Who is a good candidate for virtual pain rehabilitation?

What makes someone a good fit for virtual pain rehabilitation?

The short answer is persistent pain in a body that has already been examined. Virtual pain rehabilitation is built to change how an overprotective pain system responds to the body, which means it helps most when the pain has outlasted any injury and when the person is ready to practice. In general, a good candidate has most of the following:

• Pain that has persisted beyond three months. This is the usual threshold for chronic pain, the point at which pain stops tracking tissue healing and starts behaving like a condition of its own.
• A medical evaluation already completed. Someone has taken a history, examined the person, and ordered whatever imaging or tests the presentation called for.
• Tests that are reassuring while the pain continues. This is the classic profile of a sensitized pain system, the kind of neuroplastic pain that retraining approaches are designed for.
• A willingness to practice most days. Retraining a nervous system is a dosage question. Brief, regular practice matters more than any single session, so the person needs to be able and willing to show up repeatedly.
• A functional goal they can name. Carrying a grandchild, driving to work, sleeping through the night, walking the dog. A concrete goal gives the program something to measure and gives the person a reason to do the work on a bad day.

None of this says the pain is imaginary. The International Association for the Study of Pain's revised definition is explicit that pain is a personal experience, that it is not the same thing as activity in sensory nerves, and that a person's report of pain should be respected. Pain in a sensitized system is real pain. It is also the kind of pain that can be retrained, which is why these markers matter.

Which diagnoses are commonly appropriate?

Conditions in which the nervous system plays a large part in maintaining the pain. The diagnosis label matters less than the pattern behind it: symptoms that persist or spread after the tissue has healed, pain that flares with stress or fear as readily as with load, and a workup that has not found an ongoing structural cause.

This list is not exhaustive, and a diagnosis on it does not make someone a candidate on its own. Two people with the same label can have very different pain. The full set of conditions Karuna works with is on the conditions index, and the neuroplastic pain quiz is a reasonable way for a patient to see whether their own pattern looks like a sensitized system before anyone makes a referral.

When is it not the right first step?

When the pain still needs to be understood, or when something else needs treating first. Retraining a pain system assumes the system is overprotective rather than correctly reporting damage, and that assumption has to be checked by a clinician in person before a remote program makes sense.

• Acute injury. A recent fracture, sprain, surgery, or strain needs standard medical care and time to heal. Pain-system retraining is for pain that has outlasted that process, not for pain that is still doing its job.
• Red-flag symptoms. New weakness or numbness, loss of bowel or bladder control, unexplained weight loss, fever, pain following major trauma, or chest pain all need prompt medical evaluation. A systematic review of red flags in back pain found that most single flags are weak signals on their own, but a history of cancer, significant trauma, and prolonged steroid use were among the more informative ones. The lesson is that red flags should be assessed by a clinician, not scored by a website.
• Pain that has not been medically assessed. A prior evaluation is a prerequisite. The point of a remote program's clinician review is to confirm that retraining is appropriate, not to replace a diagnosis that was never made.
• Unstable medical or mental-health conditions. Uncontrolled heart or lung disease, an active infection, a flare of an inflammatory disease, untreated severe depression, an active eating disorder, or unmanaged substance use generally need treatment and stabilization first. Once stable, many of these people become reasonable candidates.
• Crisis situations. Someone with thoughts of self-harm or suicide needs immediate support, not a rehabilitation program. In the US, call or text 988 to reach the Suicide and Crisis Lifeline. Outside the US, contact local emergency services.

Not the right first step does not mean never. A person who was turned away at the acute stage, or while a mental-health condition was being treated, is often a strong candidate six months later. The question is sequencing, and a good program will say so rather than enrolling someone before they are ready.

What VR-specific considerations apply?

A headset adds a short list of practical questions that an in-person program never has to ask. None of them is an automatic exclusion. Each is something to raise with the program's clinician, who can decide whether the exercises can be adapted or whether a different approach makes more sense.

• History of seizures or photosensitivity. Headset displays are bright, close to the eyes, and can contain flashing or rapidly changing images. Anyone with a seizure disorder or known photosensitive epilepsy should discuss this with the program's clinician and with their own neurologist before using VR.
• Significant vestibular disorders or severe motion sickness. VR can provoke nausea, dizziness, and disorientation, especially when what the eyes see and what the inner ear feels do not match. People with a vestibular condition, or a strong history of motion sickness, may need shorter sessions, seated exercises, or a different plan.
• Uncorrected visual impairment. Headsets rely on both eyes seeing clearly. Glasses can often be worn inside a headset, and lens inserts exist, but uncorrected or significantly asymmetric vision may limit what the exercises can do.
• Inability to follow spoken instructions. Exercises are guided by voice. Significant hearing loss, a language barrier without support, or cognitive impairment that interferes with following multi-step instructions should be discussed up front, because a coach may be able to work around some of these and not others.
• No safe space to move. A few square feet of clear floor is needed, enough to sit or stand and move the arms without hitting furniture. Someone who cannot arrange that, or who has a significant falls risk when standing with their eyes covered, should raise it before starting.

