a decrease in pain following intervention from initial evaluation. Patient functional status and fear-avoidance behaviours were improved, although not significant, throughout treatment.

Matheve et al. (2018) n = 10 Median; IQR: 35.5; 28 Median; IQR: 8.5; 17.63 Serious game + standard rehabilitationStandard rehabilitation included general conditioning (cycling on a stationary bike at an intensity of 75% of the maximal heart rate, and exercises on a stepping machine and crosstrainer) and motor control exercises. Serious game was introduced into rehabilitation program after three weeks of treatment. The serious game supported exercise therapy was identical to the standard rehabilitation, except patients received sensor-based postural feedback from the serious game during 45 minutes of motor control exercises consisting of thoracolumbar dissociation exercises and functional motor control exercises. All the games were played in standing or sitting position. First, the games requiring single plane movements were selected, while the games controlled by the three-dimensional movements were added later. Patients were also asked to perform three serious game and three motor control exercises at home. Program duration and frequency18 weeks (2 times / week, 36 sessions total) Pain intensity, disability and kinesiophobia significantly improved over time.

Maclnyre et al. (2023)* n = 10 Not mentioned in abstract Mentioned only as “chronic” in abstract VR graded activity interventionAn immersive gamified VR intervention based on principles of graded activity. Program duration and frequency14 to 23 days (6–9 intervention sessions) The VR graded activity intervention resulted in a significant reduction in pain intensity with four patients achieving≥30% pain reduction.

Sato et al. (2021)* n = 40 EG = 20CG = 20 EG = 49.3 (mean age) CG = 55.60 (mean age) Mentioned only as “chronic” in abstract EG: Nintendo Ring Fit Adventure (RFA) exergameRFA exergaming was performed once a week for 40 min. CG: Oral treatment Program duration and frequency8 weeks In EG, low back pain significantly improved after eight weeks of RFA exergaming, but there was no significant improvement in kinesiphobia. In the CG, no significant improvement was observed after eight weeks of oral treatment.

