Currently accepted at: Journal of Medical Internet Research
Date Submitted: Dec 24, 2025
Open Peer Review Period: Dec 24, 2025 - Feb 18, 2026
Date Accepted: Jun 8, 2026
Date Submitted to PubMed: Jun 14, 2026
(closed for review but you can still tweet)
This paper has been accepted and is currently in production.
It will appear shortly on 10.2196/90289
The final accepted version (not copyedited yet) is in this tab.
An "ahead-of-print" version has been submitted to Pubmed, see PMID: 42289384
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Efficacy of Various Virtual Reality Exposure Therapies for Chronic Low Back Pain: A Systematic Review and Network Meta-Analysis
ABSTRACT
Background:
Chronic low back pain is a major global health challenge. While non-pharmacological 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.
Objective:
To compare and rank the efficacy of different Virtual Reality Exposure Therapy (VRET) modalities on pain intensity, functional disability, and kinesiophobia in patients with chronic low back pain (CLBP).
Methods:
Systematic searches were conducted in PubMed, Web of Science, Scopus, Embase, CINAHL, and the Cochrane Library from inception until June 2025. Randomized controlled trials assessing the effects of virtual reality exposure therapy on individuals with chronic low back pain were selected. Primary outcomes were pain intensity, functional disability (Oswestry Disability Index), and kinesiophobia (Tampa Scale of Kinesiophobia). The Cochrane Risk of Bias tool (RoB2) was used for quality assessment. 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 (SUCRA) values. The GRADE framework was adapted to evaluate the quality of evidence.
Results:
25 RCTs with a total of 2,610 participants were included in the analysis. For pain intensity, shooting games (SMD -4.40; 95% 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 (SUCRA) indicated that shooting games had the highest probability (98%) of being the most effective intervention for pain relief. For functional 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.
Conclusions:
VRET, particularly in the context of shooting games and VR-based equestrian training, appears effective for reducing pain in CLBP; Prioritize higher-ranked shooting games, reserving VR-based cognitive behavioral therapy as an alternative or adjunct for kinesiophobia. However, the benefits for functional improvement remain uncertain. Clinical Trial: PROSPERO CRD420251131116; https://www.crd.york.ac.uk/PROSPERO/view/CRD420251131116
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Copyright
© The authors. All rights reserved. This is a privileged document currently under peer-review/community review (or an accepted/rejected manuscript). Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for review and ahead-of-print citation purposes only. While the final peer-reviewed paper may be licensed under a cc-by license on publication, at this stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.