The report is a product of the VA/HSR Evidence Synthesis Program.

Extended Reality Interventions for Chronic Pain: A Systematic Review

Takeaway: Extended reality (XR) physical activity interventions may have benefits for some conditions (e.g., chronic neck pain), but the evidence is very uncertain for others (e.g., chronic low back pain, fibromyalgia, post-surgical pain, and rehabilitation). While XR psychological skills interventions may have benefit for chronic low back pain, studies did not compare effects with analogous non-XR interventions.

More than a quarter of Veterans have chronic pain, and for many, their pain causes frequent functional limitations in daily life or work activities. Non-drug therapies are first-line treatments for common pain conditions due to their known benefits and low risks, particularly as compared to opioids and invasive procedures. However, the effects of non-drug therapies may vary across common pain conditions and patient characteristics, and patient adherence is critical for effectiveness over time.

Extended reality (XR) is a spectrum of digital technologies that can deliver non-drug therapies for pain, such as teaching self-management psychological skills or guiding physical activity. Virtual reality (VR) entails the highest level of immersion in an interactive, fully digital environment, while augmented reality (AR) provides partially immersive user experiences by adding digital elements to real-world environments, or by translating user activities into the digital world. XR interventions have been implemented in clinical settings for a range of health conditions, including acute and chronic pain treatment.

In response to a request from the VHA XR Network, in collaboration with VA Health Systems Research (HSR) and VA’s National Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) Office, HSR’s Evidence Synthesis Program (ESP) Center in Minneapolis conducted a systematic review on the benefits and harms of XR interventions to treat (key question 1 [KQ1]) or prevent (key question 2 [KQ2]) chronic pain.

Investigators searched for relevant articles in MEDLINE, Embase, CINHAL, PsycINFO, and Scopus databases through May 2023, using key words and subject headings for VR and AR, exergaming, pain, and a variety of pain conditions (e.g., arthritis, fibromyalgia). They also hand-searched relevant systematic reviews identified via the database searches, and clinical trial registries for recently completed and ongoing trials through August 2023.

Eligible studies evaluated XR interventions to treat or prevent chronic pain in adults and addressed at least 1 primary outcome of interest (i.e., pain-related functioning or interference, pain intensity or severity, pain catastrophizing or kinesiophobia [fear of physical movement], pain global change, quality of life, and adverse events). Additionally, eligible studies for KQ1 were randomized controlled trials (RCTs), and KQ2 studies required ≥3 months of follow-up. In all, ESP investigators identified 71 eligible articles reporting 60 unique primary studies: 58 articles that addressed KQ1, and 13 articles that addressed KQ2.

Summary of Findings

Studies were generally very small (e.g., 30 studies with total n ≤ 50, only 4 with total n > 100). Twenty-two studies addressed chronic low back pain, while fewer examined chronic neck pain (k=6), fibromyalgia (k=5), chronic knee pain (k=5), and post-surgical pain (k=7). A variety of other pain conditions had only 1 eligible study (e.g., headache or phantom limb pain).

• For chronic low back pain, VR pain psychological skills interventions may result in greater improvement in pain intensity and pain-related functioning, compared with VR sham or usual care.
• For chronic neck pain, VR physical activity may result in greater improvement in pain intensity but little to no difference in pain-related functioning at 3–6 weeks; the evidence is very uncertain for effects at 3–4 months. VR interventions were compared with non-VR physical activity.
• The evidence is very uncertain for effects of other VR and AR interventions for chronic back pain, neck pain, and knee pain, along with other examined conditions.
• Few studies reported on adverse events, and there was a lack of studies comparing XR psychological skills interventions with analogous non-XR interventions.

Implications

XR technology has considerable potential as part of a comprehensive plan for pain treatment. Given the possibilities for home use and remote monitoring, and the increasing affordability of some XR technologies, these interventions may be able to address common patient barriers to access and use of non-drug therapies for pain. However, the evidence base reflects the early state of the science in this field, and it remains unclear how and under which circumstances XR adds the most benefit for pain treatment.

Limitations

Defining and separating VR and AR interventions can be challenging, and existing frameworks for XR technologies differ in where boundaries are drawn. To ensure the review addressed a broad range of clinically relevant XR interventions, ESP investigators included AR interventions that many would consider minimally immersive. Also, ESP investigators categorized XR interventions into broad groups (e.g., psychological skills, physical activity) that contained studies with substantial variation in intervention schedules, durations, and content.

Future Research

Future work should address how and by which mechanisms XR interventions may impact pain outcomes, particularly in more diverse populations and settings. Larger studies and application of implementation frameworks are important next steps for advancing this field. Studies should compare XR psychological skills interventions to analogous non-XR interventions, investigate added value of XR technology, and generate further evidence on participant experiences—including adverse events, attitudes toward XR, and barriers and facilitators of access and use.

Goldsmith E, Anthony M, Landsteiner A, et al. Extended Reality Interventions for Chronic Pain: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Systems Research, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-009; 2024.

To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/xr-pain.cfm (intranet only).

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management Brief is provided to inform you about recent HSR findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR Resource Center charged with disseminating important HSR findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers; and to disseminate these reports throughout VA.

See all reports online.