1 Background

Chronic pain is very challenging to treat because effective pain management is often hindered by various socio-environmental factors, such as culture, religion or personality. Consequently the inadequate treatment of pain may negatively impact a patient’s psychological wellbeing and overall quality of life (Brennan et al. 2007; Sarzi-Puttini et al. 2012). The prevailing approach used to treat and manage chronic pain is based on a multimodal and inclusive method, that encompasses both pharmacological and non-pharmacological interventions (Hooten et al. 2013; Sarzi-Puttini et al. 2012). An affordable, flexible, and practical non-pharmacological treatment option is virtual reality (VR). VR is defined as the combination of images and sounds that create a computer-generated environment that appears almost real and allows the user to interact with and make modifications (Collins English Dictionary 2022; Oxford University Press 2022). VR is typically experienced through technological tools consisting of software and hardware, (Collins English Dictionary 2022; Oxford University Press 2022), such as a head-mounted display (HMD; Chen et al. 2016; Darnall et al. 2020; Garcia et al. 2021, 2021; Hoffman et al. 2006; Nusser et al. 2021; Pozeg et al. 2017; Sarig Bahat et al. 2018; Solcà et al. 2020; Tejera et al. 2020; Wiederhold et al. 2014), 3-dimentional glasses and/or tv screen (Karamnejad Salmani 2014; Thomas et al. 2016). It can also be associated with a motion tracker (Bolte et al. 2014; Chen et al. 2016; Matheve et al. 2020; Thomas et al. 2016). While VR technology has found its place in the video game industry (Katzourin et al. 2006; Roettl and Terlutter 2018), it also has applications in the field of acute and chronic pain treatments, although at the time of this review, the evidence is still limited. To the best of our knowledge, there are two literature reviews addressing VR and chronic pain (Chuan et al. 2020; Mallari et al. 2019). Chuan et al. (2020), with their narrative review, explored the use of VR for both acute and chronic pain, reporting diverse results. The systematic review and meta-analysis of Mallari et al. (2019) provided evidence of the effectiveness of VR for acute pain, but more focus is required for chronic pain studies. A research synthesis concerning specific evidence regarding chronic pain and the impact of VR on pain reduction at the time of this review is lacking. Therefore, a systematic review focusing on the application of VR in chronic pain management is imperative to elucidate the current state of knowledge in this rapidly evolving field.

The objective of this paper is therefore to contribute to the knowledge about opportunities, usage, and effectiveness of VR-based interventions in chronic pain management.

2 Method

The current review adheres to the PRISMA statement for reporting systematic reviews and meta-analyses (Liberati et al. 2009; Moher et al. 2009).

2.1 Eligibility criteria

The articles eligible for analysis in this study were required to be written in English. There were no specific temporal boundaries regarding publication dates. On a design level, exclusions were made for meta-analyses, systematic reviews, books, exclusively qualitative studies, feasibility, usability or acceptability studies, as well as study protocols. Inclusion criteria mandated the presence of participants suffering from chronic pain and the use of VR as a therapeutic tool. Articles that did not involve VR intervention, as per the definition of VR (Collins English Dictionary 2022; Oxford University Press 2022) were excluded. Likewise, articles that did not differentiate between chronic and acute pain, articles lacking comparisons between groups with and without VR, and case studies were also excluded. Augmented reality (AR) and VR were not distinguished and were considered part of the same technology. Furthermore, several articles were unavailable in full-text versions, leading to their exclusion.

2.2 Information sources

Data collection from various databases commenced in December 2020 and concluded in February 2021. The databases consulted are Cochrane Evidence, JSTOR, Science Direct, PubMed Medline, PubMed NIH, Springer Link, PsychNET, PsychINFO - OVID and PsycARTICLES, Wiley Online Library, Web of Science, ProQuest - MEDLINE®, Sage Journals, NCBI – NLM catalog, Medline OVID, Medline EBSCO, Oxford Handbooks Online, PSYNDEX OVID, Google Scholar.

