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Virtual Reality-Based Mindfulness for Chronic Pain Management: A Scoping Review

Open AccessPublished:April 28, 2022DOI:https://doi.org/10.1016/j.pmn.2022.03.013

      Highlights

      • Mindfulness is a self-care meditative strategy that can support pain management.
      • Virtual reality technologies are emerging digital tools for pain managing.
      • This scoping review found limited evidence that suggests VR based mindfulness interventions improve self-management of chronic pain.
      • Larger, more robust scientific studies should co-design and rigorously test VR mindfulness applications to determine their efficacy in improving outcomes for patients with chronic pain.

      Abstract

      Objectives

      To identify and synthesize the scientific literature on virtual reality (VR)-based mindfulness applications for the management of chronic pain in adults.

      Design

      A scoping review methodology was followed and conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline.

      Data sources

      Combinations of key words related to “virtual reality”, “mindfulness”, and “chronic pain” were searched for in PubMed, CINAHL, EMBASE, Scopus, and the Cochrane library databases. Title, abstracts, and full-text articles were screened against inclusion criteria.

      Review/Analysis methods

      Braun and Clarke's thematic analysis approach was used.

      Results

      Seven studies were included in the review and their findings synthesized into three overarching themes: (1) physical and mental health benefits; (2) treatment engagement and satisfaction; and (3) intervention usability. The last theme had four subthemes which were cybersickness, physical limitations, technical support, and personalized design.

      Conclusions

      While studies suggested VR could improve chronic pain management by enhancing the practice of mindfulness, weak study designs and small sample sizes limited the utility of the review results. Future research should rigorously co-design and test VR-based mindfulness applications with people with chronic pain to assess if they improve health and other outcomes.
      Chronic pain affects approximately 60 million people worldwide including those with low back pain, arthritis, fibromyalgia, and cancer among others (
      • Mills S.E.E.
      • Nicolson K.P.
      • Smith B.H.
      Chronic pain: A review of its epidemiology and associated factors in population-based studies.
      ). It is described as “pain which persists beyond normal tissue healing time”, generally taken as more than three months, and can cause numerous problems including anxiety and depression, an inability to work and perform normal everyday activities, and a dependence on opioids (
      • Dahlhamer J.
      • Lucas J.
      • Zelaya C.
      • Nahin R.
      • Mackey S.
      • DeBar L.
      • Kerns R.
      • Von Korff M.
      • Porter L.
      • Helmick C.
      Prevalence of chronic pain and high-impact chronic pain among adults - United States, 2016.
      ). In addition, the health and social care costs associated with chronic pain are significant, with approximately £5 billion spent in the United Kingdom (

      The British Pain Society. (2021). The British Pain Society: Media Resources. Retrieved December 20, 2021, from https://www.britishpainsociety.org/media-resources/.

      ), and between $560 and $635 billion spent in the United States on pain management each year (
      • Gaskin D.J.
      • Richard P.
      The economic costs of pain in the United States.
      ). These costs are likely to rise given aging populations across the world. Hence, the management of chronic pain is of urgent importance. While pharmacologic interventions are commonly prescribed, alternative psychosocial therapies such mindfulness (
      • Majeed M.H.
      • Ali A.A.
      • Sudak D.M.
      Mindfulness-based interventions for chronic pain: Evidence and applications.
      ) are also used by people to self-manage chronic pain.
      Mindfulness is a practice which brings attentional focus to the present moment, for example through awareness of breathing or acknowledging one's thoughts or emotions as they occur (
      • Kabat-Zinn J.
      Mindfulness-based interventions in context: Past, present, and future.
      ;
      • Liu Z.
      • Sun Y.-Y.
      • Zhong B.-L.
      Mindfulness-based stress reduction for family carers of people with dementia.
      ). Formalized mindfulness interventions such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) are increasingly used in healthcare, particularly to support emotional regulation such as stress reduction or behavior change (
      • Schell L.K.
      • Monsef I.
      • Wöckel A.
      • Skoetz N.
      Mindfulness-based stress reduction for women diagnosed with breast cancer.
      ). It is also considered a successful psychosocial therapy to improve the management of physical health, including those that live with chronic pain, as mindfulness can enhance one's awareness of the body, increase relaxation, and facilitate stress management (
      • Chiesa A.
      • Serretti A.
      Mindfulness-based interventions for chronic pain: A systematic review of the evidence.
      ). However, traditional face-to-face mindfulness programs can be limited by cost, poor accessibility, and lack of availability (
      • Goldberg S.B.
      • Tucker R.P.
      • Greene P.A.
      • Davidson R.J.
      • Wampold B.E.
      • Kearney D.J.
      • Simpson T.L.
      Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis.
      ;
      • Hofmann S.G.
      • Gómez A.F.
      Mindfulness-based interventions for anxiety and depression.
      ). Those delivered online or through mobile applications (apps) may better address users’ needs in providing convenience and privacy (
      • Flett J.
      • Hayne H.
      • Riordan B.
      • Thompson L.
      • Conner T.
      Mobile mindfulness meditation: A randomised controlled trial of the effect of two popular apps on mental health.
      ;
      • Plaza I.
      • Demarzo M.M.P.
      • Herrera-Mercadal P.
      • García-Campayo J.
      Mindfulness-based mobile applications: Literature review and analysis of current features.
      ), and can also be inexpensive to access, particularly for hard-to-reach populations (
      • Schultchen D.
      • Terhorst Y.
      • Holderied T.
      • Stach M.
      • Messner E.-M.
      • Baumeister H.
      • Sander L.B.
      Stay present with your phone: A systematic review and standardized rating of mindfulness apps in European app stores.
      ). However, some digital mindfulness apps use poor visualizations and provide limited feedback. This may lead to low adherence to and drop out from these types of digital health interventions designed to facilitate self-management of conditions like chronic pain (
      • Mani M.
      • Kavanagh D.J.
      • Hides L.
      • Stoyanov S.R.
      Review and evaluation of mindfulness-based iPhone apps.
      ). Furthermore, an individual's digital literacy skills, their preferences towards using technology to manage health, and access to affordable digital tools among other factors may also contribute to a lack of engagement with digital health interventions (
      • O'Connor S.
      • Hanlon P.
      • O'Donnell C.A.
      • Garcia S.
      • Glanville J.
      • Mair F.S.
      Understanding factors affecting patient and public engagement and recruitment to digital health interventions: A systematic review of qualitative studies.
      ).
      Virtual reality (VR) is a synthetic world in which a user is entirely immersed in computer-generated representations of an environment, with display technologies that capture the gaze direction of the user (
      • Slater M.
      • Sanchez-Vives M.V.
      Enhancing our lives with immersive virtual reality.
      ). The immersive experiences offered by VR are used in a variety of healthcare settings (
      • O'Connor S.
      Virtual reality and avatars in health care.
      ), deployed for relaxation to mitigate against distress when experiencing acute pain (
      • Hoffman H.G.
      • Meyer III, W.J.
      • Drever S.A.
      • Soltani M.
      • Atzori B.
      • Herrero R.
      • Patterson D.R.
      Virtual reality distraction to help control acute pain during medical procedures.
      ), and to help reduce pain and anxiety for cancer patients (
      • Ahmad M.
      • Bani Mohammad E.
      • Anshasi H.A.
      Virtual reality technology for pain and anxiety management among patients with cancer: A systematic review.
      ), among others. In contrast, Augmented Reality (AR) superimposes virtual information over a real word view, blending the digital and physical environments. In both of these technologies, the sensory illusion of ‘being there’ in a specific space has a connection to mindfulness practices (
      • Flett J.
      • Hayne H.
      • Riordan B.
      • Thompson L.
      • Conner T.
      Mobile mindfulness meditation: A randomised controlled trial of the effect of two popular apps on mental health.
      ).
      A recent scoping review by
      • Austin P.D.
      The analgesic effects of virtual reality for people with chronic pain: A scoping review.
      on virtual reality for people with chronic pain, identified 44 studies across a range of application areas such as exercise, gaming, relaxation, and mindfulness (three studies). However, only two bibliographic databases, MEDLINE and Embase, were searched, only studies using validated outcomes measures were included, and single case studies were excluded, meaning some pertinent literature may have been missed. Another recent narrative review of VR-based mindfulness interventions found that the immersive and multisensory environment created by VR had potential features that could support mindfulness practice (
      • Arpaia P.
      • D'Errico G.
      • De Paolis L.T.
      • Moccaldi N.
      • Nuccetelli F
      A narrative review of mindfulness-based interventions using virtual reality.
      ). Nonetheless, the review looked broadly at a range of clinical applications including pain, stress, depression, anxiety, and borderline personality disorder. Whilst VR apps designed to enhance mindfulness practices are increasingly used to help mitigate psychosocial issues and support subjective wellbeing, there are relatively few studies which explore the potential for the management of chronic pain through mindfulness practice using virtual environments (
      • Chandrasiri A.
      • Collett J.
      • Fassbender E.
      • De Foe A.
      A virtual reality approach to mindfulness skills training.
      ). Furthermore, a review of the scientific literature in this niche area has not yet been undertaken and a review focused on VR mindfulness applications for chronic pain specifically could benefit both patients and practitioners. Hence, this scoping review aimed to identify and synthesize the current scientific evidence on VR-based mindfulness practice to manage chronic pain.

