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Bottom line
VR-based interventions show promise for modestly reducing pain catastrophizing in chronic pain, particularly immersive VR paired with psycho-cognitive approaches, but the small number of trials, high risk of bias, and loss of significance in strict analyses mean the findings are preliminary.
Preliminary evidencePublished
Evidence hierarchy
Study participants
Adults with chronic musculoskeletal pain (chronic low back pain, back/neck pain, fibromyalgia)
Study Summary
This systematic review and meta-analysis pooled nine randomized controlled trials (eight meta-analyzed; 565 adults with chronic musculoskeletal pain) to examine whether virtual reality (VR)-based interventions reduce pain catastrophizing. Overall, VR produced a small but statistically significant reduction in catastrophizing versus controls (SMD = -0.26 [-0.48; -0.04]), with the strongest and most consistent effects seen for immersive VR combined with psycho-cognitive approaches (e.g., pain neuroscience education, CBT, mindfulness, relaxation). Exercise-based VR did not show a significant effect, and the benefit lost significance when analysis was restricted to studies using the validated 13-item Pain Catastrophizing Scale. The authors conclude VR shows promise—especially immersive psycho-cognitive modalities—but caution that the small number of studies, high risk of bias in four trials, and protocol variability mean findings are preliminary and require further high-quality RCTs.
Key Findings
| Finding | Detail | Impact |
|---|---|---|
| VR produced a small but significant overall reduction in pain catastrophizing | Pooling all VR interventions versus all control groups yielded SMD = -0.26 (95% CI -0.48 to -0.04), classified as a small effect size and statistically significant (p = 0.02). | High |
| Psycho-cognitive VR worked; exercise-based VR did not | Psycho-cognitive VR interventions reduced catastrophizing (SMD = -0.32 [-0.56; -0.09]), while physical exercise-based VR showed no significant effect (MD = -0.11 [-4.36; 4.14]). Subgroup analysis confirmed significant effects only for cognitive-based VR (g = -0.32, p = 0.006) and none for motor-based VR (g = -0.01, p = 0.96). | High |
| Immersive VR with a psycho-cognitive approach was most effective against inactive controls | Immersive psycho-cognitive VR compared with non-intervened or sham controls showed a significant small effect (SMD = -0.37 [-0.75; -0.00]); all VR versus sham/passive controls also reached significance (g = -0.35, p = 0.01). | Medium |
| The benefit was not robust to the strictest analyses | When restricted to the only immersive comparison against all comparators the effect was non-significant (SMD = -0.25 [-0.51; -0.00], p = 0.053), and excluding high-risk-of-bias studies lost significance (g = -0.32, p = 0.09). Limiting to the validated 13-item PCS gave a larger but non-significant effect (MD = -1.87 [-4.24; 0.51]). | High |
| Heterogeneity was low and no publication bias was detected | Between-study heterogeneity was classified as 'might not be important' to moderate (e.g., I2 = 38.4%) and was not statistically significant. Egger's regression test showed no funnel-plot asymmetry (intercept = 0.47, p = 0.75). | Medium |
| Four of nine included trials had a high risk of bias | Using the Cochrane RoB-2 tool, four studies were rated high overall risk of bias; only one study was rated low risk across all domains. Domains D1 (randomization) and D4 (outcome measurement) showed the highest risk. | Medium |
Pooling all VR interventions versus all control groups yielded SMD = -0.26 (95% CI -0.48 to -0.04), classified as a small effect size and statistically significant (p = 0.02).
Psycho-cognitive VR interventions reduced catastrophizing (SMD = -0.32 [-0.56; -0.09]), while physical exercise-based VR showed no significant effect (MD = -0.11 [-4.36; 4.14]). Subgroup analysis confirmed significant effects only for cognitive-based VR (g = -0.32, p = 0.006) and none for motor-based VR (g = -0.01, p = 0.96).
Immersive psycho-cognitive VR compared with non-intervened or sham controls showed a significant small effect (SMD = -0.37 [-0.75; -0.00]); all VR versus sham/passive controls also reached significance (g = -0.35, p = 0.01).
When restricted to the only immersive comparison against all comparators the effect was non-significant (SMD = -0.25 [-0.51; -0.00], p = 0.053), and excluding high-risk-of-bias studies lost significance (g = -0.32, p = 0.09). Limiting to the validated 13-item PCS gave a larger but non-significant effect (MD = -1.87 [-4.24; 0.51]).
Between-study heterogeneity was classified as 'might not be important' to moderate (e.g., I2 = 38.4%) and was not statistically significant. Egger's regression test showed no funnel-plot asymmetry (intercept = 0.47, p = 0.75).
Using the Cochrane RoB-2 tool, four studies were rated high overall risk of bias; only one study was rated low risk across all domains. Domains D1 (randomization) and D4 (outcome measurement) showed the highest risk.
Strengths
- First systematic review and meta-analysis to specifically quantify VR's effect on pain catastrophizing in chronic pain populations
- Followed PRISMA reporting standards with a pre-registered protocol (INPLASY 202480099)
- Comprehensive multi-database search (PubMed, CINAHL, Scopus, Web of Science, PEDro) plus Google Scholar and reference lists, with no language or date restrictions
- Used the validated Cochrane RoB-2 tool with two independent reviewers and a third adjudicator (almost-perfect inter-rater agreement)
- Multiple sensitivity and subgroup analyses (by risk of bias, VR type, therapeutic approach, control type, and measurement instrument) tested robustness
- Low-to-moderate heterogeneity and no detectable publication bias (Egger's p = 0.75)
Limitations
- Only nine RCTs were eligible and eight meta-analyzed, a small evidence base for firm conclusions
- Four of nine included studies had a high overall risk of bias, which may have over- or underestimated effects
- Observed effect sizes were small, so clinical relevance is uncertain even where statistically significant
- Two studies used a non-validated four-item PCS variant; when analysis was restricted to the validated 13-item PCS the effect became non-significant
- Only one included study used a non-immersive VR system, limiting comparison across VR modalities
- Restriction to RCTs excluded other study designs and limited the diversity of contexts examined
- Variability in protocols, session frequency/duration, pain conditions, and baseline catastrophizing levels limits generalizability
Key Takeaways for Patients
What This Means for You
- 01Virtual reality programs may modestly help reduce 'pain catastrophizing'—the cycle of magnifying, dwelling on, and feeling helpless about pain—in people with long-term pain, but the benefit is small.
- 02The VR approaches that helped were the psychological/educational ones (immersive headsets paired with pain education, relaxation, mindfulness, or cognitive behavioral techniques), not VR used purely for exercise.
- 03The evidence is still early: only nine trials exist, several had quality concerns, and the benefit weakened in the most rigorous analyses, so VR should be seen as a possible add-on rather than a proven standalone treatment.
- 04If you are considering VR for pain, discuss it with your clinician as one part of a broader plan; results so far suggest it works best when combined with psychological or educational strategies.
Read the Full Paper
Access the complete peer-reviewed study from Journal of Clinical Medicine
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