The study selection process, as shown in Figure 1, began with a database search that yielded 11,415 results. A total of 9602 titles were screened for the following terms: education, chronic pain, chronic back pain, CLBP, VR, and AR. The title should contain a minimum of 2 of the following keywords: education, chronic pain, chronic back pain, CLBP, VR, or AR; 9291 papers were excluded due to the lack of appearance of at least 2 of the defined terms. After applying the inclusion and exclusion criteria to 311 publications, 177 studies were excluded based on the titles and 95 were excluded based on the abstracts. After reviewing the full texts of the remaining 39 publications, 27 were excluded for (1) specific applications (eg, doctor-patient communication), (2) insufficient intervention descriptions, (3) overly specific populations (eg, elite athletes, primary school students, nursing staff), (4) unspecified psychoeducation (eg, cognitive behavioral therapy [CBT], cognitive functional training), and (5) unclear differentiation between education and physiotherapy in intervention design. Finally, the scoping review analyzed 12 publications, displayed in Table 1 [44-55].

The studies originated from Italy, Spain, the Netherlands, France, Chile, India, and Tunisia (8.33% each), Germany (25%), and the United States (16.67%). The review included 9 empirical studies (1 interview study, 8 interventional studies) and 3 reviews (1 systematic, 1 scoping, and 1 narrative review). All studies were peer-reviewed, except the narrative review. The results of the analysis of the 12 publications included are presented below according to the 4 defined categories.

The systematic review evaluated clinical studies from 2011 to 2021 comparing pain education/CBT with conventional physiotherapy for CLBP [45]. Thirteen studies, including 12 randomized controlled trials with 1642 participants, were analyzed. Six studies demonstrated a significant reduction in pain compared with the control group. The review concluded that due to the multimodality and heterogeneity of treatments, no definitive statement can be made regarding the efficacy of pain education or CBT in patients with CLBP [45]. Seven studies included an educational program in conjunction with physiotherapy [45-48,52-54]. Educational content varied considerably, ranging from exclusive focus on pain biology [46-49,52,53,55] to the inclusion of psychological aspects [46,52-55] and multidisciplinary approaches [49]. Most of the programs [48,55] incorporated education on pain physiology, frequently based on the book “Explain Pain” [56] by Butler and Moseley. Psychological education encompassed topics such as physical activity [45,46,49,53], fear of physical activity, emotional management [45-49,51], lifestyle modifications, daily exercises [45,49,52], pain-specific coping strategies [45,52,54], pain sensitization [47,54,55], and relaxation techniques, including stress management and mindfulness [45,49,52-55] in 6 studies, of which 5 included VR interventions. The content, duration, and physiotherapeutic integration of the individual education programs can be found in Multimedia Appendix 1.

This category encompasses factors of psychology of learning that are pertinent to the design of interactive interventions. Analysis of 3 studies showed that VR-based education employs passive mediation strategies such as informational videos and lectures (provided conventionally and in VR), alongside active and interactive strategies [44,50,54]. Three studies mentioned VR-based gamified approaches [50,52,55] and 2 studies [50,51] mentioned the promotion of intrinsic motivation.

The technical parameters of 3 enclosed VR studies, comprising 1 needs analysis [52] and 2 feasibility studies [52,53], provide insights into the design of AR-based education and identify potential areas of focus such as user-friendliness [51,53], operational support [51-53], and various application challenges [51,53]. The needs analysis was based on semistructured interviews (n=10) in focus groups to determine the requirements of older patients with chronic back pain, physiotherapists, and psychotherapists regarding VR pain therapy in terms of overall system, hardware, and software [51]. Findings emphasize that the designed system must be user-friendly; provide personalized instructions, demonstration videos, and individual guidance; and be available for rent. Assistants should support this system. Automatic breaks were considered crucial to avoid overexertion and pain aggravation. Activity should be limited to 30 minutes followed by a 15-minute rest. The study also highlighted the importance of balancing active therapy and relaxation. For hardware, it was determined that the VR headset must be independent and removable. Software design should consider user-friendliness by integrating the game environment with the level in-game environment for individual calibration of movement restrictions, particularly in gaming activities. Finally, a spacious room and wireless head-mounted display were considered essential for safety to prevent falls.

One feasibility study also emphasized the importance of safety aspects for the usability of VR headsets. The authors indicate that 93% of the application issues were associated with handling spatial and temporal limitations [53]. The second feasibility study demonstrated that disregarding body height (insufficient arm span) was perceived as disruptive [52]. Operational support software allows therapists to intervene during instances of pain, anxiety, or improper exercise execution by using a help button or emergency assistance [51]. Incorrect exercise execution is considered disruptive [52] and often lacks adequate support personnel for error correction or clinical assistance [53].

