research article

Pain Neuroscience Education Delivered Through Virtual Reality for Common Musculoskeletal Conditions Seen in Physical Therapy: An Exploratory Study

Adriaan Louw1*, Kory Zimney2, Daniel Stopher3, K. Glen Saldanha1, Jake Shockley4, Lauren Elliott4, Daniel Macera5, Terry Cox6

1Evidence in Motion Pain Felllowship, Story City IA, USA

2University of South Dakota, School of Health Sciences, Department of Physical Therapy, Vermillion SD, USA

3ProRehab Physical Therapy, Lousville KY, USA

4Physical Therapy Central, Oklahoma City OK, USA

5PappasOPT Physical, Sports and Hand Therapy, Johnston RI, USA

6Southwest Baptist University, Bolivar MO, USA

*Corresponding author: Adriaan Louw, Evidence in Motion Pain Fellowship, 618 Broad Street, Suite B, Story City, IA, 50248, USA.

Received Date: 28 April, 2023

Accepted Date: 03 May, 2023

Published Date: 05 May, 2023

Citation: Louw A, Zimney K, Stopher D, Saldanha KG, Shockley J, et al. (2023) Pain Neuroscience Education Delivered Through Virtual Reality for Common Musculoskeletal Conditions Seen in Physical Therapy: An Exploratory Study. Rep Glob Health Res 6: 157. DOI:


Treating persistent musculoskeletal pain in healthcare and globally is clinically challenging and emerging digital therapeutic treatments such as augmented and virtual reality may help ease this burden. Current best evidence supports pain neuroscience education (PNE) as a viable strategy to ease pain and disability of patients attending physical therapy with persistent musculoskeletal pain. The objective of this exploratory study was to determine what, if any, positive effects PNE delivered via virtual reality may yield on the four largest patient groups seen in physical therapy and healthcare in general – low back, neck, knee, and shoulder pain. Forty patients (10 patients each with low back, neck, knee, and shoulder pain) underwent a 12-minute PNE session following an in-person physical therapy session. Prior to and immediately following treatment, heart rate, self-reported pain ratings (numeric pain rating scale – NPRS), pain catastrophizing (pain catastrophization scale – PCS), fear-avoidance (fear-avoidance beliefs questionnaire – FABQ) and active range of motion was measured. Additionally, the global rating of change (GROC) scale was used following treatment to assess the patient experience. No significant changes were found in heart rate and blood pressure. FABQ-PA (physical activity) improved significantly in patients with neck, shoulder, and back pain, with large effect sizes. PCS improved significantly (p = 0.034) for patients with low back pain, while only patients with shoulder pain showed a significant change in self-reported pain (p = 0.04). Active range of motion improved significantly in both peripheral joint patient populations (knee flexion [p = 0.003], knee extension [p = 0.002] and shoulder flexion [p = 0.023]), but not spinal patients (back and neck). Mean GROC scores for patients with shoulder (3.0) and knee pain (3.4) were above the minimal clinically important difference. This is the first study to explore PNE-VR for different body regions in patients with persistent pain attending PT. The largest positive shifts were seen for fear of physical activity. Patients with shoulder pain and disability received the greatest benefit from PNE-VR, followed by patients with LBP and knee pain. Future research is needed to develop, test and implement larger scale, controlled trails of virtual reality for patients seeking care for musculoskeletal pain in healthcare.

Keywords: Pain Neuroscience Education; Musculoskeletal Pain; Virtual Reality; Rehabilitation; Digital Therapeutics


For persistent musculoskeletal pain, it is well-understood that a multi-model approach is needed [9-11]. Current bestevidence treatment for persistent musculoskeletal pain calls for an approach that contains three key elements - cognitive (education), movement, and strategies to calm down a sensitized central and peripheral nervous system [11-13]. Of the three proposed treatments, it is easily argued that PT is most familiar with, and uses movement as a mainstay of its treatment [14, 15]. Within this mandate, therapists can use various forms of movement considering comorbid issues, patient preferences, current best evidence, safety, etc [16]. In the last decade, the pharmaceutical industry has spent considerable time and resources developing ways to calm down the nervous system, i.e., membrane stabilizers, selective-serotonin reuptake inhibitors, etc [17]. In rehabilitation, attention has also shifted to non-pharmacological treatment strategies to calm the central nervous system without the potential side effects of pharmaceuticals [18]. Emerging treatments and evidence supports the use of mindfulness-based stress reduction, breathing, sleep hygiene, relaxation, etc [18-20]. These treatments are now gaining more research and clinical interest from PT, thus fulfilling another one of the three key elements of a program aimed at persistent musculoskeletal pain and disability.

