Effectiveness of Virtual Reality Versus Exercise-Based Interventions in the Management of Chronic Spinal Pain: A Systematic Review and Meta-Analysis

Background/Purpose: This systematic review and meta-analysis assessed the comparative effectiveness of virtual reality (VR) versus exercise-based interventions for pain, disability, fear of movement, and quality of life in patients with chronic spinal pain. Methods: Five databases were searched for randomized control trials (RCTs) in the last 10 years, comparing VR versus exercise-based interventions (with or without passive adjunct modalities) for adults (≥ 18 years) with chronic spinal pain. Risk of bias and certainty of evidence were assessed using the Cochrane RoB 2.0 tool and GRADE framework, followed by random-effect meta-analyses. Results: Fifteen RCTs comprising 659 participants were included, with most presenting a high risk of bias. Based on very low-certainty evidence, VR showed statistically significant superiority over exercise-based interventions for pain (VAS: MD –1.05, 95% CI –1.92 to −0.18; p = 0.02; I2 = 94%; NPRS: MD –0.95, 95% CI –1.59 to −0.31; p = 0.003; I2 = 14%) and kinesiophobia (MD –3.52, 95% CI –6.08 to −0.96; p = 0.007; I2 = 0%). None of these statistically significant reductions met the commonly established thresholds for Minimal Clinically Important Difference (MCID) for chronic spinal pain populations. Very low-certainty evidence found no significant differences for functional disability (MD –1.38, 95% CI –5.43 to 2.67; p = 0.50; I2 = 0%), and results on quality of life were heterogeneous and inconclusive. Discussion: Although VR may offer statistical advantages over exercise-based interventions for pain and kinesiophobia, the overall certainty of the evidence remains very low. The non-attainment of the MCID thresholds, coupled with high risk of bias and substantial statistical heterogeneity, underscores the need for strict caution. Trial Registration: PROSPERO (CRD420251101584). © 2026 John Wiley & Sons Ltd. All rights reserved, including rights for text and data mining and training of artificial intelligence technologies or similar technologies.