Virtual and Augmented Reality for Chronic Musculoskeletal Rehabilitation: A Systematic Review and Exploratory...

Background: Chronic musculoskeletal disorders (CMDs) represent a leading cause of global disability and diminished quality of life, and they are often resistant to conventional physiotherapy. Emerging technologies such as virtual reality (VR), augmented reality (AR), and exergaming are increasingly used to enhance rehabilitation outcomes, yet their comparative effectiveness remains unclear. Objective: To systematically evaluate the effectiveness of VR, AR, and exergaming interventions in improving pain, function, balance, and psychological outcomes among adults with CMDs. Methods: This systematic review and exploratory meta-analysis followed PRISMA 2020 guidelines and was prospectively registered (PROSPERO: CRD42024589007). A structured search was conducted in PubMed, Cochrane CENTRAL, Scopus, and PEDro (up to 1 May 2025). Eligible studies were randomized controlled trials (RCTs) involving adults (≥18 years) with CMDs receiving VR, AR, or exergaming-based rehabilitation. Risk of bias was assessed using the PEDro scale and the Downs and Black checklist. Where feasible, standardized mean differences (SMDs) for pain outcomes were pooled using a random-effects model. Results: Thirteen RCTs (n = 881 participants) met the inclusion criteria. Interventions spanned immersive VR, AR overlays, exergaming platforms (e.g., Kinect, Wii), and motion-tracking systems. Pain, function, and quality of life improved in most studies. An exploratory meta-analysis of eight RCTs (n = 610) yielded a significant pooled effect favoring VR/AR interventions for pain reduction (SMD = -1.14; 95% CI: -1.63 to -0.75; I² = 0%). Exergaming showed consistent improvements in physical performance, while immersive VR was more effective for kinesiophobia and psychological outcomes. AR was underrepresented, with only one study. Risk of bias was generally low; however, publication bias could not be excluded due to limited funnel plot power (n < 10). Conclusions: VR, AR, and exergaming are effective adjuncts to conventional rehabilitation for CMDs, improving pain and function with high patient adherence. Nevertheless, gaps in long-term data, economic evaluation, and modality comparison persist. Future RCTs should address these limitations through standardized, inclusive, and longitudinal design.