Abstract

Chronic pain conditions represent one of the greatest causes of disability in the UK, affecting up to 28 million people nationwide. Despite its prevalence, chronic low back pain (cLBP) in particular remains poorly served by existing treatments. Growing evidence suggests that engagement with natural environments provides analgesic and restorative benefits, yet access to nature is profoundly limited for people living with chronic pain. This thesis investigated whether a codesigned, immersive virtual reality (VR) nature experience could deliver meaningful pain relief to individuals with cLBP, drawing on Attention Restoration Theory (ART) and Stress Reduction Theory (SRT) as key theoretical frameworks. The thesis is structured across three parts: Background, Creation, and Testing.Chapter 1 consisted of a literature review across the fields of pain, Environmental Psychology, and VR; concluding with a theoretical model proposal. Chapter 2 employed an online psychometric battery (n=48) to characterise the cLBP population, revealing a complex biopsychosocial profile including affective and continuous pain descriptors, moderate depression and anxiety, severe central sensitisation indicators, kinesiophobia activity avoidance, and coping primarily through self-efficacy statements and distraction. This complexity demanded qualitative exploration into the subjective pain experience. Chapter 3 conducted reflexive Thematic Analysis (rTA) of semi-structured interviews with ten individuals living with cLBP, deriving five themes: Pain Impacts, Clinical Care, Self-Management, Importance of Nature, and Inaccessible Nature. Whilst nature was identified as a valued self-management strategy, physical inaccessibility through disability, proximity, and environmental barriers severely limited its utility, motivating the development of a VR alternative.Chapters 4 and 5 report two codesign workshops with the cLBP community. Chapter 4 used rTA to identify four themes describing the features and qualities of an ideal restorative nature space: accessibility considerations, psychological and physical benefits of nature, tangible environmental properties (including dynamism, sound, naturalness, and light), and intangible metaphysical qualities (including freedom, privacy, and self-reflection). Chapter 5 combined rTA, quantitative Content Analysis, and the Perceived Restorativeness Scale (PRS) to compare off-the-shelf beach and forest VR scenes, finding the beach to be significantly more restorative across fascination, being away, and compatibility dimensions, but not coherence. Together, these chapters determined that the optimal restorative environment was a calming, filmed coastal beach scene characterised by dynamic audio, birdcall, sea sounds, and minimal human presence. Chapter 6 synthesises the iterative technical design process, documenting the rationale for 360-degree filmed VR over computer-generated VR, the selection of hardware, the development of a film brief for professional filmmakers, and patient and public involvement and engagement (PPIE) appraisal confirming the beach and town scenes were appropriate for experimental testing.Chapter 7 presents a mixed-methods proof-of-concept experiment (n=15) comparing the codesigned beach VR against the filmed town comparator in a within-subjects design. The beach VR produced a clinically meaningful mean 32\% reduction in self-reported pain intensity (BPI), significantly greater than the 9\% reduction observed for the town. Pain pressure thresholds at the lower back increased significantly during the beach VR, indicating a site specific reduction in sensitivity, with no equivalent effect at the leg or in the town condition. The beach was rated as significantly more restorative than the town, with subscale analyses confirming greater fascination, being away, and coherence for the beach, but equivalent compatibility. Qualitative analysis identified four themes, within which novel pathways of pain-related restoration emerged: existential reframing and psychological dwarfing, extending the attentional and autonomic mechanisms proposed by ART and SRT.The general discussion (Chapter 8) synthesises these findings through three lenses: the accessibility of nature for the cLBP community, the importance of a meaningful control condition, and the clinical case for personalised nature-based VR. The thesis concludes that a codesigned, participant-led VR nature experience can produce clinically meaningful analgesia in cLBP, with evidence consistent with top-down corticolimbic modulation as a plausible mechanism, and proposes a mechanistic RCT incorporating neuroimaging and expanded QST as the priority next step.

Awarding Institution(s)

University of Plymouth

Supervisor

Kayleigh Wyles, Sam W. Hughes, Patricia Schofield

Document Type

Thesis

Publication Date

2026

Embargo Period

2026-09-01

Deposit Date

September 2026

Creative Commons License

Creative Commons Attribution-NonCommercial 4.0 International License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License

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