Efficacy of Various Virtual Reality Exposure Therapies for Chronic Low Back Pain: Systematic Review and Network Meta-Analysis.

Background: Chronic low back pain (CLBP) is a major global health challenge. While nonpharmacological 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: The aim of the study is to compare and rank the efficacy of different VR-based training modalities on pain intensity, disability, and kinesiophobia in patients with 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 (RCTs) assessing the effects of VR-based training on individuals with CLBP were selected. Primary outcomes were pain intensity, disability (Oswestry Disability Index), and kinesiophobia (Tampa Scale of Kinesiophobia). The Cochrane Risk of Bias 2 tool was used for quality assessment. Confidence in Network Meta-Analysis (CINeMA) framework was used to evaluate the credibility of cumulative evidence. 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 values. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework was adapted to evaluate the quality of evidence. Results: In total, 25 RCTs with a total of 2610 participants were included in the analysis. For pain intensity, shooting games (SMD -4.40, 95% credible interval [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 indicated that shooting games had the highest probability (98%) of being the most effective intervention for pain relief. For 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: This first network meta-analysis to compare and rank distinct VR modalities for CLBP offers several key innovations and contributions to the field. By moving beyond aggregate VR categorizations, we provide a granular, comparative ranking of specific, actionable VR interventions. Unlike previous reviews that treated VR as a homogeneous group or only compared it to sham, our network meta-analysis directly and indirectly compares 7 distinct VR modalities, revealing that not all VR is equally effective. Our findings suggest that shooting games have the potential to be the most effective VR therapy for relieving pain intensity and kinesiophobia, though evidence for disability remains limited. Unfortunately, due to heterogeneity and low-quality evidence, there is no evidence demonstrating significant improvement in specific outcomes for patients with CLBP. More RCTs are needed to provide robust clinical evidence.