The motion sickness question is the one that comes up most, and the research is fairly reassuring about rehabilitation-style content. A systematic review and meta-analysis of VR sickness in head-mounted displays found that how sick people felt varied with the kind of content and how long they stayed in the headset, with fast-moving game content among the most provocative. Karuna's own exercises are done seated or standing in place, are short by design, and are nothing like a fast-moving VR game. Most people adapt within a few sessions, and a coach can adjust length and content for those who are sensitive. The FAQs cover motion sickness, equipment, and space in more detail; if any of the points above applies to you, raise it during the free consultation so the team can address it before a headset is shipped.

Can it run alongside physical therapy, injections, or psychotherapy?

In general, yes. Virtual pain rehabilitation is designed to complement the care a person is already receiving rather than replace it, and in many cases the treatments reinforce one another. The two things that matter are coordination and clarity about who is responsible for what.

• Physical therapy. The most natural pairing. Both approaches aim to expand safe movement, and a VR program that reduces fear of movement can make a physical therapy plan easier to carry out. The risk is contradictory advice, such as a therapist pushing load on a schedule while a VR coach is working on fear, so the two should know about each other and ideally share the same functional goals.
• Injections and procedures. A scheduled injection or minor procedure does not usually rule someone out, but timing matters. A window of relief after an injection can be a useful period in which to build movement confidence. A major surgery changes the picture, since the person is then recovering from an acute event, and the program's clinician should be told about anything planned.
• Psychotherapy. Pain and mood travel together, and a person in therapy for depression, anxiety, or trauma is often a good candidate as long as the condition is stable. Cognitive behavioral therapy, acceptance and commitment therapy, and pain reprocessing therapy share a framework with VR embodiment training, so the overlap tends to help. The therapist should know that a pain program is running, and vice versa.

How does Karuna's screening work?

In three steps, each of which can end in a no. Everything above is general guidance. What decides whether a particular person joins the Karuna program is this sequence, described in full in how Karuna works:

1. Free consultation. A conversation with the team about pain history, prior treatment, and goals, with honest guidance on whether the program is likely to fit. There is no obligation.
2. Detailed intake. A fuller account of the pain, the workup that has been done, current treatments, and the practical VR questions above.
3. Clinician review. A clinician reviews the case and confirms that the program is appropriate before anything begins. The same clinician provides oversight throughout the 12 weeks.

If the program is not a good fit, the person is told so directly, and where possible pointed toward something that is. Karuna takes workers' compensation referrals, and the care team confirms coverage case by case; the workers' compensation guide covers what that process looks like from the adjuster's side. The program is HSA/FSA eligible and backed by a money-back guarantee.

What should a referring provider ask before referring?

Mostly the same questions you would ask before any referral, plus a few that are specific to a remote program with a headset. A referral goes more smoothly when the answers travel with it.

1. Has the pain been adequately worked up? Is there a diagnosis, or at least a documented evaluation that has considered and excluded the red flags relevant to this presentation?
2. Has it persisted beyond three months, and is the picture one of a reassuring workup with pain that continues?
3. Is anything unstable? Medical conditions, mental-health conditions, or substance use that need treatment or stabilization first.
4. Are there VR-specific concerns? Seizure history, photosensitivity, vestibular problems, vision, hearing, cognition, and a safe space at home.
5. What else is in progress? Physical therapy, injections, scheduled procedures, psychotherapy, and who is coordinating them.
6. What is the functional goal? Return to a specific job task, a household activity, sleep, driving. A goal the patient has named is far more useful than a pain score.
7. Is the patient willing? Daily practice over 12 weeks is a real commitment, and a referral the patient is ambivalent about tends not to go well.

The broader guide to evaluating a remote pain rehabilitation program covers what to ask of the program itself: who the clinicians are, what is measured, how outcomes are reported, and what happens when a patient does not improve.

What this means for you

If you are living with pain

If your pain has lasted more than three months, you have seen a doctor about it, and the tests came back reassuring, you fit the general profile and it is worth a conversation. If you have not been evaluated, or you have any of the red-flag symptoms above, see a clinician first. The neuroplastic pain quiz can help you see whether your pattern looks like a sensitized system, and the free consultation will tell you whether Karuna is a fit.

If you are a referring clinician

The useful question is whether the pain has outlasted the tissue and whether anything still needs treating first. A patient who has been fully worked up, is medically and psychologically stable, and has a functional goal is a reasonable referral. Send the workup, the current treatment list, and any VR-specific concerns with the referral, and expect the program's clinician to make the final call.

If you are a case manager or adjuster

Fit is decided clinically, not administratively, so the fastest path is the free consultation rather than a pre-screening on your side. What you can do is make sure the claim file documents the evaluation that has been done, the date of injury, and the functional goal tied to return to work. Karuna takes workers' compensation referrals, and the care team confirms coverage case by case.