Author (year)	Participants	Interventions	Relevant results/conclusions
Garcia, Birckhead, Krishnamurthy, Mackey, Sackman, Salmasi, Louis, Castro, et al. (2022) / Garcia, Birckhead, Krishnamurthy, Mackey, Sackman, Salmasi, Louis, Maddox, et al. (2022) / Garcia et al. (2021) / Maddox et al. (2022) / Maddox et al. (2023)	n = 179EG = 89CG = 90	EG = 51.5±13.5CG = 51.4±12.9	At least six months	EG: Home-based immersive VR programImmersive, multimodal, skills-based, pain self-management VR program Ease VRx (AppliedVR), that incorporated evidence-based principles of cognitive behavioral therapy, mindfulness and pain-neuroscience education. Program combined biopsychosocial education, diaphragmatic breathing training, relaxation response exercises that activate the parasympathetic nervous system, and executive functioning games.CG: Home-based sham VRNon-immersive 2D content (nature footage with neutral music) delivered in a VR headset.Program duration and frequency8 weeks (1 session / day for 6 min on average)	Average pain intensity significantly decreased over time for both treatment groups. The decrease was greater for EG versus CG. Pain intensity reduced by an average of 42.8% for the EG and 25.1% for the CG. Sustained reductions for pain intensity were observed three and six months after immersive VR program, that were superior to Sham VR program. At 18- and 24-months post-treatment, the average pain reduction for EG was still significantly larger than that for CG.
Nambi, Abdelbasset, Alrawaili, et al. (2021)	n = 60EG = 20CG₁ = 20 CG₂ = 20	EG = 23.2±1.5CG₁ = 22.8±1.6CG₂ = 23.3±1.5	EG = 5.8±0.8CG₁ = 5.2±0.7CG₂ = 5.4±0.9	EG: Non-immersive VR training + PTExercises in sitting position with VR device which focused on the balance of stability of the core muscles. The game was executed and controlled by moving the trunk back and forth and left and right according to the signs. Patients performed all possible spinal movements within their pain limits. One session of VR program lasted for 30 min. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min.CG₁: Isokinetic training + PTThe trunk was trained from 10° of extension to 80° of flexion and 0° was considered neutral. Patients were allowed to perform the exercise at an angular speed of 60°/second, 90°/second, and 120°/second with 15 repetitions of three sets. Between each set 30 seconds rest and between each pace 60 seconds rest was given. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₂: Conventional training + PTConventional training of the core muscles of the trunk. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (5 days / week)	Training through VR and isokinetic training is a more effective strategy than a conventional exercise program in terms of improving pain and kinesiophobia.
Nambi et al. (2022)	n = 58 EG = 19CG₁ = 19CG₂ = 20	EG = 23.2±1.6 CG₁ = 22.9±1.7CG₂ = 22.8±1.8	EG = 4.8±1.1CG₁ = 5.2±0.9CG₂ = 5.5±0.8	EG: Non-immersive VR training + PTExercises for strengthening trunk muscles while using VR device. The exercises were performed in the upright position. Patient was asked to sit on the moving game chair and instructed to watch the game on the desktop monitor. Joystick actions were performed by changing the trunk positions, such as moving backwards, forward, to the left or right, based on the position of the target on the display screen. During the training, patients were permitted to move their trunk in all directions within their pain-free limit. One session of VR program lasted for 30 min. PT consisted of hydro collateral packs for 20 min and ultrasound for 5 min. CG₁: Isokinetic training + PTThe trunk flexor and extensor muscles were trained from 10–15° of extension to 70–80° of flexion and 0° was considered neutral. Patients were instructed to do these movements at an angular velocity of 45, 60, and 90°/s with ten repetitions of three sets. Thirty seconds rest was given between each set, and sixty seconds rest was given between each pace. PT consisted of hydro collateral packs for 20 min and ultrasound for 5 min. CG₂: Conventional training + PTRoutine balance exercises to train the lower trunk muscles (abdominal, deep abdominal, and back muscles). PT consisted of hydro collateral packs for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (five days / week)	After four weeks of different exercise protocols, there was a significant improvement in pain intensity level when comparing the VR training vs. isokinetic training program and VR vs. conventional groups. Virtual reality and isokinetic training had equal effects on reducing pain intensity.
Stamm et al. (2022)	n = 22 EG = 11 CG = 11	EG = 75±5.8CG = 75.5±4.39	EG = 15.8±18.67CG = 26.4±16.57 (In years)	EG: Immersive VRVR (ViRST application) consisted of movement therapy and psychoeducation. The training session, consisting of 12 exercises, was structured as follows: (1) warm up (training of the upper and lower extremities with “marching and rowing” exercises); (2) main part (strengthening of the abdominal and back muscles, core stability); (3) cool down (stretching, progressive muscle relaxation exercise); (4) psycho-educative units (topics: physiology of pain, pain management, stress management, everyday training). CG: Conventional multimodal pain therapyMovement therapy (seated exercises) and psychoeducation in a group setting. The intervention phase in the CG differed from EG mainly in the use of VR technology. Program duration and frequency4 weeks (30 min per session, three sessions / week)	Although the VR therapy did not reach the pain intensity reduction of the CG, the results of the present study showed that a pain intensity reduction can be reached with the current VR exergame prototype, albeit not significantly. In terms of fear-avoidance behaviour, both groups showed a reduction compared to the data before the four-week intervention, however, without significance.
Nambi et al. (2020)	n = 45 EG = 15 CG₁ = 15 CG₂ = 15	EG = 21.25±1.2 CG₁ = 20.23±1.6CG₂ = 20.78±1.6	EG = 4.1±0.5 CG₁ = 4.1±0.6 CG₂ = 4.3±0.4	EG: Non-immersive VR + PTEG received VR training with focusing on the balance of core stability muscles. Training was given in the sitting position. The game was shooting game, which consists of the subject sitting on the virtual platform and visualizing the game in the display screen. The game is executed and controlled by moving the trunk back and forth and left and right according to the signs. Patients performed all the six movements of their spine within their pain limits. One session of VR program lasted for 30 min. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₁: Isokinetic training + PTBefore isokinetic training, the subjects were asked to perform five-minute warm-up followed by slow stretching of back extensors and flexors. Subjects were allowed to perform the exercise at an angular speed of 60°/second, 90°/second, and 120°/ second with 15 repetitions of three sets. Rest between each set of 30 seconds and between each pace of 60 seconds has been given. The trunk was tested from –10° of extension to 80° of flexion and 0° was considered neutral. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₂: Conventional training + PTConventional balance training for core muscles: active isotonic and isometric exercise for abdominal muscles, deep abdominal muscles, and back muscles. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (5 days / week)	After intervention, VR program led to more reduction in pain than isokinetic training and conventional training.