The third component, often used first to set the framework for movement and strategies to calm the nervous system, is education. The objective of the educational component is to change cognitions associated with pain, including high levels of fear-avoidance, pain catastrophizing, anxiety, poor or faulty beliefs about pain, trauma, etc [21, 22]. Most of these educational approaches in PT are borrowed from psychotherapy and may include cognitive behavioral therapy, trauma-informed care, acceptance and commitment therapy, motivational interviewing, positive psychology, etc [21, 23]. In recent years, pain neuroscience education (PNE) emerged from within PT to teach patients more about the biology and physiology of their underlying pain experience, explicitly aiming at persistent musculoskeletal pain [13, 21, 22]. Various systematic reviews and meta-analyses have shown strong evidence that PNE positively influences self-rated pain scores, disability, fear-avoidance, and pain catastrophization [22, 24]. Furthermore, evidence indicates that PNE allows for improved movement and, when combined with movement, is superior to PNE-alone [13, 22, 24]. Additionally, the evidence shows PNE can also yield a calming effect on the nervous system as seen by increased pressure pain thresholds and improved neurodynamic tests of mechanosensitivity of the nervous system [22]. From a PT perspective, it is thus argued that PNE, along with various forms of movement and strategies to calm the nervous system, is in line with the current best evidence to treat persistent musculoskeletal pain.

The best-evidence approach for movement, education, and calming of the nervous system is exciting, yet a significant clinical barrier remains – clinical time to incorporate these approaches. In US PT clinics, most visits average around 30 minutes; thus, time is limited to provide reassessment, treatment, instruction, and review of home exercise programs [25-27]. This presents a clinical dilemma in delivering best-evidence multimodal approaches in limited clinical time, especially for more complex clinical cases such as persistent musculoskeletal pain. One possible emerging strategy is digital therapeutics. Digital therapeutics is a subset of digital health and aims to use digital technologies, including Internet-based health technologies, to treat patients [28]. Emerging digital therapeutics include applications, virtual and augmented reality, wearable technology, etc. [19, 29-31]. Because of the limited time in which clinicians have to treat patients with persistent musculoskeletal pain, digital therapeutics could potentially be utilized to help drive these evidence-based multimodal approaches [19, 31, 32]. In lieu of time constraints, it is argued that some treatments can be delivered in-person by the PT in the available time, i.e., exercise and hands-on therapies.

In contrast, some treatments can be added to a clinical setting via digital therapeutics, i.e., mindfulness, meditation, breathing, education, and more. In this model, a patient may receive a more comprehensive approach to treating their persistent pain and, at the same time, alleviate a clinical burden for the clinician. Recently, a PNE virtual reality (VR) program (PNE-VR) (BehaVR™) was developed to educate patients more about pain and early data showed similar positive changes compared to therapist-led treatment in self-reported pain ratings, fear-avoidance, and patient satisfaction [32]. Additionally, the platform adds other bestevidence strategies such as mindfulness and relaxation. To date, very little is known about the potential benefits of PNE-VR in PT practice. The primary aim of this exploratory case series was to determine what positive effects PNE-VR may yield on the four largest patient groups seen in PT – those with LBP, neck pain, knee pain, and shoulder pain. The secondary aim was to look for differences between diagnosis groups using PNE-VR.

Methods Patients

A convenience sample of forty consecutive patients attending outpatient PT were invited to participate in the study (Figure 1). This included 10 patients with LBP, 10 with neck pain, 10 with knee pain, and 10 with shoulder pain. Data collection was performed at 4 PT clinics in 4 different states (OK, KY, NC and RI) for 3 months. Each of these clinics have been using a recently developed PNE-VR program, which has been tested in some preliminary research [32]. Institutional Review Board approval was obtained for this study at Southwest Baptist University. After an appropriate explanation of the study and obtaining informed written consent, patient demographic data were collected. Inclusion criteria were that patients be proficient in the English language, no precautions or contraindications specific for VR (i.e., pre-existing binocular vision abnormalities or seizures), be over the age of 18, present with pain and limited range of motion, and not pregnant at the time of the study. The study was designed as an exploratory case series with pre-and post-PNE-VR measurements.

Figure 1: Study Flow Chart (DASH = Disabilities of Arm, Shoulder, and Hand; LE = Lower extremity).


The PNE-VR session was designed to be delivered after a patient’s planned PT session, thus not interfering with their current treatment plan. At the completion of their normal one-on-one session with the attending PT, patients were placed in a private treatment room for the PNE-VR session. The PNE-VR was delivered using a headset and earphones while a patient was seated in a comfortable chair (Figure 2). Patients were familiarized with the VR headset, navigating the VR dashboard the subject sees in the headset, and how to access each of the sessions utilizing a hand-held activator. The PNE-VR sessions were uploaded via a wireless signal to the headset and the subject used a hand-held activator to start, navigate and end their PNE session. The PT was not in the room during the PNE-VR. The software tracked the subject throughout the sessions, ensuring they fully complete each session. The VR system provides a total 360-degree immersion, including sound, as a means to provide a true sensory virtual environment. The total of the PNE-VR treatment session was 12 minutes to limit prolonged VR exposure and mimic typical in-person therapist-led PNE [25, 33]. The content of the PNEVR is in line with current one-on-one, clinician-led PNE research [22, 25]. The PNE-VR session included an introduction to PNE (1 minute), an introduction to the nervous system (3 minutes), a metaphor of the sensitive alarm system to educate patients on hyperalgesia and allodynia (2 minutes) [25]. A metaphor of the “nosy” neighbor to educate patients about spreading pain as a consequence of a sensitized nervous system (2 minutes), and strategies used to calm down a sensitized nervous system non-pharmacologically (4 minutes).