Effects of Gaming on Pain-Related Fear, Pain Catastrophizing, Anxiety, and Depression in Patients with Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Effects of Virtual Reality-Based Rehabilitation in the Treatment of Patients with Fibromyalgia Syndrome: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

The aim was to analyze the effects of virtual reality-based rehabilitation (VRBR) in patients with fibromyalgia syndrome (FMS). This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search was conducted in CINAHL, Medline (via PubMed), Scopus, and Web of Science up to January 2023. Eligibility criteria were defined with Participants, Interventions, Comparisons, Outcomes, and Study design. To assess the methodological quality, the modified Downs and Black scale was used. The risk of bias was assessed through The Cochrane Collaboration's tool. Meta-analysis was performed using RevMan software. Seventeen studies were included in the systematic review and 11 in the meta-analysis. We obtained significant differences in favor of VRBR for FMS impact (standardized mean difference or SMD: -0.49; 95% confidence interval or CI: -0.72 to -0.26), pain intensity (SMD: -0.50; 95% CI: -0.87 to -0.12), fatigue (SMD: -0.55, 95% CI: -0.89 to -0.22), depression (SMD: -0.39; 95% CI: -0.55 to -0.23), anxiety (SMD: -0.36; 95% CI: -0.57 to -0.14), health-related quality of life (SMD: 0.56; 95% CI: 0.29 to 0.83), health perception (mean difference or MD:10.56; 95% CI: 6.23 to 14.88), functional exercise capacity (SMD: 0.60; 95% CI: 0.33 to 0.87), and physical function (MD: 10.90; 95% CI: 7.04 to 14.77). No significant differences were found for kinesiophobia. VRBR significantly improves FMS symptoms, quality of life, and physical condition. VRBR applied alone or combined with other interventions shows good results. VRBR was superior to treatment as usual. Better results were obtained when specialized VRBR was used. More research is needed to determine how to implement this treatment and to study VRBR effects on follow-up.

Extended Reality Interventions for Health and Procedural Anxiety: Panoramic Meta-Analysis Based on Overviews of Reviews

BACKGROUND

Extended reality (XR) technologies are increasingly being used to reduce health and procedural anxieties. The global effectiveness of these interventions is uncertain, and there is a lack of understanding of how patient outcomes might vary between different contexts and modalities.

OBJECTIVE

This research used panoramic meta-analysis to synthesize evidence across the diverse clinical contexts in which XR is used to address common outcomes of health and procedural anxiety.

METHODS

Review-level evidence was obtained from 4 databases (MEDLINE, Embase, APA PsycINFO, and Epistemonikos) from the beginning of 2013 until May 30, 2023. Reviews that performed meta-analysis of randomized controlled trials relating to patient-directed XR interventions for health and procedural anxiety were included. Studies that analyzed physiological measures, or focused on technologies that did not include meaningful immersive components, were excluded. Furthermore, data were only included from studies that compared intervention outcomes against no-treatment or treatment-as-usual controls. Analyses followed a preregistered, publicly available protocol. Trial effect sizes were extracted from reviews and expressed as standardized mean differences, which were entered into a 3-level generalized linear model. Here, outcomes were estimated for patients (level 1), studies (level 2), and anxiety indications (level 3), while meta-regressions explored possible influences of age, immersion, and different mechanisms of action. Where relevant, the quality of reviews was appraised using the AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews, Revised Instrument) tool.

RESULTS

Data from 83 individual trials were extracted from 18 eligible meta-analyses. Most studies involved pediatric patient groups and focused on procedural, as opposed to general, health anxieties (eg, relating to needle insertion, dental operations, and acute surgery contexts). Interventions targeted distraction-, education-, and exposure-based mechanisms, and were provided via a range of immersive and nonimmersive systems. These interventions proved broadly effective in reducing patient anxiety, with models revealing significant but heterogeneous effects for both procedural (d=-0.75, 95% CI -0.95 to -0.54) and general health (d=-0.82, 95% CI -1.20 to -0.45) indications (when compared with nontreatment or usual-care control conditions). For procedural anxieties, effects may be influenced by publication bias and appear more pronounced for children (vs adults) and nonimmersive (vs immersive) technology interventions, but they were not different by indication.

CONCLUSIONS

Results demonstrate that XR interventions have successfully reduced patient anxiety across diverse clinical contexts. However, significant uncertainty remains about the generalizability of effects within various unexplored indications, and existing evidence is limited in methodological quality. Although current research is broadly positive in this area, it is premature to assert that XR interventions are effective for any given health or procedural anxiety indication.

Does having an external focus in immersive virtual reality increase range of motion in people with neck pain?

BACKGROUND

When instructing exercises to improve Range of Motion (ROM), clinicians often create an internal focus of attention, while motor performance may improve more when using an external focus.

OBJECTIVES

Using Virtual Reality (VR), we investigated the effect of tasks with an internal and external focus on maximal ROM in people with neck pain and explored whether this effect was associated with fear of movement.

METHOD

In this cross-over experimental design study, the cervical ROM of 54 participants was measured while performing a target-seeking exercise in a VR-environment (external focus task) and during three maximal rotation and flexion-extension movements with the VR-headset on, without signal (internal focus task). The main statistical analysis included two dependent T-tests. Pearson correlation coefficients were calculated to investigate whether the differences in ROM in both conditions were correlated to fear of movement.

