Abstract
Background: Chronic pain affects millions worldwide, influenced by biological, psychological, and social factors. Catastrophizing predicts chronic pain outcomes, increased pain intensity, and worsening recovery. Virtual reality (VR) interventions offer innovative pain management strategies, but their effects on catastrophizing remain unclear. Methods: This systematic review and meta-analysis followed the PRISMA guidelines. Studies involving adults with chronic musculoskeletal pain, VR-based interventions, and randomized controlled trials were included. The primary outcome was pain catastrophizing. Searches were conducted in PubMed, CINAHL, Scopus, WoS, and PEDro until May 2025. The risk of bias was assessed using Cochrane RoB-2. Meta-analysis calculated effect sizes using mean differences (MD) and standardized mean differences (SMD) with fixed and randomized-effects models. Results: Of 306 records, 244 were screened, 19 underwent full-text review, and two additional studies were identified via Google Scholar. Nine studies were included, eight of which were meta-analyzed. The interventions included eight immersive and one non-immersive VR studies, lasting 3 to 12 weeks. A small but statistically significant effect was found when comparing VR-based interventions with controls (SMD = -0.26 [-0.48; -0.04]). Psycho-cognitive VR-based interventions had a significant effect (SMD = -0.32 [-0.56; -0.09]), while exercise-based VR did not (MD = -0.11 [-4.36; 4.14]). Immersive VR showed a small but significant effect when compared to non-intervention or sham controls (SMD = -0.37 [-0.75; -0.00]). However, when compared to all types of comparators, the effect was not statistically significant (SMD = -0.25 [-0.51 to -0.00]). Heterogeneity was moderate and not significant (p > 0.05). Conclusions: VR-based interventions, particularly immersive with psycho-cognitive approaches, show potential in reducing pain catastrophizing. Future randomized trials are needed to elucidate VR's efficacy in managing pain catastrophizing.