      Methods

      Review Design

      Scoping reviews are a type of knowledge synthesis that tend to be more exploratory in nature, aiming to address broader topics where different study designs are utilized, and focused research questions are typically not asked or answered (
      • Arksey H.
      • O'Malley L
      Scoping studies: towards a methodological framework.
      ). They are particularly useful when an area of research is emerging and complex, and has not been comprehensively reviewed, as the process can rapidly map key concepts and the types of available evidence (
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • O'Brien K.
      • Colquhoun H.
      • Kastner M.
      • Levac M.
      • Ng D.
      • Sharpe J.P.
      • Wilson K.
      • Kenny M.
      • Warren R.
      • Stelfox H.T.
      • Straus S.E.
      A scoping review on the conduct and reporting of scoping reviews.
      ). Therefore, a scoping review was deemed an appropriate approach to reviewing the literature on VR-based mindfulness practice for managing chronic pain. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) checklist for reporting scoping reviews was followed when conducting this review (
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • O'Brien K.K.
      • Colquhoun H.
      • Levac D.
      • Moher DS.
      • Peters M.D.J.
      • Horsley T.
      • Weeks L.
      • Hempel S.
      • Akl E.A.
      • Chang C.
      • McGowan J.
      • Stewart L.
      • Hartling L.
      • Aldcroft A.
      • Wilson M.G.
      • Garritty C.
      • Straus S.E.
      PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation.
      ) (Appendix 1).

      Sources and Search Strategy

      A rigorous search of five bibliographic databases: CINAHL, the Cochrane Library, Embase, PubMed, and Scopus, were searched in November 2021 using key search terms relevant to the review, i.e., “chronic pain”, “virtual reality”, and “mindfulness”. A detailed search strategy for CINAHL can be found in Appendix 2, which was adapted for the other databases. Searches were limited to published empiric primary research using any study design, published in the English language, with a date range from 2010 to 2021, acknowledging the swift technological changes in VR technologies. The reference lists of included articles were also hand searched for any potentially relevant studies.

      Screening and Eligibility

      In line with the central tenant of scoping reviews, broad inclusion criteria were applied to identify relevant articles. The Population, Intervention, Context, Outcome (PICO) framework was used to guide the inclusion criteria for the review (
      • Methley A.M.
      • Campbell S.
      • Chew-Graham C.
      • McNally R.
      • Cheraghi-Sohi S.
      PICO, PICOS and SPIDER: A comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews.
      ). The population were those of any adult socio-demographic profile experiencing chronic pain, the intervention was a VR application used to support mindfulness practice, and the outcome related to any physical, mental, or social health outcome. In this context, studies did not necessarily involve comparators, as they were largely small-scale pilot or feasibility studies instead of randomized controlled trials. The initial search yielded 2,606 studies which were exported to Rayyan (https://www.rayyan.ai/) for screening. Duplicates were removed and then titles and abstracts were reviewed for eligibility. Studies whose participants were drawn from pediatric populations, those which focused on specific acute conditions that caused pain, mindfulness mixed with other meditative, relaxation or other therapies, where specific gamified environments such as Second Life™, or outcomes that related to the delivery of digital health services were excluded. Next, full-texts were retrieved and screened, and those not meeting the criteria were excluded (see Fig. 1). Screening was undertaken by a single reviewer and any ambiguity during the process was discussed with the research team.

