Virtual Reality Therapy for Chronic Pain Management in Veterans Residing in Community Living Centers

Virtual reality (VR) is an immersive, computer-based augmentation of reality that allows the user to experience a simulated environment using specialized hardware that engages visual, auditory, and, in sometimes, haptic senses. The simulated environment can either be based off real video footage, or it may be completely computer-generated. Hardware for VR usually includes a head-mounted display, such as glasses or goggles, and may also feature integrated audio, handheld controllers, or connection to a tablet, laptop, or other smart device.¹ This clinical initiative used VR hardware from Mynd Immersive, which designs its VR products specifically for older adults living in long-term care (LTC) facilities.

According to an article published by the Veterans Affairs (VA) Diffusion Marketplace, VR has been introduced in 12 VA medical centers’ community living centers (CLCs) across the country, two of which have already successfully adopted VR therapy.² One of the CLCs offers both LTC and short-term rehab for veterans at the James E. Van Zandt VA Medical Center (JEVZ VAMC) in Altoona, Pennsylvania. It is among the 12 VA medical centers that have received VR headsets for their CLC residents, but it has yet to successfully adopt the intervention. The objective of this clinical initiative is to implement and evaluate the efficacy of VR therapy as an alternative intervention to reduce chronic pain.

VR therapy has been extensively researched recently as an alternative intervention for chronic pain management. Although there is still much to study about this innovative modality, research about its viability is promising. A prospective pretest–posttest mixed methods assessment by Rawlins et al³ evaluated the impact of VR therapy on acute and chronic pain among veterans at the Asheville VA Medical Center in North Carolina. The assessment was conducted over 1 year and collected qualitative data from veterans who participated in VR therapy sessions lasting between 10 and 30 minutes. The data collected included pre- and post-VR session pain scores based on the Defense and Veterans Pain Rating Scale (DVPRS) as well as stress and anxiety levels. Results showed a statistically significant decrease in pain levels averaging 12%. Rawlins et al³ concluded that VR therapy is a viable alternative intervention for improving pain among the veteran population.

While the exact mechanisms of how VR therapy facilitates pain relief are not fully understood, there are plausible explanations as to its therapeutic effects. A systematic review by Smith et al⁴ suggested that VR therapy causes neurobiological changes, which in turn facilitate analgesic effects similar to pharmaceuticals. Hoffman et al⁵ used magnetic resonance imaging to observe brain activity during VR therapy and found a greater than 50% reduction in activity of the pain matrix, correlating with a decrease in patient-reported pain ratings.

Grassini⁶ and Huang et al⁷ conducted meta-analyses estimating the overall effect of VR therapy on pain management, each focusing on different types of pain. Both reviews were limited to randomized controlled trials (RCTs) and defined chronic pain as lasting longer than 3 months. Huang et al⁷ also assessed VR’s effect on acute pain, which they defined as pain lasting less than 3 months. Grassini⁶ focused specifically on pain in the lumbar and cervical region of the spine, whereas Huang et al⁷ included acute pain caused by burns, needle-related procedural pain, postoperative dressing change pain, thermal pain stimulus, and pain of total knee arthroplasty. Huang et al⁷ included chronic pain studies of lower back pain and cancer-related pain. Both studies concluded that VR is a feasible alternative therapy for pain management. Huang et al⁷ found that VR is an effective method of relieving acute pain, however they did not find a statistical difference between VR therapy and standard therapy in chronic pain relief. In contrast, Grassini⁶ found a significant decrease in pain perception when comparing chronic neck pain with conventional treatment, however, no significant improvements were observed for chronic lower back pain.

A randomized comparative effectiveness trial conducted by Spiegel et al⁸ analyzed the effectiveness of therapeutic VR as an alternative intervention for pain management in hospitalized patients. The experimental group of patients chose from a library of 21 VR experiences via the Samsung Gear Oculus headset, while the control group of patients viewed specialized television programming to promote health and wellness. Those who participated in VR therapy reported a significant reduction in pain versus the control group. These results support the viability of VR as a treatment for hospitalized patients with pain and suggest its potential use as an early option for treating pain before considering analgesia.⁸