Nambi, Abdelbasset, Alsubaie, et al. (2021)	n = 54 EG = 18 CG₁ = 18 CG₂ = 18	EG = 22.3±1.6 CG₁ = 21.4±1.8 CG₂ = 21.9±1.8	EG = 5.4±0.2 CG₁ = 5.3±0.6 CG₂ = 5.5±0.4	EG: Non-immersive VR training + PTVR balance training, focusing on the balance of core stability muscles. Training was given in the sitting position. The game used in the current study was a shooting game, which consists of the subject sitting on the virtual platform and visualizing the game on the computer display screen. The game was executed and controlled by moving the trunk back and forth and left and right according to the signs. Patients performed all the movements of their spine within their pain limits. One session of VR program lasted for 30 min. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₁: Combined physical rehabilitation + PTPatients received balance training through a Swiss ball for core muscles. The exercises performed were wall squat, Russian twist, leg lift, plank saw, cobra, and hip raise on the Swiss ball (15 times per set for three sets). Patients were asked to maintain each position for 10 seconds, with a 3-second break between the repetitions. PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. CG₂: Conventional training + PTConventional balance training for core muscles: active isotonic and isometric exercisea for abdominal muscles, deep abdominal muscles, and back muscles. They performed these exercises ten to 15 repetitions per day. Stretching was focused on each muscle group for three repetitions for 10 seconds per muscle group (hamstring, hip flexors, and lumbar extensors). PT consisted of hot pack therapy for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (5 days / week)	The results showed a greater percentage of improvement in pain intensity and kinesiophobia level in the VR training group than in the combined physical rehabilitation or conventional training groups.
Eccleston et al. (2022)	n = 42 EG = 14 CG₁ = 17 CG₂ = 11	EG = 55.14±10.53 CG₁ = 52.76±11.19 CG₂ = 57.09±8.34	At least three months	EG: Immersive VR trainingThe intervention was guided by an “embodied” model of the psychology of pain aimed to reduce fear of movement and reinjury by creating a safe virtual environment to encourage exploration and repeated movement. The virtual mentor invited the patient to the outside space where they engaged in a gamified “fruit-picking” activity. Fruits from trees appeared in all four quadrants of their peripersonal space. The activities were designed to promote fine and gross motor movements typically avoided by low back pain patients fearful of movement and reinjury. Patients were encouraged to move within their peripersonal space, owning and being agents within that space, and engaging in a full range of motion physical activities, repeatedly. Education on avoidance behavior was delivered. Techniques offered to promote problem solving, reflection on change, and increased self-efficacy for change were presented. CG₁: Immersive sham VRThe virtual environment showed a similar seashore environment to the DTxP program. None of the content provided in the DTxP was presented. Instead, the patients viewed text that instructed them to relax and enjoy the environment as used in the DTxP. CG₂: Standard careNo intervention, instructions, or education. Just standard care as usual. Program duration and frequency6–8 weeks (5 sessions / week)	Patients in the EG reported greater reductions in fear of movement when compared with sham placebo and standard care post treatment. When compared with baseline, patients in the EG reported lower disability at 5-month follow-up, lower fear of movement post treatment and follow-up, and lower pain intensity at posttreatment. The sham placebo group also reported lower disability and fear of movement at 5-month follow-up compared with baseline. Standard care did not report any significant changes.
Park et al. (2013)	n = 24 EG = 8 CG₁ = 8 CG₂ = 8	EG = 44.12±5.48 CG₁ = 43.37±5.42 CG₂ = 45.5±5.34	Over three months	EG: Nintendo Wii exercises + PTThe Nintendo Wii sports program was used for the Nintendo Wii exercise program, including the wakeboard, Frisbee dog, jet ski, and canoe games. Patients controlled a virtual character on the screen by swinging, rowing, and tilting remote controllers with motion sensors. One session of Wii program lasted for 30 min. PT (50 min / session) consisted of: hot pack, interferential therapy, ultrasound. CG₁: Lumbar stabilization exercise + PTStabilization exercises (30 min / session) included seven positions based on the back bridge, hands and knees, and side bridge. Patients maintained each position for 15 seconds for three sets. PT (50 min / session) consisted of: hot pack, interferential therapy, ultrasound. CG₂: PTPT (50 min / session) consisted of: hot pack, interferential therapy, ultrasound. Program duration and frequency8 weeks (3 sessions / week)	Pain decreased significantly in EG and lumbar stabilization exercise group, but not in PT only group.
Oh et al. (2014)	n = 37EG₁ = 9EG₂ = 9EG₃ = 10CG = 9	EG₁ = 20.44±0.27EG₂ = 20.33±0.52EG₃ = 20.56±0.69CG = 20.7±0.37	EG₁ = 6.75±2.01EG₂ =7.57±1.06EG₃ =6.21±2.11CG =6.38±2.14	EG1: Horse simulator (30 min) Horse simulator riding VR system: Horse simulator machine (HJL Co. Ltd., Korea). VR program: warmup (stretching 5 min + ordinary walking on the horse simulator 5 min) + work-out (sitting trotting and rising trotting 30 min) + cool-down (supine stretching 10 min). Time using videogame: 35 min. EG2: Horse simulator (20 min)Horse simulator riding VR system: Horse simulator machine (HJL Co. Ltd., Korea). VR program: warmup (stretching 5 min + ordinary walking on the horse simulator 5 min) + work-out (sitting trotting and rising trotting 20 min) + cool-down (supine stretching 10 min). Time using videogame: 25 min. EG3: Horse simulator (10 min)Horse simulator riding (10 min) VR system: Horse simulator machine (HJL Co. Ltd., Korea). VR program: warmup (stretching 5 min + ordinary walking on the horse simulator 5 min) + work-out (sitting trotting and rising trotting 10 min) + cool-down (supine stretching 10 min). Time using videogame: 15 min. CG: No intervention Program duration and frequency8 weeks (5 days / week)	Patients back pain reduced after an 8-week program of riding a horse simulator. Especially, 20 min horseback riding in the simulator was associated with the best results.
Yoo et al. (2014)	n = 47 EG = 24CG = 23	EG = 20.44±1.33CG = 20.7±1.45	EG = 9.41±3.64CG = 8.35±2.62	EG: Horse riding simulatorHorse simulator riding VR system: Horse simulator machine (HJL Co. Ltd., Korea). VR program: warmup (stretching 10 min) + work-out + cool-down (stretching 10 min). Workout consisted of: ordinary walking and sitting trotting (week 1), increase riding time and riding trotting (weeks 2–3), increase riding time and intensity (weeks 4–5), and increase riding time and intensity (weeks 6–8). Time using videogame: 10 min (week 1), 20 min (weeks 2–3), 30 min (weeks 4–5) and 40 min (weeks 6–8). CG: No intervention Program duration and frequency8 weeks (3 days / week)	Horse simulator exercises significantly reduced pain intensity scores after intervention. The reduced levels observed in EG were significantly higher than those in CG.
Monteiro-Junior et al. (2015)	n = 30 EG = 16CG = 14	EG + CG = 68±4	Chronic pain	EG: Wii based exercises + strength exercises and core trainingCore exercises and strength training + eight Wii Fit Plus workouts. VR system: Nintendo Wii Motion and Wii Balance Board Games (chair, tightrope walk, ski slalom, balance bubble, table tilt, sideways, rowing squat, lunge). Verbal stimulus was allowed, and rest periods (1–2 min) were administered. Time using videogame: 30 min. CG: Strength exercises and core trainingIn core exercises the postures adopted by subjects lasted 15–30 seconds or in according with the capacity of each one. The strength training emphasized lower limbs. In each exercise, ten repetitions were performed and the subjects were asked to do each exercise three times. The prescribed load of exercise was moderate (5-6; 0 to 10 values) according to rated perceived exertion.Program duration and frequency8 weeks (90 min / session, three days / week)	Both groups were effective in reducing pain and showed similar perceived pain post-training.
Chen et al. (2016)	n = 19 EG = 10CG = 9	Age range: 19–30 years	More than three months	EG: Horse riding simulatorIndoor riding machine, simulating riding a real horse through the visual information that appeared on the front screen by diving the virtual environment. One training consisted of 15 min horse riding + 15 min lumbar strengthening exercises (same as in CG). CG: Lumbar strengthening exercisesCore strengthening exercises (six movements for one set; each movement was hold for 5 sec with eight repetitions). Program duration and frequency4 weeks (3 times / week)	EG and CG showed significant within-group differences after intervention for pain intensity and ODI outcome. There were no significant differences between the groups in VAS and ODI outcomes before and after intervention.
