Feasibility and Safety of a Virtual Reality Dodgeball Intervention for Chronic Low Back Pain: A Randomized Clinical Trial

Published:September 08, 2016DOI:


      • This was a virtual dodgeball intervention to elicit increased lumbar spine flexion.
      • Virtual dodgeball increased lumbar flexion within and across gameplay sessions.
      • Safety and feasibility of novel intervention for back pain was shown.
      • Brief intervention did not translate to movements outside of the virtual environment.
      • This study provided support for a clinical trial with a longer intervention period.


      Whereas the fear-avoidance model of chronic low back pain (CLBP) posits a generic avoidance of movement that is perceived as threatening, we have repeatedly shown that individuals with high fear and CLBP specifically avoid flexion of the lumbar spine. Accordingly, we developed a virtual dodgeball intervention designed to elicit graded increases in lumbar spine flexion while reducing expectations of fear and harm by engaging participants in a competitive game that is entertaining and distracting. We recruited 52 participants (48% female) with CLBP and high fear of movement and randomized them to either a game group (n = 26) or a control group (n = 26). All participants completed a pregame baseline and a follow-up assessment (4–6 days later) of lumbar spine motion and expectations of pain and harm during standardized reaches to high (easier), middle, and low (hardest to reach) targets. For 3 consecutive days, participants in the game group completed 15 minutes of virtual dodgeball between baseline and follow-up. For the standardized reaching tests, there were no significant effects of group on changes in lumbar spine flexion, expected pain, or expected harm. However, virtual dodgeball was effective at increasing lumbar flexion within and across gameplay sessions. Participants reported strong positive endorsement of the game, no increases in medication use, pain, or disability, and no adverse events. Although these findings indicate that very brief exposure to this game did not translate to significant changes outside the game environment, this was not surprising because graded exposure therapy for fear of movement among individuals with low back pain typically last 8 to 12 sessions. Because of the demonstration of safety, feasibility, and ability to encourage lumbar flexion within gameplay, these findings provide support for a clinical trial wherein the treatment dose is more consistent with traditional graded exposure approaches to CLBP.


      This study of a virtual reality dodgeball intervention provides evidence of feasibility, safety, and utility to encourage lumbar spine flexion among individuals with CLBP and high fear of movement.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Andersson G.B.
        Epidemiological features of chronic low-back pain.
        Lancet. 1999; 354: 581-585
        • Andresen E.M.
        • Malmgren J.A.
        • Carter W.B.
        • Patrick D.L.
        Screening for depression in well older adults: Evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale).
        Am J Prev Med. 1994; 10: 77-84
        • Applegate M.E.
        • Leitkam L.T.
        • Cost J.
        • Proctor R.
        • France C.R.
        • Thomas J.S.
        Effects of avatar presentation and display environment on game perception and lumbar motion in virtual dodgeball.
        in: Program No. 282.06 2015 Neuroscience Meeting Planner. Society for Neuroscience, Washington, DC2015
        • Boersma K.
        • Linton S.
        • Overmeer T.
        • Jansson M.
        • Vlaeyen J.
        • de Jong J.
        Lowering fear-avoidance and enhancing function through exposure in vivo. A multiple baseline study across six patients with back pain.
        Pain. 2004; 108: 8-16
        • Carey T.S.
        • Garrett J.M.
        • Jackman A.M.
        Beyond the good prognosis. Examination of an inception cohort of patients with chronic low back pain.
        Spine (Phila Pa 1976). 2000; 25: 115-120
      1. CDC (Centers for Disease Control and Prevention). Prevalence and most common causes of disability among adults—United States, 2005. Morbidity and Mortality Weekly Report. 58(16):421-426, 2009

        • Chou R.
        • Shekelle P.
        Will this patient develop persistent disabling low back pain?.
        JAMA. 2010; 303: 1295-1302
        • Dagenais S.
        • Caro J.
        • Haldeman S.
        A systematic review of low back pain cost of illness studies in the United States and internationally.