Two longitudinal RCTs by Darnall et al⁹ and Garcia et al¹⁰ evaluated home-based VR therapy for chronic lower back pain. Both studies defined chronic pain as lasting longer than 6 months with an intensity rating of more than 4 (on the pain numeric rating scale) lasting at least 1 month. In Darnall et al,⁹ participants in the experimental group received VR therapy over 21 days whereas the control group listened to an audio-only variation of the therapy. Alternatively, Garcia et al¹⁰ examined the effects of VR therapy over 8 weeks. The control group wore a VR headset and was shown two-dimensional (2D) images, while the experimental group was shown the standard three-dimensional (3D) display used in VR therapy. Participants completed a survey at the end of the intervention period. Garcia et al¹⁰ concluded that an 8-week self-administered VR program is effective for reducing pain with high user satisfaction overall. In regard to adverse effects, 9.7% of participants from the control group and 6.7% from the experimental group reported experiencing nausea and motion sickness during treatment¹⁰. The results of both studies support the use of VR therapy in treating chronic pain. Darnall et al⁹ found a significant improvement in pain rating following a 2-week period of treatments, wherein 84% of the participants reported high satisfaction with the treatment. Of note, 24% of the participants did disclose experiencing motion sickness during the treatment, however, it did not interfere with VR treatment engagement⁹. These results support the long-term use of VR therapy from 3-8 weeks and the need for further longitudinal studies.

In a crossover randomized pilot study, Baker et al¹¹ compared the effectiveness of 2 different lengths of immersive VR (IVR) therapy sessions. The purpose of the study was to determine if a 10-minute session was as effective as a 20-minute session. The study included 21 patients, aged 20 to 75 years, with chronic back pain lasting longer than 3 months and a pain rating of 4 or higher on a scale of 0 to 10 (0 = no pain, 10 = worst possible pain). Participants attended 2 IVR sessions and were randomly assigned to either a 10- or 20- minute session for the first visit, followed by the alternate duration for the second visit. Quantitative sensory testing data were collected to assess pain intensity, affect, fatigue, and measures of pain sensation. Overall, IVR significantly reduced the intensity of back pain; 43% of participants reported a 30% or greater reduction in back pain after the IVR session. Additionally, Baker et al¹¹ found that while different IVR session lengths can produce different effects, the study was inconclusive and did not identify that one duration was more effective than the other.

An important consideration is that most CLC residents, particularly LTC residents, are older adults (over 65 years old). A study by Appel et al¹² assessed the feasibility of IVR technology as therapy for older adults with reduced sensory function, mobility impairments, or impaired cognition. The multisite nonrandomized interventional study included 66 older adults with varying levels of cognitive and physical abilities. Data were collected via pre- and postintervention surveys, standardized observations during the intervention, and postintervention semi-structured interviews pertaining to the VR experience. 92% of the participants denied feeling nauseous during the VR exposure, while 22% of participants who disclosed they were prone to nausea and dizziness at baseline also denied adverse symptoms during or after the exposure. Additionally, all participants that wore hearing aids during the VR experience denied any issues or interference with their devices. The average time spent in VR was 8 minutes. Overall, 76% of participants expressed that they would want to try VR again. Appel et al¹² concluded that immersive VR is a safe, feasible, and beneficial modality for older adults with reduced sensory, mobility, and cognitive impairments.

As VR technology becomes more integrated into health care, it is necessary to acknowledge the barriers to its implementation. Baniasadi et al¹³ conducted a systemic review to identify the challenges and practicality associated with applying VR technology in medical education and treatment. The study identified these general challenges to VR in health care: user education, attitudes toward VR, cost, and reduced face-to-face communications. More specific challenges involved user-centered design, ease of installation and operation, safety considerations, and the evaluation and validation of VR applications.

Proper education and appropriate guidelines are essential before implementing VR technology in a health care setting. A comprehensive approach should define how, where, and for whom VR is suitable, and educational training must be provided for all end-users (clinicians, patients, staff) to ensure successful adoption. Users’ attitudes and reluctance may also present a significant barrier to VR acceptance, as Baniasadi et al¹³ noted. User-centered design is crucial to consider; systems are often designed based on technology-oriented approaches, which can make them difficult to learn and use. VR technology intended for health care settings must be user-friendly and accessible. Most importantly, safety considerations are important, with clear guidelines and safety parameters put in place before VR technology is implemented in health care settings.