2.3 Research procedure

The literature research was conducted using the databases mentioned above. The results were gathered and documented in a separated file. To ensure accuracy and consistency, a second individual reviewed the results, eliminating duplicates and applying the eligibility criteria. The research was conducted in English, and the initial keywords entered in the databases were: virtual reality AND chronic pain. As the search progressed, the keyword “management” was added to enhance result filtering, following the PRISMA guidelines by Moher et al. (2009). In JSTOR, and Science Direct, the keywords used were virtual reality AND chronic pain. Virtual reality was searched in titles, while chronic pain was searched in all fields using the advanced search tool. In Science Direct, additional filters for review articles and research articles were applied. For the Cochrane Evidence and NCBI – NLM catalog databases, the keywords virtual reality AND chronic pain were used without additional filters. In the PsycNET database, which includes PsychINFO-OVID and PsychArticles the keywords used were virtual reality AND chronic pain. Filters for Peer-Reviewed Journals only were selected, and the search was conducted through the advanced search tool.

The Wiley Online Library and Web of Science databases utilized the keywords virtual reality AND chronic pain, both specified as titles, in the advanced search tool. In the Google Scholar database, the advanced search tool was used with the keywords virtual reality AND chronic pain in titles.

In PubMed-Medline, the keywords virtual reality AND chronic pain AND (management OR therapy) were entered in the Advanced search tool, with all keywords searched as present in titles. For PubMed – NIH, a standard search was performed with the keywords virtual reality AND chronic pain AND management and the filter Human was applied. In the Springer Link database, the Advanced Search tool was used with the keywords virtual AND reality, AND chronic AND pain, AND management, AND “virtual reality” AND (management, OR therapy). Filters for Article and English were activated. In Medline ProQuest and Sage Journals databases the keywords virtual reality AND chronic pain were used. In Medline ProQuest, the filters for humans and English were selected, while Sage Journals had no filters. For the Oxford Handbook Online database, the keywords virtual reality AND chronic pain were used. Virtual reality was searched in the summary and chronic pain in the full text. In Medline OVID and PSYNDEX OVID, the keywords virtual reality AND chronic pain were employed, searched in all fields for the former and as a normal search for the latter, without applying any filters. In the Advanced search tool of Medline EBSCO, the keywords virtual reality AND chronic pain were used, with both searched in the title field.

3 Results

3.1 Study selection

The articles collected were listed by databases in a separate document, including titles, publication dates, authors’ names, resulting in a total of 453 articles. Subsequently, duplicates were manually removed, reducing the total to 177 items. Through both databases Cochrane Evidence and JSTOR three items were found and no doubles; on Science Direct 28 items and one double were present, three items and two doubles were on PubMed Medline; on PubMed NIH 31 items were found and six doubles; 34 items and one double were found through Springer Link; 18 items and 12 doubles were found on PsychINFO – OVID, which is included, with PsycARTICLES (where no items were found), in PsychNET; through Wiley Online Library two doubles were found; Web of Science provided ten items and 29 doubles, 12 items and 30 doubles were found on ProQuest - MEDLINE®; 37 items and three doubles were found on Sage Journals; through NCBI – NLM catalog eight items and no doubles were found; Medline OVID has provided 12 items and 52 doubles; six items and 28 doubles were found on Medline EBSCO; four items and no doubles were found through Oxford Handbooks Online; PSYNDEX OVID provided 22 items and four doubles; and through Google Scholar 43 items and five doubles were found.

In the next phase, a preliminary selection of articles based on titles and abstracts led to the exclusion of 243 items. Following this initial screening process, a second step involved the full-text reading of the remaining 33 articles to determine their eligibility for inclusion in this review. The second selection reduced the number of eligible articles to 17. A diagram illustrating the selection process is presented in Fig. 1.

Fig. 1
figure 1

Diagram representing the searching and selection process divided in four phases. n = number of studies, VR = Virtual Reality. Diagram adapted by “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.” by Moher, Liberati, Tetzlaff, Altman, The PRISMA Group, 2009, PLOS Medicine, 6(7), p. 3

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3.2 Data extraction

After a thorough review of the selected articles, a table outlining the key characteristics of the 17 chosen articles was created by the same individual responsible for article selection (Table A in the appendices). The table includes sections for the authors and publication year, the study’s purpose and design, the number of participants, the type and number of control and experimental groups, inclusion and exclusion criteria, participant age and gender, the study’s location, the type of pain addressed, intervention organization and characteristics, the technology and measures employed, the presence of follow-up, and whether the study has been published or not.