Of the 12 studies [44-55] reviewed, 8 [46-49,54,55] were quantitative interventional studies. Commonly evaluated outcomes in CLBP studies encompassed pain intensity [45-49,51,52,54,55], kinesiophobia [46,48,51-53,55], pain catastrophizing [48,53-55], disability [45-47,51,52,54], health-related quality of life [51,52,54], well-being [47], self-efficacy [47,54], depression [46,53], attrition rate [49,53], and VR intervention user experience [52,53]. A comprehensive table displaying the different methods used, study results, and conclusions for each of the included studies can be found in Multimedia Appendix 2. A list of the pain-specific constructs and their measurement tools assessed in the different studies can be found in Multimedia Appendix 3.

Psychoeducation is a key element for CLBP treatment. Psychoeducation provided in AR could offer more benefits than that in VR or with conventional methods by integrating physical and virtual elements. Additionally, psychoeducation in AR was assumed to be superior to VR due to reported VR-associated discomforts in CLBP treatment, such as cybersickness and visual discomfort. Therefore, we conducted a literature review in the first step to evaluate research on CLBP treatment through psychoeducation using conventional methods and immersive technologies in order to design a psychoeducational intervention in AR for CLBP. In the second step, we applied the extracted results of the literature review to a theoretical framework, in particular, the UTAUT 2, to provide a design example for AR-based psychoeducation for CLBP.

Our findings indicate that various educational programs were combined with physiotherapy [45-48,52-54]. These studies referred to conventional methods or VR-based interventions. No relevant study with AR for CLBP treatment was found. The varying educational content encompassed pain biology [46-49], psychological education on physical activity [45,46,49,53], anxiety management [45-49,51], lifestyle modifications, daily exercises [45,49,52], coping strategies [45,52,54], pain sensitization [47,54,55], and relaxation techniques [45,49,52-55]. Passive, active [44,50,54], and gamified strategies [50,52,55] were employed alongside the promotion of intrinsic motivation [50,51]. User-friendliness [51,53], operational support [51,52,54], and application challenges [52,53] were considered important for software development. The key variables of educational CLBP interventions included physiological variables such as pain intensity [45-49,51,52,54,55] and disability level [45-47,51,52,54]; psychological variables such as kinesiophobia [46,48,51,52,54,55], pain catastrophizing [48,53-55], quality of life [51,52,55], well-being [47], self-efficacy [47,54], and depression [46,53]; and technical variables such as dropout rates [49,53] and user experience [52,53].

Our results elucidate key aspects of a useful design of a psychoeducational treatment in AR for CLBP, which does not exist to date, to the best of our knowledge. Our findings point out the relevance of the interplay of technical and psychological components, in particular, the health psychological aspects incorporating psychology of learning to foster behavior change. In the next step, the findings were applied to a theoretical framework. For this, we referred to the UTAUT 2 [8,9]. UTAUT 2 encompasses constructs such as (1) performance expectancy, (2) effort expectancy, (3) social influence, (4) facilitating conditions, (5) hedonic motivation, (6) price value, and (7) habit for intention formation as well as the moderating variables age, gender, and experience [8]. Therefore, we recommend the following design suggestions for psychoeducational interventions in AR based on UTAUT 2 for the treatment of CLBP, as exemplified in Figure 2.

This scoping review gives an overview of the most important educational content, elements of psychological training, interactive design forms, and relevant pain psychological variables for developing CLBP interventions in AR. It offers a substantiated basis for a theory-based development of a psychoeducational treatment in AR. Thus, this study provides a framework for the theory-driven extraction of hypotheses for future AR research in CLBP treatment. One limitation of this review encompasses the exclusion of certain sport science and physiotherapy databases (eg, SPORTDiscus) and the restriction to studies published in German and English, potentially omitting relevant publications. Further, the distinction between CLBP and chronic nonspecific low back pain in the included studies was often imprecise. The distinction might be relevant for the intervention design, which was neglected in our analysis.

First, the theoretically proposed design of AR-based psychoeducation for CLBP should be realized in future research. Second, an evaluation of the feasibility and user experience is needed. Third, the therapeutic efficacy of the psychoeducational content in AR must be demonstrated in a clinical evaluation study with patients with CLBP. As no studies on the psychometric properties of measurements in AR are known, psychometric assessments must be tested for measurement equivalence.

For the development of a framework for an AR-based psychoeducational intervention in CLBP, the combination of theories of acceptance and use of technologies with insights from health psychological behavior change theories appears to be of great importance. An example for a theory-based design of psychoeducation in AR for CLBP is proposed and discussed. Our results offer a substantiated basis for a theory-based development of psychoeducational treatment in AR.