      Data Extraction and Synthesis

      A data extraction sheet was prepared on Microsoft Excel and piloted and refined using a handful of studies. Then, the key characteristics of all included studies were extracted (Table 1). Thematic analysis was utilized to code and categorize data into higher order themes, which were mapped within and across studies to identify emerging themes and subthemes related to VR-based mindfulness for chronic pain management (Fig. 2) (
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      ). Coding clinics and peer debriefing sessions were held with members of the research team, to cross check samples of analyses to improve qualitative rigor and reduce researcher bias. A critical appraisal of the included studies was not undertaken, as scoping reviews focus more broadly on the heterogenous body of knowledge on a topic instead of determining the quality of the evidence base.
      Table 1Characteristics of Included Studies.
      Authors, year, country, publicationResearch aim(s)Study designParticipants and settingInterventionResults
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      , Spain, Cyberpsychology, Behavior, and Social Networking
      To examine the effectiveness of a VR intervention in the treatment of fibromyalgia as an adjunct to Cognitive Behavioral Therapy (CBT)Design: Pre-test, post-test, 10 × 2-hour group CBT sessions in a VR environment and education on pain and healthy habits; facilitated by therapists over 7 weeks, 6-month follow-upParticipants: Adult patients with Fibromyalgia (FM), Female = 6; Male = 0; Age: 47-65 years Setting: rheumatology service within a public hospitalVR hardware: 2 personal computers, a large projection screen, 2 projectors onto a 4 × 1.5 screen with surround audio (no headset) VR software: engaging Media for Mental Health Applications worldMeasures: FM Impact Questionnaire, Chronic Pain Coping Inventory, Beck Depression Inventory II, Positive and Negative Affect Schedule, VR Satisfaction Scale Findings: Participants improved over a six month follow up period; some reduction in levels of depression; increase in positive affect; no increase in negative affect; no change in use of illness-focused coping strategies; high increase in wellness-coping strategies; experience of VR rated consistently highly
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      , USA, JMIR Formative Research
      To evaluate the feasibility and preliminary efficacy of a self-administered VR program for chronic painDesign: a parallel-group, randomized controlled trial (RCT), 21-day (3-week) intervention, 1 of 2 unblinded treatments (VR or audio narration), 4-8 treatment sessions (1-5 minutes)Participants: a web-based convenience sample of adults (n = 46 audio, n = 42 VR) aged 18-75 years with self-reported chronic low back pain or fibromyalgia Setting: community-basedVR hardware: Oculus Go VR headset preloaded with software VR software: software with 3 components, 1) skills rooted in pain CBT, 2) relaxation training and 3) mindfulnessMeasures: Defense and Veterans Pain Rating Scale, Average Pain Intensity, Pain Interference on Activity, Mood, Sleep, and Stress, Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, Patient Global Impression of Change, Satisfaction with treatment, Motion Sickness and Nausea Findings: Symptom improvement was found for each pain variable (all p < .001). Most VR participants reported no nausea or motion sickness (n = 19/25, 76%). Significant time × group effects were found in favor of the VR group for average pain intensity (p = .04), pain-related inference with activity (p = .005), sleep (p < .001), mood (p < .001), and stress (p = .003).
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      , USA, Journal of Medical Internet Research
      To assess if VR would evidence superior outcomes for all baseline to post-treatment comparisons in people with chronic low back pain compared to those assigned to a Sham VRDesign: double-blind, parallel-arm, single-cohort, remote, randomized placebo-controlled trial, one of two 56-day (1 session daily) treatment programs: 1) therapeutic VR or 2) Sham VRParticipants: community-based adult individuals with chronic low back pain for 6 months or more (n = 179), female: 76.5%, 137/179; Caucasian: 90.5%, 162/179, mean age: 51.5 years Setting: community-basedVR hardware: Pico G2 4K all-in-one head-mounted VR device (exhalation is measured by the microphone embedded in the hardware) VR software: EaseVRx - principles of CBT, mindfulness, and pain neuroscience education, and Sham VR an active control that utilizes non-immersive, 2D content)Measures: Defense and Veterans Pain Rating Scale, Pain Interference With Activity, Mood, Sleep, and Stress, Patient's Global Impression of Change, NIH Physical Function and Sleep Disturbance, Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, Chronic Pain Acceptance Questionnaire, Satisfaction with treatment, VR use, System Usability Scale, Motion Sickness and Nausea, Over-the-Counter Analgesic Medication Use, Opioid use Findings: For EaseVRx, large pre–post effect sizes ranged from 1.17 to 1.3 and met moderate to substantial clinical importance for reduced pain intensity and pain-related interference with activity, mood, and stress. Pain catastrophizing, pain self-efficacy, pain acceptance, prescription opioid use did not reach statistical significance for either group.
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , Canada, Heliyon
      To explore the experiences of individuals with cancer related chronic pain in using a daily VR-based self-administered home therapyDesign: qualitative inductive (constant-comparative) approach using two focus groups (approx. 60 minutes each)Participants: patients with cancer (aged >16) with chronic involved in an ongoing RCT of a VR intervention (n = 12), 30 min of activity per day for six days

      Setting: at home
      VR hardware: HTC Vive stereoscopic headset VR software: two interventions based on cognitive engagement and two based on mindfulness meditationMeasures: none – qualitative study Findings: Five major thematic categories emerged: (1) activities; (2) usability; (3) effects; (4) mode of action; and (5) technical aspects. Mixed results in the use of adjunctive VR therapy to manage chronic cancer pain. Future designs of VR interventions engage pain patients in the design process to ensure maximum efficacy of experiences to with individuals' preferences
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      , Canada, Proceedings of the 33rd Annual ACM Conference on Human Factors in Computing Systems
      To examine the effectiveness of a VR based Mindfulness Based Stress Reduction (MBSR) program to manage long-term painDesign: focus groups and participatory design sessions, followed by a single 12-minute experimental VR session with control group (audio only)Participants: Patients with chronic pain Female = 7; Male = 6; Age: 35-55

