Persistent pain is a pertinent problem among Veterans – it is a leading cause of discharges from the Defence Force due to medical reasons (1, 2) and it is more common in Veterans than the age-matched general population (3). Psychological comorbidities are common in war Veterans. Over 80% of Veterans are exposed to at least one traumatic event in their lifetime (4, 5) and over 30% of Australia's surviving male Korean War Veterans meet the criteria for post-traumatic stress disorder (6). It is important that clinicians adopt a trauma-informed approach when treating war Veterans to ensure interventions and healthcare services meet their unique needs.

Pain science education (PSE) aims to improve people's understanding about pain, including what pain is, how pain works, its dynamic multifactorial nature and protective function (7). When provided in tandem with other interventions, PSE is moderately effective at reducing pain and disability in people with chronic low back pain (8). A recent meta-analysis also concluded that pain education provides the most sustainable benefits in improving function and reducing fear of reinjury for people with chronic non-specific low back pain (9). Data specific to Veterans are limited but promising: a 6 month multifaceted intervention including “light touch” pain education intervention, in which all Australian Veterans prescribed opioids for non-cancer pain received written materials and an accompanying behavioural tool ['the Protectometer” (10)], avoided over 25,000 patient opioid months in the subsequent two years (11). Additionally, a small-sample pilot study suggested that pain education reduced both pain and depressive symptoms in Veterans (12).

Real-world data indicate that individuals who benefit from PSE are those who successfully achieve the learning outcomes (13). Additionally, insights from recovered consumers highlight the learning objectives that they perceive as most critical to their recovery (14). Analyses of randomised controlled trial data are also corroborative; a change in understanding of the problem seems to mediate the vast majority of clinical benefit of complex multimodal care for chronic back pain (13, 15). As such, the pain field has turned towards developing more effective education tools.

Virtual reality (VR) is an established tool to deliver effective education. Meta-analysis of 45 clinical trials showed that “immersive learning” improves attainment of learning objectives by up to 60% (16). Thus, VR presents a potentially powerful tool to improve learning, pain and disability outcomes in people with persistent pain. One VR-based pain education tool (Reality Health, Sydney, Australia) is being used by people with various persistent pain conditions in rehabilitation settings with promising results, including improved average pain and pain interference (17), and is feasible and acceptable to physiotherapists (18). However, the VR program was not specifically designed for Veterans challenged by persistent pain, nor has it been rigorously explored in this population. Considering the specific needs and context of Veterans, in particular with their likelihood of a history of trauma, it is important to formally establish the acceptability, usability, and feasibility, of the platform with Veterans before incorporating it into their care.

We recruited seven Veterans and five HCPs for this study. This was a deviation from our protocol; due to time constraints with recruitment we were unable to reach our target sample size for the Veterans. Veterans' demographics are presented in Table 1 and HCPs' demographics presented in Table 2.

This mixed-methods study found that a VR-PSE and rehabilitation program is acceptable, feasible, and usable by Veterans with persistent pain and their treating clinicians. In line with the TFA constructs, the VR-PSE program was acceptable because of its easy use (“self-efficacy”), novelty (“affective attitude”), and ability to be used by Veterans with varying functional capabilities (“ethicality”). Integration of the framework analysis and the quantitative ratings from the TFA questionnaire highlights convergence and divergence between Veterans' and HCPs' perspectives on the VR-PSE program. We discuss in greater detail considerations for implementing the VR-PSE program in clinical practice for Veterans with persistent pain.

Virtual reality appears to be a novel and engaging method for delivering PSE to Veterans with persistent pain. Consumers have described that PSE is hard to take on board (39, 40). The use of VR may reduce this barrier given the VR-PSE program was well received by the Veterans in this study, who describe themselves as being particularly hard to please regarding their pain management. The findings of this study add to the preliminary real-world data from occupational rehabilitation settings that VR is an effective tool to deliver pain education for people with persistent pain (41) with the potential to improve clinical outcomes (17). Clinical benefits, such as reduced pain and disability, from a VR-PSE program are likely to be mediated by the enhanced reconceptualization of pain, although we did not set out to test this idea and our design would not allow it. Certainly, Veterans displayed an increase in pain knowledge following the workshop. This may be due to the achievement of specific learning objectives [initially identified by recovered consumers to be most helpful for their recovery (14)] through a VR-facilitated immersive embodied experience (17). The use of VR to deliver pain education may also reduce barriers commonly reported by HCPs, including difficulty delivering “good” pain education within short appointment times (42). The VR-PSE program is currently being used by consumers both in the clinic and at home under the guidance of an HCP. The ability of VR to be used at home may improve accessibility of PSE. However, the costs associated with VR technology should be considered, including set-up costs for the HCP and out of pocket costs for consumers.