3.3 Data analysis and synthesis of results

Upon close examination of the 17 articles, several aspects related to the type of chronic pain, technology, and purpose emerged.

Firstly, the type of chronic pain analyzed varied across the studies, encompassing various body parts and pain conditions. For instance, two studies focused on patients suffering from chronic neck pain, specifically non-specific chronic neck pain (Tejera et al. 2020) and non-traumatic chronic neck pain (Nusser et al. 2021). Chronic back pain was addressed in one study (Igna et al. 2014), while chronic low back pain was considered in seven studies (Bağcıer and Batıbay 2020; Chidozie et al. 2019; Darnall et al. 2020; Garcia et al. 2021; Matheve et al. 2020; Nambi et al. 2020; Thomas et al. 2016), two of which specifically focused on non-specific chronic low back pain (Bağcıer and Batıbay 2020; Matheve et al. 2020). Chronic leg pain patients were included in two studies (Karamnejad Salmani 2014; Solcà et al. 2020). One study involved various types of chronic pain (Karamnejad Salmani 2014) or did not specify the kind of chronic pain (Guarino et al. 2017). Additionally, one study compared a sample of chronic non-cancer pain patients with healthy participants (Wiederhold et al. 2014) while another compared healthy participants with paraplegic participants with spinal cord injury (Pozeg et al. 2017). Furthermore, various pain origins were considered, such as musculoskeletal (Darnall et al. 2020), neuropathic (Pozeg et al. 2017), and inflammatory (Aivaliotis et al. 2020). In particular one study included patients with spinal cord injuries (Pozeg et al. 2017); while abdominal pain was addressed in a single study (Aivaliotis et al. 2020), as well as fibromyalgia patients (Darnall et al. 2020).

The variety in the type of technology used in the examined articles is notable. While VR is a common element in all the studies, the means of delivering VR to participants differ. Most of the studies employed through head-mounted display (HMD) (Darnall et al. 2020; Garcia et al. 2021; Nusser et al. 2021; Pozeg et al. 2017; Sarig Bahat et al. 2018; Solcà et al. 2020; Tejera et al. 2020; Wiederhold et al. 2014). Although not explicitly confirmed, the use of HMD can be inferred in the articles of Aivaliotis et al. (2020), Chidozie et al. (2019) and Igna et al. (2014). Several studies incorporated three-dimensional (3D) technologies alongside VR. For instance, Thomas et al. (2016) used a 3D television combined with 3D glasses and a movement marker on the participant’s body. Karamnejad Salmani (2014) utilized a 3D screen placed in a tissue container, which participants viewed with 3D glasses. This study also included biofeedback with galvanic skin response (GSR) sensors. Another example of technological diversity can be found in the article of Bağcıer and Batıbay (2020), who utilized the game console Nintendo Wii (Nintendo, Kyoto, Japan) and its associated devices to perform yoga with a video screen and a 3D computer-supported system. Nambi et al. (2020) used a training machine equipped with a screen to provided VR. In some experiments, authors integrated other technologies to ensure a more immersive and comprehensive experience, such as headphones or audio devices (Aivaliotis et al. 2020; Darnall et al. 2020; Guarino et al. 2017; Pozeg et al. 2017). Additionally, some studies incorporated movement tracking sensors (Matheve et al. 2020; Thomas et al. 2016).

3.4 Types of intervention used and outcomes

To facilitate a more accurate comparison of the studies, three distinct groups were created based on the type of intervention:

  1. 1.

    Studies focusing on promoting physical activity or physical rehabilitation to improve chronic pain (Bağcıer and Batıbay 2020; Chidozie et al. 2019; Nambi et al. 2020; Nusser et al. 2021; Pozeg et al. 2017; Sarig Bahat et al. 2018; Solcà et al. 2020; Tejera et al. 2020; Thomas et al. 2016);

  2. 2.