Several recent studies support VR as an alternative intervention for pain management.^6,7,8,11 The purpose of this proposed clinical initiative was to implement and evaluate the efficacy of VR therapy as an alternative intervention to reduce chronic pain among veterans residing in VA CLCs. This initiative was implemented at the James E. Van Zandt VA Medical Center (JEVZ VAMC) in Altoona, Pennsylvania, over a 2-month period, from May to June 2024. It was approved for implementation by the JEVZ VAMC Quality Improvement Committee.

This clinical initiative was implemented on the CLC floors of the JEVZ VAMC, which consist of two 20-bed units offering LTC, short-term rehab, and hospice services for veterans. All veterans who did not meet the exclusion criteria for VR therapy were invited to participate. The exclusion criteria included active seizure disorder or history of seizures causing practitioner to determine lack of suitability, head, neck, or facial injury or surgery in the last 6 weeks that would interfere with proper and safe placement of the head-mounted display; stroke or head trauma in the last 6 weeks deemed unsafe by a practitioner; and implanted medical devices potentially susceptible to electromagnetic interference, as identified by the VR hardware provider.³

The VR hardware used in this initiative was the MyndVR Virtual Reality Head-Mounted Display, which is specifically designed for use by older adults. The software offered by Mynd Immersive features meditative activities, videos, and interactive games.

To assess the effectiveness of VR therapy to reduce veterans’ chronic pain, a pre- and post-session pain assessments using the DVPRS were completed. According to the VA, the DVPRS is a 5-item instrument that assesses a patient’s pain experience, including pain intensity and its biopsychosocial impact, defined by its influence on activity, sleep, mood, and level of stress. Similar to the commonly used pain numeric rating scale, the DVPRS assesses pain using a 0 to 10 scale, with 0 representing “No pain” and 10 representing “As bad as it could be, nothing else matters.”³ These pre- and post-pain assessments are embedded in the required “CLC VIRTUAL REALITY INTERVENTION NOTE” template for documentation in the veterans’ electronic health record (eMAR) after every completed VR therapy session. An intervention is considered effective if the veterans’ post-pain assessment rating is lower than their pre-pain assessment rating. For example, if a veteran reports a pre-session pain rating of 7 (“Focus of attention, prevents doing daily activities”) and a post-session pain rating of 4 (“Distracts me, can do usual activities”), the session would be considered effective for that veteran. Conversely, if the post-session pain rating is the same or higher, the session would not be considered effective.

Subjective data were analyzed, including the participants’ likelihood to use VR again, ease of use, willingness to recommend VR to other veterans, and any additional comments or concerns. This feedback is imperative to improving the implementation of this clinical initiative as well as ensuring a veteran-centric approach. Together, the analysis of both the objective and subjective data provided the basis for determining the initiative’s success.

VR therapy is a novel intervention with the potential to address chronic pain in the veteran population. It has been successfully adopted by 2 VA medical centers, with additional facilities across the country, including the JEVZ VAMC, in the process of implementation. Recent studies support VR therapy’s viability and effectiveness in clinical settings, showing it to be a safe, evidence-based practice for pain relief. While further research is needed to determine longevity of the pain relief provided by VR therapy, current research suggests it can be maintained for up to 3 to 8 weeks with continuous use. This clinical initiative seeks to garner support for establishing VR therapy as a standard alternative intervention to treat chronic pain, specifically for older adult veterans residing in VA CLCs.

Anna Turner, BSN, RN¹ • Hannah Palko, BSN, RN² • Anthony Good, DNP, MSN, MBA, APRN, FNP-BC, GNP-BC, RN³ • Camille Wendekier, PhD, CRRN, CSN, RN⁴

Affiliations:

¹ James E Van Zandt VA Medical Center, , Altoona, PA

² James E Van Zandt VA Medical Center, , Altoona, PA

³ Department of Nursing, Saint Francis University, Loretto, PA

⁴ Department of Nursing, Saint Francis University, Loretto, PA

Disclosure:

This work was supported in part by the US Department of Veterans Affairs Office of Academic Affiliations. The views expressed in this manuscript are those of the authors and do not necessarily reflect the official policy or position of the Department of Veterans Affairs Office of Academic Affiliations. The authors deny any nonfinancial or commercial, proprietary, or financial interest in the products or companies described in the manuscript. The authors did not receive grants or a consultant honorarium to write this manuscript.

Address correspondence to:

Anna Turner, BSN, RN

2907 Pleasant Valley Blvd

Altoona, PA 16602

Email: anna.turner1@va.gov

© 2025 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Annals of Long-Term Care or HMP Global, their employees, and affiliates.

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