Virtual Reality as a Therapy Adjunct for Fear of Movement in Veterans With Chronic Pain: Single-Arm Feasibility Study
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Abstract
BACKGROUND: Virtual reality (VR) has demonstrated efficacy for distraction from pain-related thoughts and exposure to feared movements. Little empirical VR research has focused on chronic pain management. OBJECTIVE: The purpose of this study was to examine the feasibility of VR as an adjunctive intervention for Veterans with chronic pain. We designed a hierarchy ranging from low-intensity pain distraction to high-intensity movement-based exposure for this purpose. VR apps were mapped onto the hierarchy. METHODS: Sixteen Veterans receiving inpatient chronic pain rehabilitation participated in daily VR sessions over a 3-week period. Trajectories across the distraction-to-exposure hierarchy and Veteran-reported intensity ratings were described and evaluated over time. Minimum clinically important differences (MCIDs), pre-post effect sizes, and 95% confidence intervals were examined for fear of movement using the Fear of Daily Activities Questionnaire (FDAQ) and Pain Outcomes Questionnaire-VA (POQ-VA; fear scale). This approach was applied to secondary outcomes: POQ-VA (pain intensity, interference, negative affect), Pain Catastrophizing Scale, and Patient-Specific Functioning Scale (PSFS). Session attendance, completion, and VR experiences were described. RESULTS: Ten of 14 Veterans (71%) who participated in three or more VR sessions completed the distraction-to-exposure hierarchy. Only three trajectories emerged more than once. Due to high completion rates, Veterans that completed the hierarchy could self-select nonhierarchy apps. Veterans rated all hierarchy levels (low, medium, high) near medium intensity. Self-selected activities were rated as high intensity. For kinesiophobia, six Veterans (38%) exceeded the MCID on the FDAQ and a small effect size improvement was observed (Cohen d=-0.35). The confidence interval (95% CI -0.71 to 0.01) indicated the possibility of a null effect. The POQ-VA fear scale yielded no effect (Cohen d=0.06, 95% CI -0.43 to 0.54). For secondary outcomes, Veterans exceeding MCID were calculated with complete data: pain intensity (1/15, 7%), pain catastrophizing (5/14, 36%), and patient-specific functioning (10/15, 67%). Effect sizes were large for patient-specific functioning (Cohen d=1.14, 95% CI 0.50-1.78), medium for mobility interference (Cohen d=-0.56, 95% CI -0.96 to -0.16), and small for pain intensity (Cohen d=-0.40, 95% CI -0.69 to -0.12) and catastrophizing (Cohen d=-0.41, 95% CI -0.79 to -0.02). No effects were observed for interference in daily activities (Cohen d=0.10, 95% CI -0.27 to 0.47) and negative affect (Cohen d=0.07, 95% CI -0.26 to 0.40). Veterans attended 85.2% (98/108) of VR sessions and completed 95% (93/96) of sessions attended. Twenty-minute sessions were rated as too short. No significant adverse events were reported. CONCLUSIONS: Findings support the feasibility of VR as an adjunct for Veterans with chronic pain. However, the hierarchy will require modification, as evidenced by homogeneous intensity ratings. Veteran-selected activities presented the highest intensity ratings, largest outcome effect size (PSFS), and MCID. This highlights the important role of utilizing Veteran stakeholders in hierarchy modification, design of VR interventions, and outcome selection.
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Most studies consist of very small samples and some did not have a control group or the control group was too small, which may have an important impact on the final results.
“most studies consist of very small samples and some of them did not count with a control group or in some cases, the control group was also too small (Bogenschutz et al., 2015; Fowler et al., 2019), which may have an important impact on the final results.”
From Virtual reality and psychedelics for the treatment of psychiatric disease: A systematic literature review (2020) · cites this paper as Fowler et al., 2019
The Results (Aim 2) report a sample of 16 veterans. The Discussion (Limitations) identifies the small sample as a limitation that likely widened the effect-size confidence intervals and says a randomized control group is needed to estimate VR’s added impact. This supports using Fowler et al. as an example of a small study without a control group, but not the broader claim that most studies have small samples or that some have undersized control groups. (LLM, conf=0.85)
Experimental — accuracy not yet measuredFowler et al. (2019) had the smallest sample (n=16).
“the study made by Fowler et al. (2019) having the smallest sample (n=16).”
From Virtual reality and psychedelics for the treatment of psychiatric disease: A systematic literature review (2020) · cites this paper as Fowler et al. (2019)
The Results (Demographic Characteristics, Table 1) identify the study sample as N=16. The cited paper does not establish that this was the smallest sample among the studies the citing document compares. (LLM, conf=0.88)
Experimental — accuracy not yet measuredTechnical difficulties and environmental noise may have hindered immersion in Fowler et al. (2019).
“Some limitations emerged, principally concerning technical difficulties during the study, such as inconsistent wi-fi source, the lack of a kiosk mode, and a need to restart the apps during sessions, as well as other factors such as environmental noise, situations that may have hindered immersion.”
From Virtual reality and psychedelics for the treatment of psychiatric disease: A systematic literature review (2020) · cites this paper as Fowler et al. (2019)
After removing an outlier, a small effect size improvement was noted for fear of movement using the FDAQ, but not the POQ-VA, in Fowler et al. (2019).
“after the removal of an outlier, a small effect size improvement was noted for the primary outcome fear of movement when using the FDAQ, but not the POQ-VA.”
From Virtual reality and psychedelics for the treatment of psychiatric disease: A systematic literature review (2020) · cites this paper as Fowler et al. (2019)
Fowler et al. (2019) found that 38% exceeded the Minimum Clinically Important Difference on the FDAQ for kinesiophobia.
“the Minimum Clinically Important Difference (MCID) for kinesiophobia indicated that 38% exceeded MCID on the FDAQ”
From Virtual reality and psychedelics for the treatment of psychiatric disease: A systematic literature review (2020) · cites this paper as Fowler et al. (2019)
Fowler et al. (2019) showed improvements in interference with mobility and pain intensity.
“Improvements observed in interference with mobility and pain intensity”
From Virtual reality and psychedelics for the treatment of psychiatric disease: A systematic literature review (2020) · cites this paper as Fowler et al. (2019)
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Percentages, sums and reported differences re-computed from the paper’s own numbers.
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- Authors
- Fowler, C. A., Ballistrea, L. M., Mazzone, K. E., Martin, A. M., Kaplan, H., Kip, K. E., Ralston, K., Murphy, J. L., & Winkler, S. L.
- Affiliations
- James A. Haley Veterans' Hospital (US)
- University of South Florida (US)
- Corresponding author
- Fowler, Christopher A
- ORCID
- Venue
- JMIR Formative Research
- Publisher
- JMIR Publications Inc.
- Published
- 2019-10-30
- Volume
- 3
- Issue
- 4
- Pages
- e11266
- ISSN
- 2561-326X (ISSN-L)
- PMC
- PMC6914277
- OpenAlex
- W2976186436
- Cited by
- 36
- References
- 77
- Citations by year
- 2026: 1 · 2025: 5 · 2024: 9 · 2023: 7 · 2022: 7 · 2021: 4 · 2020: 3
- FWCI
- 3.31
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JMIR Formative Research (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Veterans Affairs
- University of South Florida
- Topics
- Physical Sciences › Computer Science › Human-Computer Interaction › Virtual Reality Applications and Impacts
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Keywords
- virtual reality therapy, kinesiophobia, chronic pain, veterans, pain distraction, pain catastrophizing, chronic pain rehabilitation, feasibility, pain interference, negative affect, session attendance, minimal clinically important difference, confidence intervals, effect size
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