    Studies using Cognitive Behavioral Therapy (CBT) including mindfulness techniques, meditation, or relaxation to manage chronic pain (Darnall et al. 2020; Garcia et al. 2021; Guarino et al. 2017; Igna et al. 2014; Karamnejad Salmani 2014);

  3. 3.

    Studies examining the use of distraction techniques to assess their impact on pain perception, some of which also incorporate physical or mindfulness/meditative/relaxation techniques (Aivaliotis et al. 2020; Matheve et al. 2020; Wiederhold et al. 2014).

Tables 1, 2 and 3 provide a summary of the analyzed articles, focusing on the study’s purpose, type of chronic pain addressed, characteristics of the intervention, and the study’s results. Table 1 specifically summarizes the studies that utilized VR in combination with physical activity and/or physical rehabilitation programs to evaluate their effects on chronic pain.

Table 1 Table representing the purpose, type of pain, characteristics and results of studies using physical activity and/or physical rehabilitation activities to intervene against chronic pain
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The technique of modified visual feedback combined with VR has been used in various studies (Pozeg et al. 2017; Solcà et al. 2020). The results of Solcà et al.‘s (2020) study demonstrate an analgesic effect of VR immersive intervention with modified visual feedback combined with spinal cord stimulation in individuals suffering from chronic leg pain. Visual feedback modification is also considered by Pozeg et al. (2017). In their study, the authors combined visual and tactile stimulation presented with VR both in both synchronized and a synchronized ways for individuals with neuropathic pain due to a spinal cord injury (Pozeg et al. 2017). The results highlight the presence of a general slight analgesic effect during the virtual leg illusion condition for the neuropathic pain group (Pozeg et al. 2017). A minor sensitivity to multisensory stimulations, inducing the illusory leg ownership, has been found in comparison to the healthy group (Pozeg et al. 2017). The effect of VR presentation of multisensory stimulation leads to a difference in the ownership of legs, i.e. the participant’s perception of experiencing their legs as their own (Gallagher 2000), compared to the body’s one (Pozeg et al. 2017). Moreover, a slight analgesic effect during (Pozeg et al. 2017) and after (Solcà et al. 2020) the use of this technology was found.

One study used a popular game station to investigate the effects of a non-immersive VR-based yoga program and usual exercises on pain, functionality, and myofascial trigger points (Bağcıer and Batıbay 2020). The results showed a statistically significant improvement in the experimental group of these elements regardless of the type of physical activity used, compared with a treated-as-usual control group (Bağcıer and Batıbay 2020). These results suggest that both the practice of usual exercise and VR-based yoga exercise have a positive impact on chronic pain and functionality (Bağcıer and Batıbay 2020). Sarig Bahat et al. (2018) explored the effects of an immersive VR game-based intervention on pain, motion, and disability in the near and middle term compared to a no VR group and a control group. The authors highlight improvements in pain intensity, speed. Accuracy and overall state of health in both intervention groups, with a greater improvement in the VR condition. This article suggest a good applicability of VR technologies to an home-based training program (Sarig Bahat et al. 2018). Nambi et al. (2020) compared the effects of VR training with isokinetic training and a conventional training group on university football players with chronic low back pain. The VR training group exhibited a reduction in pain intensity score, an increase in wellness score, and improvements in the variables determining sports performance, suggesting that the use of a VR training protocol may lead to a greater improvement in pain and sports performance in these individuals.

Nusser et al. (2021) compared a non-VR sensorimotor training with VR rehabilitation training to evaluate their effects on chronic non-traumatic neck pain. The VR group showed a significant enhancement in extension, flexion, headaches, self-described disability, and left rotation. Compared to the control group, the VR group had enhancements in extension, flexion, and headaches. When compared to the sensorimotor group, the VR group exhibited a statistically significant enhancement in cervical extension. In patients with chronic non-traumatic neck pain, the use of VR appears to enhance the effects of an average rehabilitation intervention.