RESULTS

Maximal neck rotation was larger in the external focus condition than in the internal focus condition (mean difference: 26.4°, 95% CI [20.6, 32.3]; p < 0.001, d = 1.24). However, there was a difference favouring the internal focus condition for flexion-extension (mean difference: 8.2°, 95% CI [-14.9, -1.5]; p = 0.018, d = 0.33). The variability in ROM was not explained by variability in fear of movement (for all correlations p ≥ 0.197).

CONCLUSION

An external focus resulted in a larger range of rotation, but our flexion-extension findings suggest that the task has to be specific to elicit such an effect. Further research, using a task that sufficiently elicits movement in all directions, is needed to determine the value of an external focus during exercise.

Telehealth and Virtual Reality Technologies in Chronic Pain Management: A Narrative Review

PURPOSE OF REVIEW

This review provides medical practitioners with an overview of the present and emergent roles of telehealth and associated virtual reality (VR) applications in chronic pain (CP) management, particularly in the post-COVID-19 healthcare landscape.

RECENT FINDINGS

Accumulated evidence points to the efficacy of now well-established telehealth modalities, such as videoconferencing, short messaging service (SMS), and mobile health (mHealth) applications in complementing remote CP care. More recently, and although still in early phases of clinical implementation, a wide range of VR-based interventions have demonstrated potential for improving the asynchronous remote management of CP. Additionally, VR-associated technologies at the leading edge of science and engineering, such as VR-assisted biofeedback, haptic technology, high-definition three-dimensional (HD3D) conferencing, VR-enabled interactions in a Metaverse, and the use of wearable monitoring devices, herald a new era for remote, synchronous patient-physician interactions. These advancements hold the potential to facilitate remote physical examinations, personalized remote care, and innovative interventions such as ultra-realistic biofeedback. Despite the promise of VR-associated technologies, several limitations remain, including the paucity of robust long-term effectiveness data, heterogeneity of reported pain-related outcomes, challenges with scalability and insurance coverage, and demographic-specific barriers to patient acceptability. Future research efforts should be directed toward mitigating these limitations to facilitate the integration of telehealth-associated VR into the conventional management of CP. Despite ongoing barriers to widespread adoption, recent evidence suggests that VR-based interventions hold an increasing potential to complement and enhance the remote delivery of CP care.

Associations between the perception of dental pain and pain anxiety, mental pain, and dental anxiety in Iranian sample

OBJECTIVE

This study examined the perception of dental pain and its relationship to pain anxiety, dental anxiety, and mental pain.

METHODS

This cross-sectional study was conducted on 328 patients referred to dental clinics in Kermanshah (Iran) from 2020 to 2021. The instruments used in this study included scales assessing pain anxiety, dental anxiety, mental pain, and pain perception.

RESULTS

There was a significant relationship (p = .001) between pain perception with dental anxiety (r = .38), pain anxiety (r = .45), and mental pain (r = .25).

CONCLUSION

Psychological factors are associated with the perception of dental pain. Given the importance of dental care to overall health, psychological interventions may help to reduce the perception of dental pain and fear of seeing dentists in Iran.

Clinical Applications of Virtual Reality in Musculoskeletal Rehabilitation: A Scoping Review

(1) Background: VR is based on a virtual world that creates sounds effects and videos that replace the real environment. Arising literature shows VR efficacy in the field of neurological rehabilitation (NR) and that its use is also taking a place in musculoskeletal rehabilitation (MSR), as a treatment of various disorders that cause disability and chronic pain. (2) Aim: We discuss the role of VR in MSR, presenting its use and development on acute and chronic musculoskeletal disorders, based on the most recent literature. (3) Design and Methods: Literature searches were conducted in the databases Pubmed and Medline up to 30 September 2023. The PRISMA-Scr Checklist was followed. (4) Results: A total of 51 records were included. The analysed studies were conducted within a variety of populations, musculoskeletal disorders, settings, and VR technologies. Only a few studies could statistically affirm the efficacy of VR in MSR, as mentioned for the rehabilitation of the upper limb. Nevertheless, the observed trend is an improvement of the global perceived effect compared to traditional rehabilitation. (5) Conclusion: VR allows for the personalisation of treatment with an adaptable treatment platform, which may improve the participation of the patient and increase acceptability and adherence to long-term rehabilitation programs. We provide recommendations and suggestions for future research and use of VR in musculoskeletal rehabilitation.

Role of Immersive Virtual Reality in Motor Behaviour Decision-Making in Chronic Pain Patients

Primary chronic pain is a major contributor to disability worldwide, with an estimated prevalence of 20-33% of the world's population. The high socio-economic impact of musculoskeletal pain justifies seeking an appropriate therapeutic strategy. Immersive virtual reality (VR) has been proposed as a first-line intervention for chronic musculoskeletal pain. However, the growing literature has not been accompanied by substantial progress in understanding how VR exerts its impact on the pain experience and what neurophysiological mechanisms might be involved in the clinical effectiveness of virtual reality interventions in chronic pain patients. The aim of this review is: (i) to establish the state of the art on the effects of VR on patients with chronic pain; (ii) to identify neuroplastic changes associated with chronic pain that may be targeted by VR intervention; and (iii) to propose a hypothesis on how immersive virtual reality could modify motor behavioral decision-making through an interactive experience in patients with chronic pain.