Zadro et al. (2019)	n = 58 EG = 30CG = 28	EG = 68.8±5.5CG = 67.8±6	At least three months	EG: Wii Fit UNintendo Wii U console with Wii Fit U software was used. Patients were given a booklet outlining a range of flexibility, body weight resistance, and aerobic exercises preselected by the research team. Wii Fit U exercises included video and audio instructions, gave patients feedback on their performance during and after exercises, and scored their performance.CG: No intervention Program duration and frequency8 weeks (3 times / week)	Patients completing Wii Fit U exercises demonstrated significantly greater improvements in pain immediately postintervention compared with the control group. However, these effects were small and did not reach the minimal clinically important difference. There were no significant between-group differences in disability and fear of movement.
Kim et al. (2020)	n = 48 EG = 24CG = 24	EG = 26±3.82CG = 28.79±9.05	EG = 58.22±37.37CG = 101.55±97.12	EG: Simulated horseback ridingThe simulated horseback riding system used in the present study produced similar patterns to a real horse gait by using anteroposterior, vertical, and oblique motion axes. The workout consisted of walking, slow trotting, and fast trotting of a real horse gait. Each pattern was provided with continuously specified velocity (walking = 80 m/min, slow trotting = 135 m/min, and fast trotting = 159 m/min). CG: Stabilization exercises with suspensionExercise with suspension consisted of a supine pelvic lift, supine and prone bridging exercise, and side-lying hip abduction. Time required to perform each movement was about 10 seconds. Program duration and frequency8 weeks (46 min / session, two sessions / week)	Both groups presented significant within-group differences in NPRS (both EG and CG after four weeks), ODI (both EG and CG after six months), and RMDQ (EG after six months and CG after eight weeks) compared with baseline values.
Park et al. (2020)	n = 80 EG = 40CG = 40	EG = 71.5±6.34CG = 72.05±6.82	EG = 23.61±8.47 CG = 22.10±7.47	EG: Equine riding simulatorThe equestrian simulator was designed to mechanically reproduce the movement of an actual horse. Program included: 8 min warm up, 15 min exercise, 7 min cool down. After boarding the simulator, patients walked for three min as a pre-exercise before the actual exercise. After the actual exercise, patients walked again for 2 two min and finished with stretching on the ground. Work-out consisted of: walking (weeks 1–4), walking 10 min + trotting 5 min (weeks 5–8) and trotting 10 min + cantering 5 min (weeks 9–12). Time using videogame: 15 min. CG: Watching videoThey sat on the horse and watched the video from the monitor (no exercise). Program duration and frequency12 weeks (3 times / week)	The EG showed a significant decrease in back pain compared to the CG. The effects of equine riding simulator exercise led to more significant relief of back pain for activities done on a daily basis.
Tomruk et al. (2020)	n = 42 EG = 21CG = 21	(Median, IQR: (25–75%)) EG = 46.00 (40.05–50.50) CG = 45.00 (44.00–48.00)	At least three months	EG: Computer-based stability trainingComputer-based postural balance training using postural stability, limits of stability, weight shift and maze control training parameters on Biodex Balance System. One session duration: 30 min. CG: Traditional trainingTraditional postural control exercises by giving visual, vestibular, or proprioceptive stimulus under the cues of a physiotherapist. Program duration and frequency12 weeks (2 times / week)	Both, computer-based and traditional training could be useful to decrease pain and disability in patients with chronic low back pain.
Afzal et al. (2022)	n = 84 EG = 42CG = 42	EG = 37.5±12.5 CG = 38.2±11.8	Mentioned only as chronic pain	EG: Non-immersive VR + PTVR using kinetic exergames, like the body ball game and reflex ridge, along with routine PT. The patients were subjected to trunk slide flexion, sitting to avoid obstacles, jumping and combined movement of arms for 5 min, as displayed on the mounted LCD. After 30 seconds of rest, the body ball game, including moving arm, head pushing and kicking of ball, for 5 min was introduced. VR exercises were combined with routine PT (same program as in CG). CG: PTRoutine PT with 10 minutes of heat therapy by a moist hot pack, hamstring stretching and back strengthening exercises. Program duration and frequency4 weeks (3 sessions / week)	While both groups showed significant intra-group differences post-intervention, EG registered significantly better results than CG for both, pain intensity and disability outcome.
Fatoye et al. (2022)	n = 46 EG = 22CG = 24	EG = 32.6±11.5CG = 48.8±10.2	More than three months	EG: Non-immersive Back Extension VR gameBack extension VR game which involves a less invasive 3D graphic environment on computer/television screen. Each intervention comprised of warm up and the cool down phases (low intensity active stretching of the upper extremities, as well as the low back for about 5 min). The choice and design of the tasks in this group was based on the intention to achieve therapeutic activities that is comparable with the McKenzie ‘extension in standing’ protocol, as well as, the relevance of the tasks in rehabilitation of the patient. Patients carried out the activities in an upright standing position with the feet slightly apart, while holding the waist with both hands. Then, they were asked to head virtual balls seen on the screen as though coming towards them, while their feet were stationary but the trunk and head moves to accomplish heading of the ball. The main therapeutic movement that was intended is trunk extension while standing. However, side-glide of the spine to the left and also to the right were accompanied movements during the tasks. During game play, visual and textual feedback on the patient’s performance and results were displayed on the screen. CG: McKenzie TherapyMcKenzie ‘extension in standing’ protocol required that a patient stand upright with the feet slightly apart while placing his/her hands in the small of the back with the fingers pointing backwards. Then, the patient was asked to stretched the trunk backwards at the waist level as far as he/she could, using the hands as a fulcrum while keeping the knees straight. The protocol involved a course of specific lumbosacral repeated movements in extension that caused the symptoms to centralize, decrease or abolish. Each intervention comprised of warm up and the cool down phases (low intensity active stretching of the upper extremities, as well as the low back for about 5 min). Program duration and frequency8 weeks (3 times / week)	There was a significant difference in the scores of ODI between EG and CG at baseline, weeks four and weeks 8.
Nambi, Abdelbasset, Elsayed, et al. (2021)	n = 60 EG = 20CG₁ = 20CG₂ = 20	EG = 21.45±1.5CG₁ = 21.39±1.4 CG₂ = 20.97±1.5	EG = 4.8±0.5CG₁ = 5.2±0.6CG₂ 4.9±0.5	EG: Non-immersive VR + PTExercises for the core muscles of trunk with Pro-Kin system PK 252 N Techno body, Italy. The patient was asked to sit in the virtual platform which offers challenges to the trunk movement. The firing game was executed by trunk movements (flexion, extension and lateral flexion) within the limitations of pain. PT included: heat modality for 20 min and ultrasound for 5 min. CG₁: Core stabilization training + PTThe core stability training through therapeutic ball for the spinal stabilizers. Different set of exercises were performed on the ball such as: Quadruped arm rise, cat and camel, pelvic tilt, side plank and extension exercises. PT included: heat modality for 20 min and ultrasound for 5 min. CG₂: Conventional exercises + PTThe traditional active balance exercise for the abdominal muscles and back muscles. Self-stretching was done to all the group muscles of lower limb for 30 seconds. PT included: heat modality for 20 min and ultrasound for 5 min. Program duration and frequency4 weeks (5 times / week)	There was a substantial improvement in each group in pain status. However, VR group showed more statistical improvement in pain status compared to other groups.