To assess whether VR can be an alternative to in-person treatment, the study by Chidozie et al. (2019) compared the Clinic-Based McKenzie Therapy with its VR game version to evaluate their effects on pain, kinesiophobia and on other aspects (details in Table A) in participants with chronic non-specific low back pain. The results showed no differences between the two groups, making the two versions of the therapy comparable regarding results (Chidozie et al. 2019). An exception was observed for kinesiophobia, which decreased more in the VR group, and for vitality/energy, which was lower in the same group (Chidozie et al. 2019). The results of this article suggest that the VR version can be a great alternative to clinic-based therapy (Chidozie et al. 2019).

However, no differences between the VR groups and the control groups, and no significant results, were found in the studies of Tejera et al. (2020) and Thomas et al. (2016). In their article, Thomas et al. (2016) evaluated the effects of a VR 3D basketball game on kinesiophobia and lumbar spine flexion. No statistically significant differences between groups on lumbar spine flexion or kinesiophobia indicators such as expected injuries or pain were found (Thomas et al. 2016). Nevertheless, a reduction in the expected pain level from pre- and post-test was observed, although the change was present in both the control and gaming groups (Thomas et al. 2016). A decrease in some pain scores, but not in all, was observed from pre- to post-intervention (Thomas et al. 2016). Thomas et al. (2016) justified the lack of significant results by claiming that the experience was too brief to be generalized beyond the game. A similar pattern of results is present in the study by Tejera et al. (2020). The authors evaluated the effects of a VR intervention in comparison to physical exercise in participants with non-specific chronic neck pain (Tejera et al. 2020). No statistically significant differences emerged between the VR group and the exercise group in the pain variables (see Table 2; Tejera et al. 2020).

Table 2 describes the articles that have focused their investigation on the effects of a VR intervention combined with mindfulness, relaxation, or meditation on chronic pain.

Table 2 Table representing the objectives, types of pain, characteristics and results of studies employing mindfulness, meditation, and relaxation as interventions for chronic pain
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Three studies use VR combined with biofeedback technology, and all seem to have positive results on pain (Darnall et al. 2020; Garcia et al. 2021; Karamnejad Salmani 2014). In their study, Darnall et al. (2020) found a reduction in pain symptoms during and after a VR CBT intervention in patients with chronic low back pain and fibromyalgia. The intervention was based on a CBT program delivered via VR with virtual scenarios designed to improve self-regulation of pain and stress and to learn CBT’s self-management, mindfulness, and biofeedback skills (Darnall et al. 2020).

Following the analyses of Garcia et al. (2021), the improvement in pain intensity, pain interference with activity, mood and stress, appears to be comparable to a VR treatment combined with biofeedback experiences and pain and stress management techniques. In their article, a comparison between the control group (viewing a 2D nature scene) and the experimental group (VR interactive immersive program with biofeedback experiences and activities aimed at teaching pain and stress management strategies) was conducted (Garcia et al. 2021), showing a greater improvement in both groups, with a greater improvement observed in the experimental group (Garcia et al. 2021). Another study (Karamnejad Salmani 2014) analyzed the effect of biofeedback technology combined with mindfulness in a VR intervention. In this study, the results suggests that VR combined with biofeedback can lead to a reduction in pain in chronic pain patients. Karamnejad Salmani (2014) proposed a single VR intervention lasting 12 min, during which the participants engaged in a mindfulness meditation combined with biofeedback technique. This intervention appears to lead to a decrease in pain scores in the experimental group (Karamnejad Salmani 2014). Mindfulness and relaxation are also employed in the context of a study that combined Cognitive-Behavioral Therapy (CBT) supplemented with mindfulness and relaxation, CBT with exercises in VR, and treatment as usual (Igna et al. 2014). The results show a reduction in pain levels in the CBT group with the mindfulness intervention compared to treatment as usual, but no differences are reported between the two CBT groups (Igna et al. 2014). Guarino et al. (2017) compare two groups of chronic pain patients, one treated with a VR relaxation and breathing intervention and one treated as usual with pharmacotherapy, magneto therapy, treatment with ultrasounds, and thermotherapy. A reduction in pain and anxiety scores in the VR group compared to the treatment as usual group suggests a greater efficacy of the VR treatment (Guarino et al. 2017).