      Setting: university hospital pain clinic
      VR hardware: Deepstream VR viewer and galvanic skin response (GSR) sensors VR software: Virtual Meditative Walk (forest environment)Measures: Numerical Rating Scale Findings: As slow movement of camera mimics act of walking, GSR sensors respond to arousal levels with changing weather immersive visuals and stereoscopic sounds. Responses suggest observing biofeedback data helps participants monitor management of perceived pain. VR appears effective in teaching MBSR to manage attention as therapeutic pain control intervention and more effective than MBSR
      • Igna R.
      • Stefan S.
      • Onac I.
      • Ungur R.A.
      • Szentagotai-Tatar A.
      Mindfulness-based cognitive-behavior therapy (MCBT) versus virtual reality (VR) enhanced CBT, versus treatment as usual for chronic back pain. A clinical trial.
      ), Romania, Journal of Evidence-Based Psychotherapies
      To evaluate the effectiveness of a VR enhanced CBT intervention with MCBT usual care in reducing pain intensity and associated emotional and cognitive problems, improving quality of lifeDesign: clinical trial, 6 session intervention program, with 2 individual meetings per week, all participants received physiotherapy and pharmacotherapyParticipants: 68 adult patients with chronic pain (CBT = 18, MBCT = 25, control = 25), mean age of 47, most were female n = 36, Setting: unclearVR hardware: HTC Vive stereoscopic headset VR software: five minutes of exposure to the “SnowWorld” and afterwards debriefing about how shifting attention from pain decreases intensity of painMeasures: Visual Analogue Scale, McGill Pain Questionnaire, State-Trait Anxiety Inventory, Beck Depression Inventory, Profile of Mood States Short Version, Functional Assessment of Cancer Therapy Scale – General Version, General Attitudes and Beliefs Scale – short version, Pain Anxiety Symptoms Scale, Pain Catastrophizing Scale, Automatic Thoughts Questionnaire, Mindful Attention Awareness Scale, Chronic Pain Acceptance Questionnaire Findings: There were no significant differences between intervention groups and control group at post-treatment, except for the pain intensity scores but there were significant differences between pre-treatment and post treatment, for all three conditions, in mindfulness (t(62) = -3.365, p = .001) and pain catastrophizing (t(49) = 4.147, p = .000).
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      , Canada, International Conference on Virtual, Augmented and Mixed Reality
      To examine effectiveness of Virtual Meditative Walk VR system (based on MBSR) in managing chronic painDesign: Single 12-minute VR test sessions; control group continued usual clinic MBSR exerciseParticipants: Patients with chronic pain, Female = 4, Male = 3 (in VR group); Female = 3, Male = 3 (control group); Age: 35-55 Setting: established pain clinicVR hardware: stereoscopic display mounted on movable arm (gazing into device held at shoulder height) and GSR sensors VR software: prototype of Virtual Meditative Walk (foggy forest)Measures: Numerical Rating Scale Findings: VR and MBSR training with biofeedback appears significantly more effective than MBSR alone in reducing reported pain levels. Specific benefits of combination of VR and MBSR mediation identified as immersive sonic and visual signals about real time feedback to reinforce training.
      Abbreviations: CBT = cognitive-behavior therapy; FM - Fibromyalgia; MCBT = mindfulness-based cognitive-behavior therapy; MBSR = mindfulness based stress reduction; RCT = randomized controlled trial; VR = virtual reality

      Results

      Study Characteristics

      Seven articles were included in the final scoping review, published between 2013 and 2021 (Table 1). Five were set in North America: two in the United States (
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      ;
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ) and three in Canada (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      ;
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      ;
      • Tong X.
      • Gromala D.
      • Choo A.
      • Amin A.
      • Shaw C.
      The virtual meditative walk: An immersive virtual environment for pain self-modulation through mindfulness-based stress reduction meditation.
      ). A further two studies were based in Europe: one in Spain (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ) and one in Romania (
      • Igna R.
      • Stefan S.
      • Onac I.
      • Ungur R.A.
      • Szentagotai-Tatar A.
      Mindfulness-based cognitive-behavior therapy (MCBT) versus virtual reality (VR) enhanced CBT, versus treatment as usual for chronic back pain. A clinical trial.
      ). Two were published in medical informatics (
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      ;
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ) and psychology journals (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ;
      • Igna R.
      • Stefan S.
      • Onac I.
      • Ungur R.A.
      • Szentagotai-Tatar A.
      Mindfulness-based cognitive-behavior therapy (MCBT) versus virtual reality (VR) enhanced CBT, versus treatment as usual for chronic back pain. A clinical trial.
      ), one in an all-science journal (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      ), and two were conference proceedings in the computer science and virtual reality domains (
      • Tong X.
      • Gromala D.
      • Choo A.
      • Amin A.
      • Shaw C.
      The virtual meditative walk: An immersive virtual environment for pain self-modulation through mindfulness-based stress reduction meditation.
      ;
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      ). The study authors held a variety of professional backgrounds including business, computer science, medicine, nursing, psychology, and science, along with clinical and industry co-authors. The populations recruited to the included studies were a mixture of men and women with chronic pain, chronic low back pain, chronic cancer pain, or fibromyalgia. However, women comprised the majority of participants where these data were available. Other sociodemographic data such as ethnicity and educational level were often not reported, except in
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      who noted that 90.5% of participants were White. Typically, the sample size was small, ranging from a minimum of 6 (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ) up to 179 participants (
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ).
      In terms of the VR interventions, the interpretation of mindfulness varied across studies with some mixing mindfulness with relaxation, CBT, and other techniques (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ), whereas others were based specifically on MBCT (
      • Igna R.
      • Stefan S.
      • Onac I.
      • Ungur R.A.
      • Szentagotai-Tatar A.
      Mindfulness-based cognitive-behavior therapy (MCBT) versus virtual reality (VR) enhanced CBT, versus treatment as usual for chronic back pain. A clinical trial.
      ), or MBSR (
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      ;
      • Tong X.
      • Gromala D.
      • Choo A.
      • Amin A.
      • Shaw C.
      The virtual meditative walk: An immersive virtual environment for pain self-modulation through mindfulness-based stress reduction meditation.
      ). The VR sessions lasted from as little as 1-5 minutes (
      • Igna R.
      • Stefan S.
      • Onac I.
      • Ungur R.A.
      • Szentagotai-Tatar A.
      Mindfulness-based cognitive-behavior therapy (MCBT) versus virtual reality (VR) enhanced CBT, versus treatment as usual for chronic back pain. A clinical trial.
      ;
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      ) to a maximum of 120 minutes (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ), with some taking place only once (
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      ;
      • Tong X.
      • Gromala D.
      • Choo A.
      • Amin A.
      • Shaw C.
      The virtual meditative walk: An immersive virtual environment for pain self-modulation through mindfulness-based stress reduction meditation.
      ), while other VR mindfulness sessions were run over several weeks (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ;
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      ;
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ;
      • Igna R.
      • Stefan S.
      • Onac I.
      • Ungur R.A.
      • Szentagotai-Tatar A.
      Mindfulness-based cognitive-behavior therapy (MCBT) versus virtual reality (VR) enhanced CBT, versus treatment as usual for chronic back pain. A clinical trial.
      ). Only a single study incorporated a 6-month follow-up (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ). A range of VR hardware was used across the included studies such as Oculus (Go, Quest, or Rift), HTC, and Samsung headsets, with only two studies incorporating physiologic monitoring devices (
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      ;
      • Tong X.
      • Gromala D.
      • Choo A.
      • Amin A.
      • Shaw C.
      The virtual meditative walk: An immersive virtual environment for pain self-modulation through mindfulness-based stress reduction meditation.
      ). Participants were immersed in a variety of virtual environments, namely natural landscapes such as forests.
      The outcomes included a range of measures for chronic pain such as the Chronic Pain Coping Inventory, Chronic Pain Acceptance Questionnaire, and Fibromyalgia Impact Questionnaire, as well as general pain measures such as the Pain Interference on Activity, Pain Catastrophizing Scale, and Pain Self-Efficacy Questionnaire among others. Other aspects impacted by chronic pain such as depression, and quality of life were also assessed. One study measured mindfulness using the Mindful Attention Awareness Scale (
      • Igna R.
      • Stefan S.
      • Onac I.
      • Ungur R.A.
      • Szentagotai-Tatar A.
      Mindfulness-based cognitive-behavior therapy (MCBT) versus virtual reality (VR) enhanced CBT, versus treatment as usual for chronic back pain. A clinical trial.
      ), while others evaluated aspects of the VR experience such as VR usability (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ;
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ). The study designs varied from randomized controlled trials (
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      ;
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ;
      • Igna R.
      • Stefan S.
      • Onac I.
      • Ungur R.A.
      • Szentagotai-Tatar A.
      Mindfulness-based cognitive-behavior therapy (MCBT) versus virtual reality (VR) enhanced CBT, versus treatment as usual for chronic back pain. A clinical trial.
      ), to quasi-experimental studies (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ;
      • Tong X.
      • Gromala D.
      • Choo A.
      • Amin A.
      • Shaw C.
      The virtual meditative walk: An immersive virtual environment for pain self-modulation through mindfulness-based stress reduction meditation.
      ), with one taking a qualitative approach (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      ), and another utilizing a mixture of methods (
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      ). The settings ranged from hospital outpatient clinics (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ;
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      ;
      • Tong X.
      • Gromala D.
      • Choo A.
      • Amin A.
      • Shaw C.
      The virtual meditative walk: An immersive virtual environment for pain self-modulation through mindfulness-based stress reduction meditation.
      ), to those based in the community (
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      ;
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ), or in participants’ homes (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      ). Overall, the small-scale nature of the studies and the diversity of their designs, participants, interventions, and outcome measures meant the effectiveness of VR mindfulness applications for managing chronic pain could not be determined, as a meta-analysis was not feasible to undertake.

