Skill-Based Virtual Reality Therapy Shows Durable Benefit in High-Impact Chronic Pain

Key Takeaways

• At 2 years, larger improvements in pain interference, pain intensity, sleep disturbance, and disability were observed in high-impact chronic pain, while depression was not statistically different.
• At 2 years, 71.1% of participants with high-impact chronic pain who had follow-up data were reclassified as low-impact chronic pain, consistent with earlier follow-up patterns.
• The program used 56 daily home VR sessions with mailed devices, and no serious adverse events or side effects were reported.

This secondary analysis focused on the randomized trial’s skill-based VR arm in chronic low back pain. In the Journal of Medical Internet Research report, investigators reported larger durable improvements in the high-impact subgroup than in the low-impact subgroup. The pattern was sustained benefit concentrated in participants who entered treatment with greater pain-related impact.

This secondary analysis came from a randomized, placebo-controlled parent trial that assigned 1067 participants 1:1 in a double-blind design to skill-based virtual reality therapy or sham VR. The sham program presented 2D nature videos with neutral music and no pain-relief skill content. The skill-based VR sample included 536 participants, including 192 classified as high-impact and 344 classified as low-impact. The subgroup contrast was examined within the skill-based VR arm rather than through randomization between pain-impact categories. Baseline classification used the study’s validated Brief Pain Inventory pain interference threshold of 7 to distinguish high-impact from low-impact chronic pain, framing the later outcome comparisons.

At 2 years, the high-impact subgroup had a mean 3.1-point reduction in pain interference, with a 95% CI of 2.66 to 3.54 and an effect size of 1.12. Pain intensity in that subgroup fell by 2.6 points, with a 95% CI of 2.18 to 3.02 and an effect size of 1.01. Reductions were also larger than in the low-impact subgroup for sleep disturbance and disability, with between-group differences reported at P<.001. Within the high-impact subgroup, sleep disturbance decreased by 7.8 points and disability by 14.7 points, while depression changed by 0.9 points. Depression did not differ significantly between subgroups, with P=.34, leaving the most pronounced sustained gains among participants who started with higher pain-related impact.

End-of-treatment and 1-year findings followed the same subgroup pattern seen at 2 years. At 2 years, 71.1% of participants who began with high-impact chronic pain and had follow-up data, 106 of 149, were reclassified as low-impact chronic pain. Earlier reports showed similar reclassification rates of 70% at the end of treatment and 67% at 1 year. Two-year survey completion reached 88.1%, with 420 of 477 end-of-treatment completers providing follow-up data, supporting the durability pattern over time.

The intervention used a fixed sequence of 56 daily immersive 3D sessions that combined pain neuroscience education with self-regulatory strategies. Devices were mailed to participants in a national community sample of adults with chronic low back pain who were recruited and tested online. No serious adverse events or side effects were reported, and harms were assessed in the primary trial rather than reassessed in this secondary analysis.

These findings reflect adults with self-reported chronic low back pain, and the high-impact versus low-impact comparison within the VR arm was not randomized.