Mbada et al. (2019)	n = 46 EG = 22 CG = 24	EG = 32.6±11.5CG = 48.8±10.2	EG = 8.00±4.2CG = 8.4±3.3	EG: Back Extension VR game + back care educationThe choice of tasks in the VR game was based on the intention that they had to be comparable with the McKenzie extension protocol, as well as relevant in rehabilitation of low back pain. Each patient was asked to maintain an upright standing position with the feet, while holding the waist with both hands. Stretching the trunk, the subject was asked to head balls coming to them as seen on the screen. The intended therapeutic motion was extension of the spine while standing. However, side-glides of the spine to the left and also to the right were observed as accompanying motions in that position. Back care education: instructions comprising a 9-item instructional guide on standing, sitting, lifting, and other activities of daily living for home. CG: McKenzie Therapy + back care educationThe McKenzie extension in standing protocol involved a course of specific lumbosacral repeated movements in extension that caused the symptoms to centralize, decrease, or abolish. Back care education: instructions comprising a 9-item instructional guide on standing, sitting, lifting, and other activities of daily living for home. Program duration and frequency8 weeks (3 times / week)	For kinesiophobia, VR group led to significantly higher decline in mean rank at week four and 8. Back extension VR game was comparable with the McKenzie extension therapy in its effects on pain, pain-related characteristics and disability.
Groenveld et al. (2023)	n = 40 EG = 20CG = 20	EG = 51±2.9CG = 52±2.5	EG = 10.05±8.6 CG = 9.6±8.5	EG: Immersive VRBehavioral therapy-based VR application was used. The application is designed as a game, in which a patient “travels” through the nervous system sitting in a pod. During the journey, a calm voice explains the mechanisms of pain, which are made visual in the virtual environment. Along the way, patients are offered five different games, each containing exercises based on different psychological treatment principles (i.e., acceptance and commitment therapy, mindfulness, hypnotherapy, eye movement, and desensitization and reprocessing) incorporating an education element, explaining the maladaptive changes in the central nervous system, in every game. Patients were instructed to use the VR intervention for at least 10 minutes daily for four weeks with the restriction of 30 minutes per session and three sessions per day. CG: No intervention Program duration and frequency4 weeks (at least 10 min daily)	VR seemed to positively affect worst and least experienced pain. A significant main treatment effect of VR was seen on the daily worst experienced pain score. A significant main treatment effect was seen on the daily least experienced pain score. No between-group differences were seen at four weeks and four months for the ODI outcome.
Yalfani et al. (2022)	n = 25 EG = 13CG = 12	EG = 68±2.94CG = 67.08±2.9	Mentioned only as chronic	EG: Immersive VRThe VRT exercises were implemented with the help of a HTC Vive virtual reality system. A patient was positioned 1.5 to 2 m away from the Vive sensor. The VRT exercises and games included Fisher, Boxing, Tennis, Football, Bowling, Beat Saber, Audio shield, and Skiing. Notably, the selected exercises involved a variety of movements, and they induced the simultaneous use of the upper and lower limbs and the trunk. CG: No intervention Program duration and frequency8 weeks (3 times / week)	The pain intensity score of the EG significantly decreased after participation in the VR program.
Alemanno et al. (2019)	n = 20	47.5±15.3	35.0±42.4	VR sensorimotor rehabilitationThe aim of the exercises was to regain a correct body image by improving the control of single movements of the trunk. Patients underwent a series of exercises consisting mainly in trunk rotation, flexion and extension realized in various positions (standing, sitting, and kneeling). Program duration and frequency4–6 weeks (12 sessions total, one hour per session)	Both, pain and disability significantly reduced after intervention.
Vries et al. (2023)	n = 8	A minimum age of 18 years	More than six months	Immersive VR gameGame consisted of five different phases: Nerves, Spinal cord, Brain, Alarm center and Control room. Phase Nerves was conceptualized as a strong visual metaphor for taking control over the threat-related stimuli in the nervous system. Phase Spinal cord aimed at educating patients how a state of relaxation may positively influence perceived pain. The game Brains explained how to let your brain react less strongly to pain stimuli. Phase Alarm center focused on how feelings, thoughts and actions affect sensitivity of the brain for pain stimuli. The Control room was the final exercise of the training and visualized the inside of alarm center (the part of the brain that processes pain stimuli and determines to what extent pain stimuli are transmitted to the brain). Program duration and frequency21–26 days (45 min per session, three times / week)	None of the patients showed a reliable change in TSK total score from the baseline phase compared to post intervention. A significant decrease in pain intensity was shown across all the eight patients.
Trujilo et al. (2020)	n = 2	Patient A: 37 year-old Patient B: 64 year-old	Patient A: more than seven yearsPatient B: twenty years	Immersive VR gameExercises were designed based on the principles of graded motor imagery and include motor imagery (virtual sit-to-stand exercise), graded exposure (soccer exercise, target shooting exercise, and a dish stacking exercise), and corrective exercises (virtual ball rolling task). Each exercise increased in duration as patients became more successful at completing the tasks. One session duration increased from 20 min to 45 min. Program duration and frequency7 sessions total (2 times / week)	There was a significant improvement in pain intensity after single sessions of VR intervention for both patients. Pain intensity improved in six of seven sessions for Patient A and all seven sessions for Patient B.
Birchem et al. (2020)	n = 2	Patient A: 59 year-oldPatient B: 55 year-old	Patient A: five monthsPatient B: four months	VR game + PTPT included: manual therapy, pain neuroscience education, and core activation/stabilization exercises. At the conclusion of each treatment, the patient completed 15 min of VR training that encouraged functional movements such as: punching, squatting, ducking, and twisting. VR was implemented using a PlayStation^®VR that promoted movement and pain distraction. Program duration and frequencyPatient A: nine sessions total; patient B: 14 sessions total (2 visits per week for two months)	The study showed a decrease in pain following intervention from initial evaluation. Patient functional status and fear-avoidance behaviours were improved, although not significant, throughout treatment.
Matheve et al. (2018)	n = 10	Median; IQR: 35.5; 28	Median; IQR: 8.5; 17.63	Serious game + standard rehabilitationStandard rehabilitation included general conditioning (cycling on a stationary bike at an intensity of 75% of the maximal heart rate, and exercises on a stepping machine and crosstrainer) and motor control exercises. Serious game was introduced into rehabilitation program after three weeks of treatment. The serious game supported exercise therapy was identical to the standard rehabilitation, except patients received sensor-based postural feedback from the serious game during 45 minutes of motor control exercises consisting of thoracolumbar dissociation exercises and functional motor control exercises. All the games were played in standing or sitting position. First, the games requiring single plane movements were selected, while the games controlled by the three-dimensional movements were added later. Patients were also asked to perform three serious game and three motor control exercises at home. Program duration and frequency18 weeks (2 times / week, 36 sessions total)	Pain intensity, disability and kinesiophobia significantly improved over time.
Maclnyre et al. (2023)*	n = 10	Not mentioned in abstract	Mentioned only as “chronic” in abstract	VR graded activity interventionAn immersive gamified VR intervention based on principles of graded activity. Program duration and frequency14 to 23 days (6–9 intervention sessions)	The VR graded activity intervention resulted in a significant reduction in pain intensity with four patients achieving≥30% pain reduction.
Sato et al. (2021)*	n = 40 EG = 20CG = 20	EG = 49.3 (mean age) CG = 55.60 (mean age)	Mentioned only as “chronic” in abstract	EG: Nintendo Ring Fit Adventure (RFA) exergameRFA exergaming was performed once a week for 40 min. CG: Oral treatment Program duration and frequency8 weeks	In EG, low back pain significantly improved after eight weeks of RFA exergaming, but there was no significant improvement in kinesiphobia. In the CG, no significant improvement was observed after eight weeks of oral treatment.