      Key Themes

      Three main themes were identified around VR mindfulness practice for managing chronic pain: (1) physical and mental health benefits; (2) treatment engagement and satisfaction; and (3) intervention usability, which had a number of subthemes.

      Physical and Mental Health Benefits

      All seven studies reported some physical or mental health benefit from those who practiced VR-based mindfulness to manage chronic pain (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ;
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      ;
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ;
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      ;
      • Gromala D.
      • Tong X.
      • Choo A.
      • Karamnejad M.
      • Shaw C.D.
      The virtual meditative walk: Virtual reality therapy for chronic pain management.
      ;
      • Tong X.
      • Gromala D.
      • Choo A.
      • Amin A.
      • Shaw C.
      The virtual meditative walk: An immersive virtual environment for pain self-modulation through mindfulness-based stress reduction meditation.
      ;
      • Igna R.
      • Stefan S.
      • Onac I.
      • Ungur R.A.
      • Szentagotai-Tatar A.
      Mindfulness-based cognitive-behavior therapy (MCBT) versus virtual reality (VR) enhanced CBT, versus treatment as usual for chronic back pain. A clinical trial.
      ). For instance,
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      , reported that the post-treatment scores of the Fibromyalgia Impact Questionnaire and Beck Depression Index showed a reduction in impairment and depression levels for participating patients. Likewise,
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      found that a number of pain related measures (i.e., pain intensity, pain-related activity, mood, sleep, and stress interference) were lowered by 30%-50% in the VR group using the digital mindfulness intervention during the three-week RCT, demonstrating a clinically important change, particularly after Day 15. However, the measures for pain self-efficacy and pain catastrophizing improved for both the treatment and control groups, who received an audio-only version. Furthermore,
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      showed that physical function and sleep disturbance improved during their RCT of a VR mindfulness intervention, as the treatment group had higher physical function (p = .022) and lower sleep disturbance (p = .013) compared with the control after eight weeks.
      A qualitative exploration by
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      supports the physical health benefits of VR mindfulness applications, as many participants reported less pain, due to the relaxing, immersive, or distracting nature of the virtual experience, although for some this only lasted a short time (approximately 30 minutes). A handful of participants also reported improvements in sleep and mobility due to being more relaxed and feeling less pain (Table 2). Another physical health benefit reported in one study was a substantial decrease in over-the-counter analgesic medication use by the VR mindfulness intervention group (p = .01), although prescribed opioid use remained unchanged (
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ).
      Table 2Quotes from Included Studies.
      Theme / subthemeSupporting quote from included study
      Theme 1: Physical and mental health benefits“I also looked forward to my sessions every day. Because I actually would get to the point where I was in the game and I realized I had no pain. And it was like, wow! I'm not only enjoying myself, but I actually have no pain!” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 6) “The meditation was great, the scenery was beautiful, and the scenery in the other one with the ocean scenes and that, that was relaxing, beautiful. Those were good” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 6) “One of the things that I found too, before I had bone cancer I was very active. I was hiking, I was always into rock climbing, sports, things like that. So, for me to be able to like virtually go to, like... I would just go and check and explore something and watch the water. I really enjoyed that part, it took me to places that I just relate to from my climbing days” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 7)

      “It was about 30 min…that I felt sort of calmer and more relaxed, and just… you'd felt like you'd had a break from the pain” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 6) “With the slight analgesic effect yes, mobility was increased somewhat…When I'm in pain I'm less mobile, whereas with the VR headset, when I was done the VR, I was thinking about my pain less” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 6)
      Theme 3, Subtheme 3.1: Cybersickness“The butterfly [Wildflowers], that made me nauseous. I couldn't do it, I couldn't control the butterfly flying around, and it was making me sick” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 6)
      Theme 3, Subtheme 3.2: Physical limitations“I just thought it was important to have a comfortable chair to make sure that - because I have leg issues, so you have to start off with a comfortable chair, because after a half an hour, if you're sitting on a stool, the pain can be worse. So, I made sure I had a pillow and my heat blanket” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 5) “I found that the headset was really quite heavy, which actually affected my neck” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 5) “For me, half an hour is long enough. In actual fact, I did have eye strain after about 20 min and I needed to remove the glasses from my head and take a break. So, it did bother me, with the eyes” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 6)
      Theme 3, Subtheme 3.3: Technical support“I just want it to work and I don't know how to fix things like that. So, it's something that I would absolutely educate myself on and want somebody that I could reach out to if I was having problems” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 7)
      Theme 3, Subtheme 3.4: Personalized design“Most of us here I would assume spend a lot of our effort and time in the day trying to escape from pain, and in a variety of ways, so this is a tool that we could use. Especially in the future, you could have thousands of different situations that you could immerse yourself in, for as much time as you want in the day” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 5) “I found that - I'm not sure which one, one of the talking ones – where they got you to focus on your pain [VMW]. I found that that made my pain much worse, and I think part way through I actually stopped doing it and went to a different one to do my 30 min a day, because the pain was just so aggravated by concentrating on it.” (
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , p. 6)