The articles described in Table 3 utilize VR as a straightforward pain distraction (found in the last section of the table), or combine it for both purposes, such as distraction and training with physical activity (found in the first section of the table) or for mindfulness, meditative, and relaxing activities (found in the second section of the table).

Table 3 Table representing the purpose, type of pain, characteristics, and results of studies using VR as a simple distraction (last section of the table), combining both distraction and physical exercises (first section) or integrating it with mindfulness/relaxation/meditation (second section)
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The study by Aivaliotis et al. (2020) compares the use of VR combined with mindfulness to VR as a distractor for patients with chronic abdominal pain. Both VR interventions lead to a decrease in pain and anxiety scores, with no significant difference between the two groups. This suggests the effectiveness of VR as a supportive tool for delivering other types of treatment such as mindfulness and as a distractor for managing chronic abdominal pain (Aivaliotis et al. 2020). Matheve et al. (2020) also explore the use of VR as a distractor. Specifically, they investigate the effects of non-immersive VR physical exercises as a distraction from pain (Matheve et al. 2020). The VR group shows a reduction in pain and pain-related thoughts during and immediately after the treatment (Matheve et al. 2020). The role of VR in pain distraction is further analyzed in the study by Wiederhold, Gao, Kong, et al. (2014), where healthy participants are compared with chronic pain patients. The primary purpose of this study was to compare the effectiveness of mobile technology for delivering VR with traditional VR (Wiederhold et al. 2014). The authors used the cold pressor experiment to induce pain in healthy participants, allowing them to compare the control group with the chronic pain group (Wiederhold et al. 2014). The results demonstrate that VR is effective for pain management whether delivered through a mobile device or an HMD display (Wiederhold et al. 2014).

3.5 Outcomes of the studies

The most common measure used to assess pain intensity among the studies described above is the Visual Analog Scale (VAS; Collins et al. 1997), which appears in ten studies (Aivaliotis et al. 2020; Bağcıer and Batıbay 2020; Chidozie et al. 2019; Igna et al. 2014; Nambi et al. 2020; Pozeg et al. 2017; Sarig Bahat et al. 2018; Solcà et al. 2020; Tejera et al. 2020; Wiederhold et al. 2014). The second pain evaluation instrument used is the McGill Pain Questionnaire (Melzack 1975), employed in four studies (Guarino et al. 2017; Igna et al. 2014; Karamnejad Salmani 2014; Thomas et al. 2016). An 11-point Numerical Rating Scale (NRS), where 0 means no pain and 10 means the worst pain possible, was also used to assess pain intensity in five studies (Darnall et al. 2020; Karamnejad Salmani 2014; Matheve et al. 2020; Nusser et al. 2021; Wiederhold et al. 2014). Two studies (Darnall et al. 2020; Garcia et al. 2021) also used the Defense and Veterans Pain Rating Scale (DVPRS; Buckenmaier et al. 2013) to assess pain intensity. One study (Chidozie et al. 2019) used a variant of the VAS (Collins et al. 1997): the Quadruple Visual Analogue Scale (QVAS; Von Korff et al. 1993). In addition, one psychophysiological experimental measure, conditioned pain modulation (Smith and Pedler 2018), was used by Tejera et al. (2020) to assess the inhibitory pathway of painful stimuli. Guarino et al. (2017), along with the McGill Pain Questionnaire (Melzack 1975), also employed the Brief pain Inventory Severity and Brief pain Inventory Interference scale (BPI; Cleeland and Ryan 1994); while Wiederhold et al. (2014) used a pain intensity scale questionnaire including the VAS (Collins et al. 1997), the NRS, a descriptive pain intensity scale.