n: numerus; EG: experimental group; CG: control group; VR: virtual reality; SD: standard deviation; PT: physical therapy; ODI: The Oswestry Disability Index; VAS: The visual analog scale; NPRS: The Numeric Pain Rating Scale; RMDQ: Roland-Morris Disability Questionnaire; TSK: Tampa Scale of Kinesiophobia. ^*Only abstract available.

3.2 Assessment of study quality

The assessment of study quality according to PEDro Scale is shown in Table 2. Most studies were of good quality, with 12/22 reaching a score between 6 and 8 points on the PEDro scale. One additional study was of poor quality (3 points) and 9 were of fair quality (4-5 points).

Table 2
Assessment of study quality with Pedro Scale

Study/Score TOTAL SCORE Eligibility criteria Random allocation Concealed allocation Baseline compar. Blind subjects Blind therapists Blind assess. Adequate follow-up Intention-to-treat analysis Between-group compar. Point estim. and variab.

Garcia et al. (2021) 6 1 1 1 1 0 0 0 1 1 1 0

Nambi, Abdelbasset, Alrawaili, et al. (2021) 6 1 1 0 1 0 0 0 1 1 1 1

Nambi et al. (2022) 6 1 1 0 1 0 0 1 1 0 1 1

Stamm et al. (2022) 6 0 1 0 1 0 0 0 1 1 1 1

Nambi et al. (2020) 7 1 1 0 1 0 0 1 1 1 1 1

Nambi, Abdelbasset, Alsubaie, et al. (2021) 6 1 1 0 1 0 0 0 1 1 1 1

Eccleston et al. (2022) 8 1 1 1 0 1 1 0 1 1 1 1

Park et al. (2013) 5 1 1 0 1 0 0 0 1 0 1 1

Oh et al. (2014) 4 1 1 0 1 0 0 0 0 0 1 1

Yoo et al. (2014) 4 1 1 0 0 0 0 0 1 0 1 1

Monteiro-Junior et al. (2015) 6 1 1 0 1 0 0 1 1 0 1 1

Chen et al. (2016) 4 1 1 0 1 0 0 0 0 0 1 1

Zadro et al. (2019) 8 1 1 1 1 0 0 1 1 1 1 1

Kim et al. (2020) 5 1 1 0 1 0 0 0 0 1 1 1

Park et al. (2020) 4 1 1 0 1 0 0 0 0 1 1 0

Tomruk et al. (2020) 7 1 1 1 1 1 0 0 1 0 1 1

Afzal et al. (2022) 5 0 1 0 1 0 0 0 1 0 1 1

Fatoye et al. (2022) 3 1 1 0 0 0 0 0 0 0 1 1

Nambi, Abdelbasset, Elsayed, et al. (2021) 8 1 1 0 1 1 1 0 1 1 1 1

Mbada et al. (2019) 5 1 1 0 1 1 0 0 0 0 1 1

Groenveld et al. (2023) 6 1 1 1 1 0 0 0 1 0 1 1

Yalfani et al. (2022) 4 1 1 0 1 0 0 0 0 0 1 1

Study/Score	TOTAL SCORE	Eligibility criteria	Random allocation	Concealed allocation	Baseline compar.	Blind subjects	Blind therapists	Blind assess.	Adequate follow-up	Intention-to-treat analysis	Between-group compar.	Point estim. and variab.
Garcia et al. (2021)	6	1	1	1	1	0	0	0	1	1	1	0
Nambi, Abdelbasset, Alrawaili, et al. (2021)	6	1	1	0	1	0	0	0	1	1	1	1
Nambi et al. (2022)	6	1	1	0	1	0	0	1	1	0	1	1
Stamm et al. (2022)	6	0	1	0	1	0	0	0	1	1	1	1
Nambi et al. (2020)	7	1	1	0	1	0	0	1	1	1	1	1
Nambi, Abdelbasset, Alsubaie, et al. (2021)	6	1	1	0	1	0	0	0	1	1	1	1
Eccleston et al. (2022)	8	1	1	1	0	1	1	0	1	1	1	1
Park et al. (2013)	5	1	1	0	1	0	0	0	1	0	1	1
Oh et al. (2014)	4	1	1	0	1	0	0	0	0	0	1	1
Yoo et al. (2014)	4	1	1	0	0	0	0	0	1	0	1	1
Monteiro-Junior et al. (2015)	6	1	1	0	1	0	0	1	1	0	1	1
Chen et al. (2016)	4	1	1	0	1	0	0	0	0	0	1	1
Zadro et al. (2019)	8	1	1	1	1	0	0	1	1	1	1	1
Kim et al. (2020)	5	1	1	0	1	0	0	0	0	1	1	1
Park et al. (2020)	4	1	1	0	1	0	0	0	0	1	1	0
Tomruk et al. (2020)	7	1	1	1	1	1	0	0	1	0	1	1
Afzal et al. (2022)	5	0	1	0	1	0	0	0	1	0	1	1
Fatoye et al. (2022)	3	1	1	0	0	0	0	0	0	0	1	1
Nambi, Abdelbasset, Elsayed, et al. (2021)	8	1	1	0	1	1	1	0	1	1	1	1
Mbada et al. (2019)	5	1	1	0	1	1	0	0	0	0	1	1
Groenveld et al. (2023)	6	1	1	1	1	0	0	0	1	0	1	1
Yalfani et al. (2022)	4	1	1	0	1	0	0	0	0	0	1	1