      Treatment Engagement and Satisfaction

      Two studies mentioned that participant engagement with the VR mindfulness application was excellent, with
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      reporting users completed 34 sessions over 21 days and
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      reporting participants used the VR device on average 43 times. Satisfaction with VR mindfulness as a treatment intervention to help manage chronic pain was also indicated in three studies (
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      ;
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      ;
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ). In
      • Botella C.
      • Garcia-Palacios A.
      • Vizcaíno Y.
      • Herrero R.
      • Baños R.M.
      • Belmonte M.A.
      Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study.
      satisfaction levels of six women with fibromyalgia ranged from 7 to 10, where zero was “not at all” and ten was “very much”.
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      also highlighted the majority of participants in the VR group, with selvvf-reported chronic low back pain or fibromyalgia, were either extremely satisfied or very satisfied (n = 21/25, 84%) with the treatment. In
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      , the VR group reported greater satisfaction with the treatment, were also more likely to recommend VR to another person, and were more likely to continue using the VR headset, than the control (p < .001). However, the authors noted their clinical trial took place during the coronavirus pandemic and so engagement and satisfaction may have been higher than normal as people were social distancing and working in more remote, isolated environments.

      Intervention Usability

      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      was the only study that explicitly measured VR usability, via the System Usability Scale, with both treatment groups (VR and Sham VR) who had chronic low back pain reporting high levels of VR usability, 84.33% and 81.16% respectively. Four usability sub-themes emerged from the review findings: (1) cybersickness; (2) physical limitations; (3) technical support; and (4) personalized design. Supporting quotations from included studies can be found in Table 2.

      Cybersickness

      Three studies commented that participants experienced some type of motion sickness or nausea while using a VR mindfulness application (
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      ;
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      ;
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      ). Most individuals in
      • Darnall B.D.
      • Krishnamurthy P.
      • Tsuei J.
      • Minor J.D.
      Self-administered skills-based virtual reality intervention for chronic pain: A randomized controlled pilot study.
      reported never experiencing cybersickness (n = 19/25, 76%), with five out of the six individuals who did only experiencing it ‘sometimes’ and the other participant ‘often’. This did not seem to affect engagement with the digital intervention, except for the single participant reporting it ‘often’ as they used the VR application a third less times compared with the rest of VR group. Similarly, a small number of participants in
      • Garcia L.M.
      • Birckhead B.J.
      • Krishnamurthy P.
      • Sackman J.
      • Mackey I.G.
      • Louis R.G.
      • Salmasi V.
      • Maddox T.
      • Darnall B.D.
      An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19.
      experienced nausea and motion sickness during the VR treatment (n = 7/72, 9.7% and n = 5/75, 6.7%). Some individuals interviewed during focus group sessions in
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      also mentioned negative physical effects of motion sickness from being immersed in a virtual world.

      Physical limitations

      Most of the cancer patients with chronic pain in
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      found physical limitations with the VR equipment or software. This ranged from being uncomfortable when sitting or standing during the VR mindfulness intervention, discomfort when wearing the VR headset or eyeglasses inside the headset to improve vision, or eye strain from immersion in a three-dimensional, digitized environment.

      Technical support

      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      was the only study to highlight that technical support might be needed for those using a VR mindfulness application, as several participants mentioned this during the focus group sessions, particularly if using the digital intervention at home. The author hypothesized that this could reflect the early stage of VR development and how complex it could be to use some of the headsets and virtual software applications:

      Personalized design

      The need for more personalized design was highlighted in
      • Garrett B.M.
      • Tao G.
      • Taverner T.
      • Cordingley E.
      • Sun C.
      Patients perceptions of virtual reality therapy in the management of chronic cancer pain.
      , as some participants would have preferred more open environments that they could explore rather than following a guided virtual experience. More choice over the type of virtual environment and stimulus when practicing mindfulness for pain management was noted by a couple of participants, who valued the ability to curate their own virtual world that was tailored to their needs. One individual felt the design of the virtual space he inhabited made the pain worse and changed to a different VR experience, indicating a need for a variety of virtual environments within which to practice mindfulness.