4 Discussion

The primary aim of this paper was to investigate the impact of various VR interventions on chronic pain and explore the effects of this technology on pain perception in individuals suffering from chronic pain. To address these objectives, we conducted a systematic review of the literature following the PRISMA guidelines for reporting systematic reviews and meta-analyses (Liberati et al. 2009; Moher 2009). The qualitative analysis revealed a consistent pattern of positive impacts of pain variables (Aivaliotis et al. 2020; Bağcıer and Batıbay 2020; Darnall et al. 2020; Garcia et al. 2021; Guarino et al. 2017; Igna et al. 2014; Karamnejad Salmani 2014; Matheve et al. 2020; Nambi et al. 2020; Nusser et al. 2021; Sarig Bahat et al. 2018; Solcà et al. 2020; Thomas et al. 2016; Wiederhold et al. 2014) Some studies reported these positive outcomes only during the treatment (Pozeg et al. 2017; Wiederhold et al. 2014) or in both intervention and control groups (Aivaliotis et al. 2020; Igna et al. 2014). However, Tejera et al. (2020) and Thomas et al. 2016) found no statistically significate differences between control groups and VR groups regarding pain variables. Chidozie et al. (2019) did not observe differences between intervention and control groups, suggesting comparable efficacy of clinic-based in-person intervention and home-based VR therapy. This finding implies the potential for a more accessible way of treating chronic pain, such as in a domestic environment. Similarly, Igna et al. (2014) found no significant difference between two intervention groups, namely Cognitive Behavioral Therapy (CBT) and CTB with VR. The absence of improvement attributable to VR could be explained by the presence of CBT in both intervention groups, as CBT has been repeatedly shown to be effective in managing chronic back pain (Hajihasani et al. 2019; Sveinsdottir et al. 2012).

Some studies involving healthy participants demonstrated an increase in pain intensity (Hoffman et al. 2006; Patel et al. 2020) and pain tolerance (Loreto-Quijada et al. 2014) during controlled painful experiences. These results in healthy participants reinforce the observed pattern of results in chronic pain patients. Furthermore, Patel et al. (2020) illustrated the efficacy of an intervention using a low-cost VR device, which is intriguing considering VR as a potential meanas to extend part of the rehabilitative process to a patient’s home. Conversely, Hoffman et al. (2006) highlighted a greater efficacy in reducing pain with high-technology VR compared to low-technology. In summary, the systematic review indicates a generally positive impact of VR interventions on chroinc pain. While consistent improvements were noted, variations in outcomes across studies raise context-specific considerations. The comparability of clinci-based and home-based therapy sugessts a potential for more accessible treatments. The lack of significant differences in certain intervention groups underscores the role of established approaches like CBT. Findings form healthy participants affirm the efficacy of both low-cost and high-technology VR interventions. As we navigate the potential of VR in chronic pain management, these insights contribute to a more comprehensive understanding of its varied applications, highlighting the need for tailored interventions based on specific patient populations and contexts.

5 Limitations

This paper acknowledges several limitations. The primary concern is the heterogeneity of the articles, encompassing varied VR technologies and pain conditions. To address this, we categorized interventions into three groups: physical, meditative/mindfulness/psychologic, and distractive interventions. However, the diverse range of interventions, from game-like approaches to visual reality manipulation, poses a challenge to direct comparisons. Additionally, the paper treats VR and AR as a unified technology, without distinguishing the two. The study did not consider specific chronic pain types or participants’ sex and gender, contributing to result heterogeneity. The exclusion of 15 studies due to unavailability of full-text versions may have influenced result patterns. Moving forward, future studies should refine inclusion criteria, focusing on specific VR interventions to enhance result homogeneity and provide a clearer understanding of VR’s impact on chronic pain.

6 Conclusion

This paper aimed to explore the existing literature on the impact of VR interventions on pain perception among chronic pain patients. Despite challenges in comparing various VR intervention types and specific chronic pain conditions, the results suggest a broad applicability of VR interventions. While further research is warranted, VR has demonstrated adaptability, showing positive effects across different types of chronic pain and settings. The transportability of this technology suggests potential widespread use in domestic contexts, offering a promising avenue of pain management and rehabilitation, particularly for individuals with difficulties in travel. In conclusion, VR emerges as an adaptable, effective, and valuable tool for pain management in individuals experiencing different forms of chronic pain.