3.3 Disability – VR vs. Placebo VR, no intervention or exercise

Two studies compared VR with a placebo VR for ODI outcome (54 and 57 patients in VR and placebo VR groups, respectively). The pooled effect strongly favoured VR (SMD = –3.12; 95% CI = –8.14 to 1.90), but the two studies were highly heterogenous (I² = 98%) and the effect was not statistically significant (p = 0.220).

Two studies compared VR with no intervention, one for ODI and one for RMD outcome (44 and 39 patients in VR and control groups, respectively). The pooled effect favored VR (SMD = –0.24; 95% CI = –0.68 to 0.19; I² = 0%) but was not statistically significant (p = 0.270).

Three studies compared VR with exercise for ODI outcome (67 and 69 patients in VR and exercise groups, respectively). The analysis indicated no difference between the two interventions (SMD = –0.05; 95% CI = –0.57 to 0.48; I² = 58%; p = 0.860).

3.4 Pain intensity – VR vs. Placebo VR

Three studies compared VR with a placebo VR (143 and 147 patients in VR and placebo VR groups, respectively) for pain intensity outcome (studies used NRS, VAS and DVPRS measures). The pooled effect was statistically significant and strongly favoured VR (SMD = –1.90; 95% CI = –3.60 to –0.20; p = 0.03), however, the studies were highly heterogenous (I² = 96%).

3.5 Pain intensity – VR vs. no intervention

Six studies compared VR with no intervention (110 and 103 patients in VR and control groups, respectively). Included studies used NRS and VAS measures for pain intensity. The pooled effect strongly favoured VR (SMD = –1.66; 95% CI = –2.49 to –0.83; p < 0.001). However, the heterogeneity between the studies was high (I² = 84%).

3.6 Pain intensity – VR vs. exercise

Five studies compared VR with exercise (98 and 100 patients in VR and exercise groups, respectively). Included studies used NRS and VAS measures for pain intensity. The effect favoured VR interventions over exercise (SMD = –0.61; 95% CI = –1.06 to –0.16; p = 0.008) for pain intensity, with moderate heterogeneity between the studies (I² = 57%). Two studies also compared VR with exercise at eight weeks and six months follow-up period (35 and 35 patients in VR and exercise groups, respectively). In this case, the overall effect still favoured VR, but was not statistically significant (SMD = –0.84; 95% CI = –3.07 to 1.39; p = 0.460).

3.7 Pain intensity – VR combined with exercise vs. exercise alone

Two studies compared VR interventions combined with exercise therapy with exercise interventions alone (26 and 23 patients in each group, respectively), one for VAS and one for NRS outcome. The pooled effect indicated no difference between the interventions in pain intensity (SMD = –0.08; 95% CI = –0.78 to 0.62; I² = 32%; p = 0.820).

3.8 Pain intensity – VR combined with PT vs. exercise combined with PT

Seven studies compared VR interventions combined with PT with exercise therapy combined with PT for VAS outcome (142 and 142 patients in VR combined with PT and exercise groups, respectively). The effect strongly favoured VR combined with PT over exercise combined with PT (SMD = –1.42; 95% CI = –2.33 to –0.52; p = 0.002), with moderate to high heterogeneity between the studies (I² = 88%). Four studies also compared VR combined with PT with exercise combined with PT during a follow-up (71 and 72 patients in VR combined with PT and exercise combined with PT groups, respectively). In this case, the overall effect was still very large and favoured VR (SMD = –2.01; 95% CI = –2.42 to –1.60; p < 0.001; I² = 0%).

4 Discussion

The aim of this systematic review with meta-analysis was to investigate the effects of VR on pain, disability, and kinesiophobia compared with other therapeutic interventions in CLBP patients. Thirty-three studies were included in this review and twenty-two were eligible for meta-analysis. In meta-analyses, VR was compared to placebo VR, no intervention, exercise, or PT combined with exercise. The experimental groups included stand-alone VR interventions or combined VR interventions with exercise or PT. We were able to partially confirm our hypothesis regarding the effects of VR on pain intensity and fully confirm our hypothesis regarding the effects on disability. In the short term, VR interventions were found to be superior than placebo VR, no intervention, exercise and exercise combined with PT in terms of pain intensity. However, the meta-analysis showed no significant difference in pain reduction between VR combined with exercise and exercise only. There were also no significant differences in disability outcomes between VR and non-VR interventions. Due to the high heterogeneity among studies and the small number of studies included in some meta-analyses, our evidence is of low quality, which calls for further research in the future.