      Discussion

      This scoping review found that there was limited scientific evidence to support using VR mindfulness applications to manage chronic pain, as this is an emerging research area with evolving technologies and more robust, large-scale studies are needed to determine the effect of VR based mindfulness interventions on those who experience chronic pain. However, preliminary evidence suggests that VR may help enhance aspects of mindfulness practice, such as feeling relaxed, centered, or distracted, which could lessen pain and improve sleep and mobility for some people. Although sample sizes were generally small, those who used VR mindfulness applications tended to engage with them on a regular basis and were satisfied with this type of digital treatment modality. The usability of the technology, both the hardware and software, seemed to be an issue as some participants experienced cybersickness, discomfort from wearing a VR headset, or eye strain from being fully immersed in a virtual environment. In these cases, potential benefits in the self-management of chronic pain could have been outweighed by short-term discomfort and nociceptive pain from the VR equipment. Others recommended technical support when using VR technology at home and more personalized designs of virtual worlds to support tailored mindfulness practice.
      The findings of this review have been mirrored in other literature.
      • Rice V.J.
      • Liu B.
      • Allison S.C.
      • Schroeder P.J.
      Mindfulness training offered in-person and in a virtual world—Weekly self-reports of stress, energy, pain, and sleepiness among US military active duty and veteran personnel.
      found that a non-patient population, U.S. military veterans, had less pain (24.4%) and stress (17%) after eight weeks of a mindfulness meditation training program delivered virtually using customized avatars in Second Life. Although few studies have examined VR-based mindfulness in relation to pain,
      • Flores A.
      • Linehan M.M.
      • Todd S.R.
      • Hoffman H.G.
      The use of virtual reality to facilitate mindfulness skills training in dialectical behavioral therapy for spinal cord injury: A case study.
      found similar results when examining a VR mindfulness intervention to deliver dialectical behaviour therapy (DBT) among patients with a spinal cord injury, as they felt less depressed, anxious, and emotionally upset afterwards. Equally,
      • Gomez J.
      • Hoffman H.G.
      • Bistricky S.L.
      • Gonzalez M.
      • Rosenberg L.
      • Sampaio M.
      • Garcia-Palacios A.
      • Navarro-Horo M.V.
      • Alhalabi W.
      • Rosenberg M.
      • Meyer 3rd, W.J.
      • Linehan M.M.
      The use of virtual reality facilitates Dialectical Behavior Therapy® “Observing Sounds and Visuals” mindfulness skills training exercises for a Latino patient with severe burns: A case study.
      tested a VR DBT mindfulness skills training program with a patient with severe burns and found it decreased negative emotions.
      The level of satisfaction with VR as a mental health treatment modality found in this review has been noted elsewhere, as
      • Navarro-Haro M.V.
      • Lopez-del-Hoyo Y.
      • Campos D.
      • Linehan M.M.
      • Hoffman H.G.
      • Garcia-Palacios A.
      • Modrego-Alarcón M.
      • Borao L.
      • Garcia-Campayo J.
      Meditation experts try Virtual Reality Mindfulness: A pilot study evaluation of the feasibility and acceptability of Virtual Reality to facilitate mindfulness practice in people attending a Mindfulness conference.
      tried a VR DBT mindfulness skills training technique with meditation experts and reported high levels of acceptance towards using VR to practice mindfulness.
      • Navarro-Haro M.V.
      • Hoffman H.G.
      • Garcia-Palacios A.
      • Sampaio M.
      • Alhalabi W.
      • Hall K.
      • Linehan M.
      The use of virtual reality to facilitate mindfulness skills training in dialectical behavioral therapy for borderline personality disorder: A case study.
      also tried the same approach with a patient with borderline personality disorder and found the intervention was well accepted by the participant. The high level of engagement with VR mindfulness interventions reported in this review has been echoed elsewhere, as
      • Sol Roo J.
      • Gervais R.
      • Frey J.
      • Hachet M.
      Inner garden: Connecting inner states to a mixed reality sandbox for mindfulness.
      reported meditation practitioners who used a VR Zen garden enjoyed the immersion and sense of control it offered and found the design of the virtual experience engaging. Likewise,
      • Navarro-Haro M.V.
      • Modrego-Alarcón M.
      • Hoffman H.G.
      • López-Montoyo A.
      • Navarro-Gil M.
      • Montero-Marin J.
      • García-Palacios A.
      • Borao L.
      • García-Campayo J.
      Evaluation of a mindfulness-based intervention with and without virtual reality Dialectical Behavior Therapy® mindfulness skills training for the treatment of generalized anxiety disorder in primary care: A pilot study.
      highlighted those with general anxiety disorders were more adherent to VR DBT mindfulness skills training than those receiving standard mindfulness-based interventions.
      The factors affecting the usability of VR identified in this review have also been highlighted by others. The negative physical side effects of being immersed and interacting with virtual environments such as nausea and motion sickness, along with discomfort when wearing VR headsets have been widely reported in the literature (
      • Austin P.D.
      The analgesic effects of virtual reality for people with chronic pain: A scoping review.
      ;
      • Brown P.
      • Powell W.A.
      Pre-exposure cybersickness assessment within a chronic pain population in virtual reality.
      ). Although technical support is not often mentioned in the VR literature, it emerged as a facilitating factor in this review and warrants further exploration in light of the ever-changing technologies in this area. For example, some headsets such as the Oculus Go are no longer available on the market and newer technologies such as immersive AR glasses like Magic Leap (2021) are available for mindfulness practice that could help people better manage chronic pain. The importance of personalized design of VR mindfulness applications also came to the forefront in the review. Similarly,
      • Prpa M.
      • Tatar K.
      • Françoise J.
      • Riecke B.
      • Schiphorst T.
      • Pasquier P.
      Attending to breath: Exploring how the cues in a virtual environment guide the attention to breath and shape the quality of experience to support mindfulness.
      highlighted how virtual environments closely attuned to users’ preferences when practicing mindfulness are more likely to be effective. Co-creating VR and AR mindfulness environments with those experiencing chronic pain is also being explored to improve future designs based on these technologies (
      • Mayne A.
      • O'Connor S.
      • Hood B.
      ), as more complex realizations using AR, bringing together mindfulness practitioners’ awareness of both ‘being there’ and ‘being elsewhere’ by combining the affordances of the augmented as well as the familiar may be helpful in managing chronic pain.

      Strengths and Limitations

      This scoping review was strengthened by employing a systematic approach to identify relevant literature and following best practice guidelines such as PRISMA Extension for Scoping Review (PRISMA-ScR) to improve reporting. A robust thematic analysis was undertaken to reflect emerging themes in this novel area of research. However, a number limitations are present as only a handful of relevant studies, hailing from North America and Europe, were identified. This lack of geographic diversity means some cultural and socioeconomic aspects of VR-based mindfulness practice for managing chronic pain may be missing. The seven studies were also heterogeneous in nature in terms of their definitions of mindfulness, populations, digital interventions, and outcome measures, making meaningful comparisons challenging, particularly given their small scale and weaknesses in some of the study designs employed. This raises some questions about the generalizability of the review findings and hence they should be interpreted with caution.

      Clinical and Research Implications

      This review indicates that VR-based mindfulness interventions have the potential to alleviate chronic pain and some of its side effects such as depression and anxiety. Therefore, nurses and other healthcare professionals should consider alternative technology-based therapies for patients experiencing long-term pain. More studies related to different types of VR applications for managing acute pain exist (
      • Haisley K.R.
      • Straw O.J.
      • Müller D.T.
      • Antiporda M.A.
      • Zihni A.M.
      • Reavis K.M.
      • Bradley D.D.
      • Dunst C.M.
      Feasibility of implementing a virtual reality program as an adjuvant tool for peri-operative pain control; Results of a randomized controlled trial in minimally invasive foregut surgery.
      ;
      • Malloy K.M.
      • Milling L.S.
      The effectiveness of virtual reality distraction for pain reduction: A systematic review.
      ), but those who experience chronic pain may require lengthier and more in-depth digital interventions due to the lasting nature of their pain and its impact on quality of life. Future researchers should examine the effect of VR mindfulness applications over months and years, to ensure people with chronic pain adhere to this type of digital intervention and the longitudinal impact of this technology on managing pain long-term can be established (
      • Scherer E.A.
      • Ben-Zeev D.
      • Li Z.
      • Kane J.M
      Analyzing mHealth engagement: Joint models for intensively collected user engagement data.
      ).
      While the levels of engagement with VR as a treatment option is encouraging,
      • Liaw S.Y.
      • Wu L.T.
      • Soh S.L.H.
      • Ringsted C.
      • Lau T.C.
      • Lim W.S.
      Virtual reality simulation in interprofessional round training for health care students: A qualitative evaluation study.
      warns that a novelty factor may be influencing how often people utilize VR technologies. Hence, the uptake and retention of these types of digital health interventions needs to be examined in more depth to determine if people with chronic pain will remain using them long-term. Clinicians could re-assess how often a patient engages with VR applications during clinic or outpatient visits and researchers could employ the Digital Health Engagement Model to help assess if people will adopt VR mindfulness applications for chronic pain management or not (
      • O'Connor S.
      • Hanlon P.
      • O'Donnell C.A.
      • Garcia S.
      • Glanville J.
      • Mair F.S.
      Understanding factors affecting patient and public engagement and recruitment to digital health interventions: A systematic review of qualitative studies.
      ). Nurses are also well placed to advise patients to limit the time spent in a virtual simulation to reduce the risk of cybersickness or physical discomfort from wearing a VR headset. The timing, frequency, and duration of VR mindfulness practice for managing chronic pain also needs further exploration, so that recommendations for an optimal digital intervention can be made. The Template for Intervention Description and Replication (
      • Hoffmann T.C.
      • Glasziou P.P.
      • Boutron I.
      • Milne R.
      • Perera R.
      • Moher D.
      • Altman D.G.
      • Barbour V.
      • Macdonald H.
      • Johnston M.
      • Lamb S.E.
      • Dixon-Woods M.
      • McCulloch P.
      • Wyatt J.C.
      • Chan A.W.
      • Michie S.
      Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide.
      ) is a 12‐item checklist that could be used to clearly describe future VR interventions to aid their design and development, and enhance the quality, transparency and replicability of research studies.
      Finally, the cost-effectiveness of VR mindfulness applications did not emerge in the review findings which could be a barrier for some people. Therefore, understanding the costs associated with virtual, online, mobile, and in-person mindfulness program for managing chronic pain would help patients and practitioners make more informed decisions about which type of intervention to pursue. Future research should examine this to determine which is most affordable and effective, as there could be a trade-off between the two.

