Orthopedics · Medical Literature
Efficacy of Various Virtual Reality Exposure Therapies for Chronic Low Back Pain: Systematic Review and Network Meta-Analysis.
Abstract
Chronic low back pain (CLBP) is a major global health challenge. While nonpharmacological therapies are recommended, patient compliance is often hindered by kinesiophobia. Virtual reality (VR) offers an immersive, distraction-based approach, but the comparative effectiveness of different VR modalities remains unclear. The aim of the study is to compare and rank the efficacy of different VR-based training modalities on pain intensity, disability, and kinesiophobia in patients with CLBP. Systematic searches were conducted in PubMed, Web of Science, Scopus, Embase, CINAHL, and the Cochrane Library from inception until June 2025. Randomized controlled trials (RCTs) assessing the effects of VR-based training on individuals with CLBP were selected. Primary outcomes were pain intensity, disability (Oswestry Disability Index), and kinesiophobia (Tampa Scale of Kinesiophobia). The Cochrane Risk of Bias 2 tool was used for quality assessment. Confidence in Network Meta-Analysis (CINeMA) framework was used to evaluate the credibility of cumulative evidence. A Bayesian network meta-analysis with standardized mean difference (SMD) as effect size was performed to synthesize evidence and rank interventions using surface under the cumulative ranking curve values. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework was adapted to evaluate the quality of evidence. In total, 25 RCTs with a total of 2610 participants were included in the analysis. For pain intensity, shooting games (SMD -4.40, 95% credible interval [CrI] -6.80 to -2.20) and VR-based equestrian training (SMD -2.00, 95% CrI -3.70 to -0.57) were significantly superior to all types of controls. Surface under the cumulative ranking curve indicated that shooting games had the highest probability (98%) of being the most effective intervention for pain relief. For disability, no intervention demonstrated statistically significant superiority. For kinesiophobia, shooting games (SMD -3.40, 95% CrI -5.60 to -1.10) significantly outperformed traditional exercise controls. The quality of evidence ranged from very low to moderate across outcomes. This first network meta-analysis to compare and rank distinct VR modalities for CLBP offers several key innovations and contributions to the field. By moving beyond aggregate VR categorizations, we provide a granular, comparative ranking of specific, actionable VR interventions. Unlike previous reviews that treated VR as a homogeneous group or only compared it to sham, our network meta-analysis directly and indirectly compares 7 distinct VR modalities, revealing that not all VR is equally effective. Our findings suggest that shooting games have the potential to be the most effective VR therapy for relieving pain intensity and kinesiophobia, though evidence for disability remains limited. Unfortunately, due to heterogeneity and low-quality evidence, there is no evidence demonstrating significant improvement in specific outcomes for patients with CLBP. More RCTs are needed to provide robust clinical evidence.
Clinical relevance
Among adults with chronic low back pain (CLBP), which specific virtual reality (VR)-based training modality — when compared with each other and with conventional controls — is most effective for reducing pain intensity, functional disability (ODI), and kinesiophobia (Tampa Scale)? __SNAPSHOT__ {"studyDesign":"Systematic review with Bayesian network meta-analysis of randomized controlled trials (NMA); evidence quality assessed via Cochrane Risk of Bias 2 tool, CINeMA framework, and adapted GRADE","setting":"Multi-database international search (PubMed, Web of Science, Scopus, Embase, CINAHL, Cochrane Library); inception through June 2025; affiliated institutions include Beijing Sport University and National Institute of Sports Medicine, General Administration of Sport of China","sampleSize":"n=2,610 participants across 25 RCTs","population":"Adults with chronic low back pain (CLBP); specific inclusion criteria (e.g., pain duration threshold, age range, comorbidity exclusions) not fully reported in the available abstract","intervention":"Seven distinct VR-based training modalities: VR shooting games, VR-based equestrian training, pelvic flexibility game, VR-based walking training, VR-based cognitive behavioral therapy (CBT), VR-based yoga training, and multicomponent mixed game","comparator":"Three control categories: traditional exercise control (CON1), nonexercise control (CON2), and placebo control (CON3); direct and indirect comparisons synthesized via network meta-analysis","primaryOutcome":"Pain intensity, disability measured by the Oswestry Disability Index (ODI), and kinesiophobia measured by the Tampa Scale of Kinesiophobia (TSK)","followUp":"Not reported in the available abstract","fundingSource":"Not reported in the available abstract"}
Key findings
Twenty-five RCTs enrolling 2,610 participants were included. The Bayesian NMA compared 7 distinct VR modalities across 3 control conditions. For pain intensity, VR shooting games (SMD −4.40, 95% credible interval [CrI] −6.80 to −2.20) and VR-based equestrian training (SMD −2.00, 95% CrI −3.70 to −0.57) were statistically superior to all control types. Surface under the cumulative ranking curve (SUCRA) analysis assigned VR shooting games the highest probability (98%) of being the most effective intervention for pain relief. For disability (ODI), no VR modality demonstrated statistically significant superiority over any control. For kinesiophobia (TSK), VR shooting games were significantly superior to traditional exercise controls (SMD −3.40, 95% CrI −5.60 to −1.10). NNT/NNH are not calculable from SMD-based data without distributional assumptions. Absolute effect sizes in original scale units (e.g., VAS points, ODI percentage points) were not reported in the available abstract. The magnitude of the SMDs reported for shooting games (pain: −4.40; kinesiophobia: −3.40) are very large by conventional benchmarks, but their clinical interpretation is substantially constrained by the very low to moderate quality of the underlying evidence. Adverse events were not reported in the available abstract.