4.1 Effects on pain intensity

Pain intensity was assessed in all studies included in the meta-analysis. In the short term, VR demonstrated significant advantages over placebo VR, no intervention, or exercise in terms of pain outcomes. In the short and long term, addition of VR to PT showed better results regarding pain intensity outcomes compared with PT combined with exercise. However, the results should be interpreted with caution. While in the studies that found superiority of VR, the effect size, represented by the standardized mean differences (SMD), appears substantial (SMD ≥0.61), the wide confidence intervals (CI) indicate potential unreliability in the estimation of the true effect or substantial heterogeneity between studies. On the contrary, VR combined with exercise therapy was not superior in reducing pain intensity than exercises alone. Six single-arm studies that were excluded from the meta-analysis showed a significant pain reduction after VR intervention [28 , 49]. In a recent experimental study by Afzal et al. [50], a three-week intervention of VR combined with PT resulted in a significant improvement in pain levels as well. The mechanisms underlying pain reduction due to VR interventions primarily involve creating distraction from the painful area, engaging attention resources (i.e., focus shifting), and blocking external stimuli [51]. This increases pain tolerance and threshold, while also decreasing pain intensity and rumination [52, 53]. Long-term pain management can be achieved by skill-building through VR, which can empower patients to build capacities necessary to regulate their response to painful stimuli and take an active role in their own care [9]. Moreover, long-term VR use is expected to induce neuroplastic changes in sensory and motor brain regions [54]. While our results suggest that VR can be used to reduce pain intensity in CLBP patients, the question remains whether the use of VR is preferable to exercise therapy in reducing pain levels. Based on our study, VR and non-VR exercises have similar long-term effects on pain reduction in CLBP patients. Furthermore, our meta-analysis showed similar short-term effects on pain improvement between VR combined with exercise and exercise only interventions. In addition, the use of VR in training can have certain additional side effects that we need to keep in mind when prescribing such training, and these are: dizziness, headaches and motion sickness. VR can cause visually induced motion sickness, as the sensory information often contradicts the expected information from body movement, which is primarily due to visual information rather than the vestibular sense or proprioception [67]. Further research is needed to draw definite conclusions regarding the benefits of using VR interventions compared with exercise for pain management in CLBP patients.

Fig. 2

Comparison of virtual reality with no intervention for pain scores.

Fig. 3

Comparison of virtual reality with exercise for pain scores.

Fig. 4

Comparison of virtual reality combined with physical therapy with exercise combined with physical therapy for pain scores.

4.2 Effects on disability

Six studies included in the meta-analysis assessed disability outcomes in patients with CLBP. Consistent with a previous systematic review Brea-Gómez et al. [6], VR interventions were no better than no VR interventions in improving disability in the short term. VR showed similar effects on disability compared with placebo VR, exercise, or no intervention. However, it should be noted that the pooled effect favoured VR in all meta-analyses related to disability outcome. It is possible that significant effects would be obtained if more studies were included in the meta-analysis. Two single armed studies [48, 49] that were not included in our meta-analyses found a significant improvement in disability after VR intervention, whereas one study [33] reported a non-significant disability improvement overtime. Studies that examined the effects of VR interventions lasting less than four weeks on CLBP patients also found conflicting results. Some report a significant impact on disability after the intervention [50], while others do not [55]. Although our results do not confirm significant differences regarding the short-term improvements in disability between VR intervention and non-VR interventions, the use of VR in patients with CLBP may still be useful in the long term, as it may contribute to a better patient compliance [56, 57].

4.3 Effects on kinesiophobia

Due to the lack of studies that observed changes in kinesiophobia that had comparable study design, meta-analyses could not be performed for kinesiophobia outcomes. However, we included nine studies that reported changes in kinesiophobia in the narrative review. As a stand-alone intervention, VR has been shown to result in greater improvements in kinesiophobia outcomes compared with placebo VR or standard treatment [42]. Similarly, studies report greater improvements in kinesiophobia levels following combined VR interventions with PT or patient education when compared with non-VR interventions (exercise therapy combined with PT or patient education) [22 , 58]. Kinesiophobia reduction through VR interventions can be achieved by patients paying less attention to fear and shifting attention from harmful stimuli to more pleasant experiences [59]. However, when VR was compared to no intervention, [38] found no significant between-group differences in kinesiophobia. No significant improvements in kinesiophobia post VR intervention were seen in the majority of single-armed studies [39, 44]. Given the inconsistent results between studies and comparisons of VR interventions with different control groups, it is difficult to recommend a VR intervention over other non-VR interventions to improve kinesiophobia levels in patients with CLBP.

4.4 Strengths and limitations

This review represents an update of our understanding of the effects of VR treatment in CLBP by including a meta-analysis of recently published studies not included in previous meta-analyses. Furthermore, in our meta-analyses, we examined the effects of VR on additional outcomes such as disability and kinesiophobia, which were not analysed in the most recent meta-analysis by Choi et al. [60]. According to the PEDro scale, most studies included in our meta-analysis (12 of 22) were of good methodological quality. However, most meta-analyses (five of eight) were small and included only two to three studies. One of the main limitations was the high heterogeneity of the included studies. Studies differed primarily in the type of VR used, sample size, duration of intervention and gender and age of the participants. Almost a third of the included studies (10 of 33 studies) had a sample size of less than 30. In addition, the average age of participants in 9 of the 33 included studies was below 30 years, which does not represent the population with the highest incidence of CLBP, which is between 50 and 60 years old [66]. It is possible that different conclusions would have been drawn if the studies had been more homogeneous or more research was available for inclusion in the meta-analysis. In addition, if more research had been available in this area, we could have included more studies in our meta-analysis, which could also have led to different results.

5 Conclusion

The aim of this systematic review and meta-analysis was to examine the effects of VR on pain, disability, and kinesiophobia compared with other therapeutic interventions in CLBP patients. We found short-term superiority of VR interventions over non-VR interventions in terms of pain intensity. However, no significant differences were found in disability outcomes between VR and non-VR interventions. Furthermore, the inconsistent results across studies prevent us from recommending VR interventions over other non-VR interventions for changes in kinesiophobia in patients with CLBP. Due to the high heterogeneity between studies and the small number of studies included in some meta-analyses, our evidence is of low quality, which calls for further research in the future. Future research should focus primarily on the population that best represents patients with CLBP, i.e. patients older than 50 years. At the same time, more research would be needed on the use of VR in CLBP, investigating the effects on kinesiophobia.

Footnotes

Acknowledgments

The authors were supported by the Slovenian Research and Innovation Agency through the research program KINSPO - Kinesiology for the effectiveness and prevention of musculoskeletal injuries in sports (P5-0443). The funder played no role in conceptualization of the article and decision to publish.

Data availability

Raw data may be obtained by request to the corresponding author.

Conflict of interest

The authors have no conflict of interest to report.

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