        Spine J. 2008; 8: 8-20
        • Dahlquist L.M.
        • McKenna K.D.
        • Jones K.K.
        • Dillinger L.
        • Weiss K.E.
        • Ackerman C.S.
        Active and passive distraction using a head-mounted display helmet: Effects on cold pressor pain in children.
        Health Psychol. 2007; 26: 794-801
        • Faul F.
        • Erdfelder E.
        • Lang A.G.
        • Buchner A.
        G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
        Behav Res Methods. 2007; 39: 175-191
        • Foster N.E.
        Barriers and progress in the treatment of low back pain.
        BMC Med. 2011; 9: 108
        • Freburger J.K.
        • Holmes G.M.
        • Agans R.P.
        • Jackman A.M.
        • Darter J.D.
        • Wallace A.S.
        • Castel L.D.
        • Kalsbeek W.D.
        • Carey T.S.
        The rising prevalence of chronic low back pain.
        Arch Intern Med. 2009; 169: 251-258
        • Garrett B.
        • Taverner T.
        • Masinde W.
        • Gromala D.
        • Shaw C.
        • Negraeff M.
        A rapid evidence assessment of immersive virtual reality as an adjunct therapy in acute pain management in clinical practice.
        Clin J Pain. 2014; 30: 1089-1098
        • George S.Z.
        • Beneciuk J.M.
        Psychological predictors of recovery from low back pain: A prospective study.
        BMC Musculoskelet Disord. 2015; 16: 49
        • Hides J.A.
        • Richardson C.A.
        • Jull G.A.
        Magnetic resonance imaging and ultrasonography of the lumbar multifidus muscle. Comparison of two different modalities.
        Spine (Phila Pa 1976). 1995; 20: 54-58
        • Hides J.A.
        • Richardson C.A.
        • Jull G.A.
        Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain.
        Spine (Phila Pa 1976). 1996; 21: 2763-2769
        • Hoffman H.G.
        • Seibel E.J.
        • Richards T.L.
        • Furness T.A.
        • Patterson D.R.
        • Sharar S.R.
        Virtual reality helmet display quality influences the magnitude of virtual reality analgesia.
        J Pain. 2006; 7: 843-850
        • Hoy D.
        • Brooks P.
        • Blyth F.
        • Buchbinder R.
        The epidemiology of low back pain.
        Best Pract Res Clin Rheumatol. 2010; 24: 769-781
        • Institute of Medicine
        Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.
        The National Academies Press, Washington (DC)2011
        • Keefe F.J.
        • Huling D.A.
        • Coggins M.J.
        • Keefe D.F.
        • Zachary Rosenthal M.
        • Herr N.R.
        • Hoffman H.G.
        Virtual reality for persistent pain: A new direction for behavioral pain management.
        Pain. 2012; 153: 2163-2166
        • Klenerman L.
        • Slade P.D.
        • Stanley I.M.
        • Pennie B.
        • Reilly J.P.
        • Atchison L.E.
        • Troup J.D.
        • Rose M.J.
        The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting.
        Spine (Phila Pa 1976). 1995; 20: 478-484
        • Leeuw M.
        • Goossens M.E.
        • Linton S.J.
        • Crombez G.
        • Boersma K.
        • Vlaeyen J.W.
        The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence.
        J Behav Med. 2007; 30: 77-94
        • Leeuw M.
        • Goossens M.E.
        • van Breukelen G.J.
        • de Jong J.R.
        • Heuts P.H.
        • Smeets R.J.
        • Koke A.J.
        • Vlaeyen J.W.
        Exposure in vivo versus operant graded activity in chronic low back pain patients: Results of a randomized controlled trial.
        Pain. 2008; 138: 192-207
        • Lieber R.L.
        Skeletal Muscle Structure, Function, and Plasticity: The Physiological Basis for Rehabilitation.
        2nd ed. Lippincott, Williams &Wilkins, Baltimore2002
        • Linton S.J.