      Conclusion

      The review findings suggest VR could improve self-management of chronic pain by enhancing mindfulness practice through the use of immersive virtual environments and employing design that considers the diversity of users’ needs. Further research examining the efficacy of VR-based mindfulness applications in more rigorous ways is needed to demonstrate positive health outcomes, alongside in-depth co-design of virtual environments with people who experience chronic pain so that personalized mindfulness practice can be facilitated and some of the usability issues associated with these digital health interventions can be addressed.

      Declaration of Competing Interest

      None.

      Funding

      This study was supported by funding from The University of Edinburgh, College of Arts, Humanities and Social Sciences (CAHSS) Challenge Investment Fund from 2019.

      Appendix 1. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist

      Tabled 1
      SECTIONITEMPRISMA-ScR CHECKLIST ITEMREPORTED ON PAGE #
      TITLE
      Title1Identify the report as a scoping review.3
      ABSTRACT
      Structured summary2Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.1
      INTRODUCTION
      Rationale3Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.3 - 5
      Objectives4Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.5
      METHODS
      Protocol and registration5Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.NA
      Eligibility criteria6Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.6
      Information sources*7Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.6
      Search8Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.6 and appendix 2
      Selection of sources of evidence†9State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.6
      Data charting process‡10Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.8
      Data items11List and define all variables for which data were sought and any assumptions and simplifications made.7
      Critical appraisal of individual sources of evidence§12If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).NA
      Synthesis of results13Describe the methods of handling and summarizing the data that were charted.7
      RESULTS
      Selection of sources of evidence14Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.8
      Characteristics of sources of evidence15For each source of evidence, present characteristics for which data were charted and provide the citations.9-14
      Critical appraisal within sources of evidence16If done, present data on critical appraisal of included sources of evidence (see item 12).NA
      Results of individual sources of evidence17For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.9-14
      Synthesis of results18Summarize and/or present the charting results as they relate to the review questions and objectives.15-19
      DISCUSSION
      Summary of evidence19Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.19-23
      Limitations20Discuss the limitations of the scoping review process.22
      Conclusions21Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.24
      FUNDING
      Funding22Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.NA
      JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.
      * Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites.
      † A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote).
      ‡ The frameworks by Arksey and O'Malley (6) and Levac and colleagues (7) and the JBI guidance (4, 5) refer to the process of data extraction in a scoping review as data charting.
      § The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).
      From: Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMAScR): Checklist and Explanation. Ann Intern Med. 2018;169:467–473. doi: 10.7326/M18-0850.

      Appendix 2. Search strategy for CINAHL (EBSCO)

      Tabled 1
      No.Search terms
      S1(MH "Chronic Pain")
      S2(MH "Chronic Pain (NANDA)")
      S3(MH "Chronic Pain Control (Saba CCC)")
      S4(MH "Chronic Pain (Saba CCC)")
      S5TI (pain* OR painful OR "chronic pain" OR fibromyalgia OR “back pain” OR ache OR sciatica OR "knee pain" OR “joint pain” OR “idiopathic pain” OR “musculoskeletal pain” OR “limb pain” OR “neuropathic pain”) or AB (pain* OR painful OR "chronic pain" OR fibromyalgia OR “back pain” OR ache OR sciatica OR "knee pain" OR “joint pain” OR “idiopathic pain” OR “musculoskeletal pain” OR “limb pain” OR “neuropathic pain”)
      S6S1 OR S2 OR S3 OR S4 OR S5
      S7(MH "Virtual Reality")
      S8(MH "Virtual Reality Exposure Therapy")
      S9TI (virtual OR "virtual reality" OR VR OR "virtual simulation" OR “virtual realism” OR “virtual environment” OR “virtual setting” OR “virtual therapy” OR “virtual rehabilitation” OR “virtual system” OR “virtual world” OR “virtual object” OR “haptic device” OR haptics) or AB virtual OR "virtual reality" OR VR OR "virtual simulation" OR “virtual realism” OR “virtual environment” OR “virtual setting” OR “virtual therapy” OR “virtual rehabilitation” OR “virtual system” OR “virtual world” OR “virtual object” OR “haptic device” OR haptics)
      S10S7 OR S8 OR S9
      S11(MH "Mindfulness")
      S12(MH "Mind Body Techniques")
      S13TI (mindfulness OR " Mindfulness-Based Stress Reduction" OR MBSR OR " Mindfulness-Based Cognitive Therapy" OR MBCT OR body‐mind OR mind‐body OR “Mindfulness‐Oriented Recovery Enhancement” OR "Mindfulness‐Based Relapse Prevention" OR MBRP OR "mindfulness meditation") OR AB (mindfulness OR " Mindfulness-Based Stress Reduction" OR MBSR OR " Mindfulness-Based Cognitive Therapy" OR MBCT OR body‐mind OR mind‐body OR “Mindfulness‐Oriented Recovery Enhancement” OR "Mindfulness‐Based Relapse Prevention" OR MBRP OR "mindfulness meditation")
      S14S11 OR S12 OR S13
      S15S6 AND S10 AND S14

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