Veterans emphasised the importance of integrating their lived experience into the VR-PSE program. Specifically, they wanted content on pain conditions that are common among Veterans, including hip and knee pain. This request is consistent with the theoretical frameworks that guide contemporary approaches to the PSE, most obviously constructivism (41). In this framework, people learn through actively constructing their knowledge based on their own experiences and are active in their learning rather than just a passive recipient of information (43). The integration of consumer perspectives and context within education material is at the crux of constructivism (41). This approach aims to counteract one key barrier to the uptake of traditional pain education interventions - that the content is not applicable nor relevant to the consumer, and therefore perceived as not being useful or beneficial (40). While Veterans in this study did describe the VR-PSE program as useful and engaging, it may be enhanced by including specific content to Veterans' experiences. Given this program has been developed for multiple one-on-one sessions under the guidance of a HCP, VR may be a preferable but not necessary tool to deliver any Veteran-specific content. Additional learning materials that are more cost-efficient, such as web resources or workbooks, may be appropriate alternatives to provide alongside VR-PSE. This may overcome limitations reported here without incurring excessive development costs.

Beyond the content, it is also important to consider how pain education should be best delivered. One motivator for this study was to explore whether VR is considered safe for use by Veterans given they are more likely to experience PTSD and traumatic injuries than the general population is (38). These specific contexts are important to consider when developing and delivering interventions for Veterans with persistent pain, including education. While the HCPs in this study raised concerns about the VR-PSE program to be a potential PTSD trigger, the Veterans did not voice the same concerns, despite many of them reporting a history of PTSD. These findings are in line with preliminary evidence that VR technology appears beneficial for improving PTSD symptoms across different populations (44). Similarly, the HCPs queried whether the VR program would be appropriate for use by Veterans with functional limitations, such as upper limb function. This study found that Veterans of various functional capabilities were able to successfully complete the VR-PSE program, despite not be initially developed to cater to those needs.

This study supports the need for a whole of community approach to PSE. While Veterans in this study described how PSE should be introduced earlier into the Defence Force training, they also emphasized that this would be difficult to achieve because the learnings of the VR-PSE program conflict with their experiences of how pain is managed in the Defence Force. Community level pain education, including upskilling of HCPs working with people with persistent pain, is one approach being taken to tackle the widespread misconceptions about pain (45). For the Veteran community specifically, pain education has been integrated into initiatives such as the Veterans' Medicines Advice and Therapeutics Education Services (MATES) programme with a good effect on opioid prescriptions (11). Similarly, the United States Veterans Health Administration endorse the Stepped-Care Model of Pain Management (46) – a three-tier, holistic approach for Veterans with persistent pain that involves the continual development of Interdisciplinary Pain Management Centres and places pain education at the heart of intervention. These initiatives have demonstrated a positive impact on clinical outcomes for Veterans with persistent pain, including decreased opioid use (11).

Strengths of this study include: the use of a mixed-methods approach that allowed for an in-depth exploration into the acceptability, feasibility, and usability of a VR-PSE program for Veterans with persistent pain; inclusion of two key interest holders – Veterans with persistent pain and HCPs; a priori registration of the protocol and transparent reporting of deviations, as recommended for all pain research (47). The study also had limitations. First, the use of focus groups may reduce the richness of the qualitative data collected, as compared to one-on-one interviews. Second, our sample size was smaller than intended because we were limited to a small geographical location in Australia and had a short time frame to recruit and conduct the workshops. Although we targeted a region that has the largest Army base in Australia, it does limit the generalizability of our findings. Third, we did not assess equity-related characteristics across all relevant domains (48–50) – an oversight that also limits the generalizability of our findings. Last, due to the pragmatic nature of the study, the workshop did not replicate exactly how the VR-PSE program is intended for use in clinical practice, which is over several sessions on different days. Some HCPs did note that the workshop environment caused disruptions (e.g., too many participants in the one space) which would not occur in most clinical settings. Completing the program in its entirety in the one session may also have impacts on participant engagement and knowledge retention. Notably, this was not reported and did not seem to impact the experience overall with using the VR-PSE program. A final limitation of the current work is that its scope and constricts meant that we were not able to recruit participants with a wide range of chronic pain diagnoses and a wide range of pain intensity and impact levels. This should be considered when planning future clinical trials.

Future research may explore further tailoring PSE content to Veterans with persistent pain. Similar work has been performed for other pain populations, including pelvic pain (51), complex regional pain syndrome (52), and adolescent pain (53), and has been instrumental in developing targeted pain education curricula. A clinical trial to investigate the efficacy of the VR-PSE program in a larger sample of Veterans with persistent pain may be indicated given there is a paucity of data on VR-enhanced pain education for Veterans with various pain conditions and a history of trauma. Although extensive evidence supporting the clinical benefit of pain education (8), that its effects are mediated by learning certain target objectives (13), and that VR-based learning improves learning outcomes (16) should be considered in designing, and weighing up the cost-benefit, of a clinical trial.

This mixed-methods study found that a VR-PSE program was acceptable, feasible, and usable by Veterans with persistent pain and HCPs experienced in treating Veterans. The VR-PSE program was considered easy to use, engaging, and adaptable for different functional capabilities. Appropriate screening for contraindications (e.g., PTSD) was considered important by HCPs, and both Veterans and HCPs emphasized the need for a trusting client-clinician relationship. Our sample size was smaller than expected. This raises two important considerations. First, it suggests that, although participants were very positive about the VR-PSE once they tried it, there may be barriers to overcome for Veterans to consider trying it. Second, the current feasibility findings would be strengthened by replication in a larger sample.