        • Boersma K.
        • Jansson M.
        • Overmeer T.
        • Lindblom K.
        • Vlaeyen J.W.
        A randomized controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-related activities.
        Eur J Pain. 2008; 12: 722-730
        • Mafi J.N.
        • McCarthy E.P.
        • Davis R.B.
        • Landon B.E.
        Worsening trends in the management and treatment of back pain.
        JAMA Intern Med. 2013; 173: 1573-1581
        • Main C.J.
        • George S.Z.
        Psychologically informed practice for management of low back pain: Future directions in practice and research.
        Phys Ther. 2011; 91: 820-824
        • McCracken L.M.
        • Gross R.T.
        • Sorg P.J.
        • Edmands T.A.
        Prediction of pain in patients with chronic low back pain: Effects of inaccurate prediction and pain-related anxiety.
        Behav Res Ther. 1993; 31: 647-652
        • McGill S.M.
        • Cholewicki J.
        • Peach J.P.
        Methodological considerations for using inductive sensors (3SPACE ISOTRAK) to monitor 3-D orthopaedic joint motion.
        Clin Biomech (Bristol, Avon). 1997; 12: 190-194
        • McHugh M.P.
        • Connolly D.A.
        • Eston R.G.
        • Gleim G.W.
        Exercise-induced muscle damage and potential mechanisms for the repeated bout effect.
        Sports Med. 1999; 27: 157-170
        • Melzack R.
        The McGill pain questionnaire: Major properties and scoring methods.
        Pain. 1975; 1: 277-299
        • Melzack R.
        • Katz J.
        The McGill Pain Questionnaire: Appraisal and current status.
        in: Turk D.C. Melzack R. Handbook of Pain Assessment. Guilford Press, New York2001
        • Nicholas M.K.
        • Linton S.J.
        • Watson P.J.
        • Main C.J.
        Decade of the Flags Working Group. Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: A reappraisal.
        Phys Ther. 2011; 91: 737-753
        • Patterson D.R.
        • Hoffman H.G.
        • Palacios A.G.
        • Jensen M.J.
        Analgesic effects of posthypnotic suggestions and virtual reality distraction on thermal pain.
        J Abnorm Psychol. 2006; 115: 834-841
        • Radloff L.
        The CES-D Scale: A self-report depression scale for research in the general population.
        Appl Psychol Meas. 1977; 1: 385-401
        • Roland M.
        • Morris R.
        A study of the natural history of back pain. Part I: Development of a reliable and sensitive measure of disability in low-back pain.
        Spine (Phila Pa 1976). 1983; 8: 141-144
        • Saunders J.B.
        • Aasland O.G.
        • Babor T.F.
        • de la Fuente J.R.
        • Grant M.
        Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption–II.
        Addiction. 1993; 88: 791-804
        • Schneider K.L.
        • Ferrara J.
        • Lance B.
        • Karetas A.
        • Druker S.
        • Panza E.
        • Olendzki B.
        • Andersen V.
        • Pbert L.
        Acceptability of an online health videogame to improve diet and physical activity in elementary school students: “Fitter Critters”.
        Games Health J. 2012; 1: 262-268
        • Spitzer W.
        • LeBlanc F.
        • Dupris M.
        Scientifice approach to the assessment and management of activity related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders.
        Spine (Phila Pa 1976). 1987; 12: S1-S59
        • Stratford P.W.
        • Binkley J.
        • Solomon P.
        • Finch E.
        • Gill C.
        • Moreland J.
        Defining the minimum level of detectable change for the Roland-Morris questionnaire.
        Phys Ther. 1996; 76 (discussion: 366-358): 359-365
        • Sullivan M.J.
        • Rodgers W.M.
        • Wilson P.M.
        • Bell G.J.
        • Murray T.C.
        • Fraser S.N.
        An experimental investigation of the relation between catastrophizing and activity intolerance.
        Pain. 2002; 100: 47-53
        • Thomas J.S.
        • Corcos D.M.
