Cognitive Behavioural Therapy-informed Virtual Reality (VR-CBT) for low back pain

Participants will undergo an initial VR-CBT intervention (total 90 minutes). This will include i) a standardized pain education session (45 min); ii) Virtual reality gameplay (20min) with guided post-gameplay reflection (15 minutes); and iii) setup for home-based use of VR gameplay and mindfulness (10 minutes). i) Pain education: The standardised session will be delivered by an experienced physiotherapist and will cover topics including pain science education and graded activity strategies. Pain physiology will include a basic overview of how the nervous system works and its role in persistent pain, outlining contrasts between acute pain and chronic pain, and addressing potentially unhelpful health beliefs. People with persistent pain have decreased activity levels as a result of either avoidance of symptoms, or engaging in activity in a way that severely worsens pain severity, leading to extended periods of rest. To address this, participants will establish their current baseline (e.g. walking 20 minutes), and pacing strategies will be explained to increase physical activity using quota contingences to minimise flare up of symptoms (e.g. start at 15 minutes, 3 times a week, and increase duration by 5% weekly). Participants will have the opportunity to ask specific questions relating to the session content. A handout summarizing the presentation content will be provided ii) Virtual Reality Gameplay with guided post-gameplay reflection: Participants will be familiarized with the Oculus Quest 2 virtual reality system (Oculus VR, California USA) before undergoing 20 minutes VR gameplay - 3x5 minute sessions with small breaks. This session will be supervised by the physiotherapist researcher. The emphasis of the VR session will be graduated exposure to forward bending during self-paced, age-appropriate game scenarios (i.e.: throwing basketball through hoop, air hockey, 10-pin bowling). Video footage will be collected during VR gameplay using LIV Augmented reality capture and recorded using OBS Studio software. Following gameplay, participants will be guided through a 15-minute reflective learning interview delivered by the physiotherapist researcher to consolidate links between pain education content and the virtual reality experience using a semi-structured interview process. Video footage will also be replayed to the participant in which positive movement strategies will be highlighted. iii) Home-based use of VR gameplay and mindfulness: Participants will be instructed to complete 3-4 sessions of VR each week consisting of 20 minutes of gameplay followed by 10 minutes of mindfulness. The specific number of sessions will be based on participant availability. A suite of VR games will be available, and selection and progression of games will be participant-specific, developed with the participant by the Research Officer (a physiotherapist); and guided by their presenting condition (i.e., elicited aggravating movements, apprehension with movement, baseline pain severity) and initial response to VR-CBT. A progression plan will be developed by the research officer with gradual increases in movement requirements (range and speed of movement) during gameplay over the 4-week intervention period. Mindfulness sessions will be completed on Guided Meditation VR. Participants will be seated and guided through mindfulness strategies such as deep breathing, body scanning, and relaxation strategies. Participants will have opportunity to contact the researcher if required to adjust the intervention or flag any issues. Participants will additionally be provided with weekly reflective learning insights electronically or by post (depending on participant preference) designed to consolidate pain education learning. These will be standardised based on the education content and will take approximately 5 minutes to read.