Practice implications
This network meta-analysis — described by its authors as the first to directly compare and rank distinct VR modalities for CLBP rather than treating VR as a homogeneous category — suggests that VR shooting games may hold the greatest promise for short-term pain reduction and kinesiophobia mitigation compared with traditional exercise or non-exercise controls. VR equestrian training also demonstrated significant pain reduction. However, the authors themselves explicitly caution that, due to heterogeneity and low-quality evidence, no modality can be definitively recommended for improving any specific outcome in CLBP patients at this time. The disability outcome (ODI) was not significantly improved by any intervention, which is the most functionally relevant endpoint in clinical practice. Critically, the quality of evidence ranged from very low to moderate across outcomes, meaning that the large SMDs observed — particularly for shooting games — cannot be interpreted with confidence. The patient populations represented in the 25 constituent RCTs were not uniformly characterized in the abstract (age range, pain chronicity, prior treatment, comorbidities), limiting generalizability. Patients with severe structural pathology, those already compliant with conventional exercise, elderly patients, and those with limited technology access were likely underrepresented. Practice should not change on the basis of this review alone; confirmation from high-quality, adequately powered, individual RCTs is required. Note: Only the abstract was available for this summary, which limits full appraisal of methodology, individual study characteristics, follow-up duration, and adverse event reporting. __LIMITATIONS__ Evidence quality ranged from very low to moderate across all outcomes by CINeMA/GRADE, severely limiting confidence in effect estimates.,Very large SMDs (e.g., −4.40 for shooting games on pain) may reflect small, underpowered constituent trials, publication bias, or measurement heterogeneity rather than true clinical superiority.,The abstract does not report follow-up durations; durability of VR-mediated effects on pain and kinesiophobia is unknown.,Network geometry details (e.g., number of direct vs. indirect comparisons per node, loop inconsistency testing results) are not available from the abstract alone.,Blinding of participants to VR versus non-VR conditions is inherently impractical, introducing performance and detection bias across all included trials.,Disability (ODI) — arguably the most clinically meaningful functional endpoint — showed no significant difference for any VR modality, which tempers enthusiasm for translation to practice.,Heterogeneity in VR hardware, dose, session frequency, and co-interventions across 25 RCTs limits transitivity assumptions underlying the network meta-analysis.,Adverse events, including cybersickness and musculoskeletal injury during VR use, were not reported in the available abstract.,Funding sources for both the review and included primary studies are not reported, preventing assessment of sponsorship bias.,Geographic and population representativeness (age, sex, comorbidity distribution) cannot be assessed from the abstract alone; findings may not generalize to older adults or those with significant comorbidity. __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This Bayesian network meta-analysis of 25 RCTs (n=2,610) found that VR shooting games produced the largest reductions in pain intensity and kinesiophobia in CLBP patients compared with traditional exercise and nonexercise controls, with a 98% SUCRA ranking probability for pain relief; VR equestrian training also outperformed all control types for pain. However, evidence quality was very low to moderate across outcomes, no VR modality significantly improved functional disability (ODI), and the authors explicitly state that heterogeneity precludes definitive clinical recommendations. Clinicians should regard these findings as hypothesis-generating; VR modalities for CLBP remain promising but require confirmation from large, well-conducted RCTs before integration into standard care.