        • Hasan Z.
        Kinematic and kinetic constraints on arm, trunk, and leg segments in target-reaching movements.
        J Neurophysiol. 2005; 93: 352-364
        • Thomas J.S.
        • Corcos D.M.
        • Hasan Z.
        Kinematic rules underlying multi-joint reaching movements, in: 30th Annual Meeting.
        Society for Neuroscience, New Orleans, LA2000: 1719
        • Thomas J.S.
        • Corcos D.M.
        • Hasan Z.
        Effect of movement speed on limb segment motions for reaching from a standing position.
        Experimental Brain Research. 2003; 148: 377-387
        • Thomas J.S.
        • France C.R.
        Pain-related fear is associated with avoidance of spinal motion during recovery from low back pain.
        Spine (Phila Pa 1976). 2007; 32: E460-E466
        • Thomas J.S.
        • France C.R.
        The relationship between pain-related fear and lumbar flexion during natural recovery from low back pain.
        Eur Spine J. 2008; 17: 97-103
        • Thomas J.S.
        • France C.R.
        • Lavender S.A.
        • Johnson M.R.
        Effects of fear of movement on spine velocity and acceleration after recovery from low back pain.
        Spine (Phila Pa 1976). 2008; 33: 564-570
        • Thomas J.S.
        • France C.R.
        • Sha D.
        • Vander Wiele N.
        • Moenter S.
        • Swank K.
        The effect of chronic low back pain on trunk muscle activations in target reaching movements with various loads.
        Spine (Phila Pa 1976). 2007; 32: E801-E808
        • Thomas J.S.
        • France C.R.
        • Sha D.
        • Wiele N.V.
        The influence of pain-related fear on peak muscle activity and force generation during maximal isometric trunk exertions.
        Spine (Phila Pa 1976). 2008; 33: E342-E348
        • Thomas J.S.
        • Gibson G.E.
        Coordination and timing of spine and hip joints during full body reaching tasks.
        Hum Mov Sci. 2007; 26: 124-140
        • Trost Z.
        • France C.R.
        • Sullivan M.J.
        • Thomas J.S.
        Pain-related fear predicts reduced spinal motion following experimental back injury.
        Pain. 2012; 53: 1015-1021
        • Van Damme S.
        • Van Ryckeghem D.M.
        • Wyffels F.
        • Van Hulle L.
        • Crombez G.
        No pain no gain? Pursuing a competing goal inhibits avoidance behavior.
        Pain. 2012; 153: 800-804
        • Vlaeyen J.
        • Morley S.J.
        • Linton S.J.
        • Boersma K.
        • de Jong J.
        Pain-Related Fear: Exposure-Based Treatment Of Chronic Pain.
        International Association for the Study of Pain Press, Seattle, WA2012
        • Vlaeyen J.W.
        • Kole-Snijders A.M.
        • Boeren R.G.
        • van Eek H.
        Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance.
        Pain. 1995; 62: 363-372
        • Vlaeyen J.W.
        • Linton S.J.
        Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art.
        Pain. 2000; 85: 317-332
        • Vlaeyen J.W.
        • Linton S.J.
        Fear-avoidance model of chronic musculoskeletal pain: 12 years on.
        Pain. 2012; 153: 1144-1147
        • Von Korff M.
        Studying the natural history of back pain.
        Spine (Phila Pa 1976). 1994; 19: 20415-20465
        • Wertli M.M.
        • Rasmussen-Barr E.
        • Held U.
        • Weiser S.
        • Bachmann L.M.
        • Brunner F.
        Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: A systematic review.
        Spine J. 2014; 14: 2658-2678
        • Woods M.P.
        • Asmundson G.J.
        Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: A randomized controlled clinical trial.
        Pain. 2008; 136: 271-280
        • Yudko E.
        • Lozhkina O.
        • Fouts A.
        A comprehensive review of the psychometric properties of the Drug Abuse Screening Test.
        J Subst Abuse Treat. 2007; 32: 189-198