Virtual Reality-Based Rehabilitation in Chronic Low Back Pain: Effects on Muscle Architecture, Balance, and Satisfaction (VR-LBPREHAB)

Chronic low back pain is a prevalent musculoskeletal condition associated with altered muscle activation, impaired postural control, and thoracolumbar fascia changes that may contribute to persistent pain and disability. Conventional rehabilitation approaches such as stabilization and motor control exercises are widely recommended, yet patient adherence and motivation often limit their effectiveness.

Virtual reality (VR)-based rehabilitation integrates visual, auditory, and interactive elements that can enhance engagement, provide distraction from pain, and encourage more consistent exercise participation. While VR interventions have shown benefits in populations such as stroke, cerebral palsy, and multiple sclerosis, the evidence in chronic low back pain remains limited.

This randomized controlled trial is designed to investigate the clinical and functional effects of VR-based rehabilitation compared with conventional motor control exercises in individuals with chronic low back pain. The intervention will combine traditional physiotherapy approaches with VR-based exercises to evaluate potential improvements in muscle architecture, balance control, and patient-centered outcomes such as satisfaction and adherence.

The study will contribute novel data on the feasibility and effectiveness of VR-based rehabilitation in chronic low back pain, with the goal of providing physiotherapists and clinicians with evidence to guide innovative treatment strategies. The adapted approach is expected to promote adherence, improve functional outcomes, and address gaps in the current literature on VR applications in musculoskeletal rehabilitation.

• Virtual Reality-Based Rehabilitation (Behavioral), also known as VR-Based Exercise, VR Rehabilitation: Participants receive 20 minutes of motor control exercises combined with 20 minutes of Pilates-inspired virtual reality games (5 repetitions per set). Training will be delivered three times per week, 40 minutes per session, for 8 weeks (24 sessions in total).
• Conventional Motor Control Exercises (Behavioral), also known as Progressive Stabilization Exercises, Standard Exercise Therapy: Participants perform 40 minutes of progressive spinal stabilization and motor control exercises (10 repetitions per set), three times per week for 8 weeks (24 sessions in total).

Primary outcomes

• Change in Transversus Abdominis Thickness (mm) [Baseline, 8 weeks, 3 months, 6 months.]: Measured by ultrasound in supine hook-lying position.
• Change in Internal Oblique Thickness (mm) [Baseline, 8 weeks, 3 months, 6 months.]: Measured by ultrasound in supine hook-lying position
• Change in External Oblique Thickness (mm) [Baseline, 8 weeks, 3 months, 6 months.]: Measured by ultrasound in supine hook-lying position
• Change in Rectus Abdominis Thickness (mm) [Baseline, 8 weeks, 3 months, 6 months.]: Measured by ultrasound in supine hook-lying position
• Change in Thoracolumbar Fascia Thickness (mm) [Baseline, 8 weeks, 3 months, 6 months.]: Measured bilaterally at L3 level in prone position.
• Change in Thoracolumbar Fascia Morphology (categorical) [Baseline, 8 weeks, 3 months, 6 months.]: ssessed bilaterally at L3 level in prone position (regular vs. irregular morphology).
• Change in Postural Sway (mm) [Baseline, 8 weeks, 3 months, 6 months.]: Anterior-posterior and medio-lateral sway measured by force platform (Freemed, Sensor Medica).
• Change in Limits of Stability (mm/°/s) [Baseline, 8 weeks, 3 months, 6 months.]: Maximum excursion, reaction time, movement velocity, and directional control measured by force platform (Freemed, Sensor Medica).

Secondary outcomes

• Pain Intensity [Baseline, 8 weeks, 3 months, 6 months.]: Pain severity measured using the Numeric Pain Rating Scale (0-10).
• Functional Disability [Baseline, 8 weeks, 3 months, 6 months.]: Functional status assessed with the Oswestry Disability Index
• Functional Disability [Baseline, 8 weeks, 3 months, 6 months.]: Functional status assessed with the Back Performance Scale.
• Lumbar Paravertebral Muscle Stiffness (N/m) [Baseline, 8 weeks, 3 months, 6 months.]: Assessed with MyotonPRO at bilateral L5.
• Lumbar Paravertebral Muscle Elasticity (ratio) [Baseline, 8 weeks, 3 months, 6 months.]: Assessed with MyotonPRO at bilateral L5.
• Trunk Muscle Endurance (mmHg, seconds) [Baseline, 8 weeks, 3 months, 6 months.]: Endurance of the Transversus Abdominis muscle assessed with the Stabilizer Pressure Biofeedback device.
• Fear-Avoidance Beliefs [Baseline, 8 weeks, 3 months, 6 months.]: Psychological aspects evaluated using the Fear-Avoidance Beliefs Questionnaire (FABQ).
• Change in Quality of Life (Nottingham Health Profile Total Score) [Baseline, 8 weeks, 3 months, 6 months.]: Quality of life assessed using the Nottingham Health Profile (NHP); includes domains of pain, emotional reaction, sleep, social isolation, physical activity, and energy. Higher scores indicate poorer quality of life.
• Patient Satisfaction [8 weeks, 3 months, 6 months.]: Satisfaction levels assessed using the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0).
• Exercise Adherence [During the 8-week intervention.]: Recorded via exercise diary including weekly frequency and duration of sessions.
• Body Composition [Baseline, 8 weeks, 3 months, 6 months.]: Body weight, BMI, and body fat percentage measured using a bioimpedance analyzer (Tanita MC180MA).

Sex: All, ages: 18 Years to 65 Years

Inclusion Criteria:

* Age 18-65 years.
* Chronic low back pain persisting for ≥ 3 months.
* Literacy and Montreal Cognitive Assessment (MoCA) score > 21.
* Voluntary participation with signed informed consent.

Exclusion Criteria:

* Malignancy.
* Pregnancy.
* History of epilepsy (including photosensitive seizures), dementia, migraine, or other neurological disorders limiting VR use.
* Surgery within the past 6 months.
* Received physiotherapy or rehabilitation services in the past 6 months.
* Presence of acute infection.
* Unhealed fracture.
* Withdrawal of informed consent at any stage of the study.

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• Özlem Ülger, PT, PhD, Study director, Hacettepe University, Faculty of Physical Therapy and Rehabilitation
• Abdurahim Aslıyüce, Research Assistant, MSc, PT, Principal investigator, Hacettepe University, Faculty of Physical Therapy and Rehabilitation