A prospective, double-blind, pilot, randomized, controlled trial of an "embodied" virtual reality intervention for adults with low back pain

Extended Reality (XR) in Pediatric Acute and Chronic Pain: Systematic Review and Evidence Gap Map

BACKGROUND

The use of extended reality (XR), including virtual reality (VR) and augmented reality (AR), for treating pain has accelerated in the last 10 years. XR is an attractive biobehavioral intervention that may support management of pain or pain-related disability. Reviews of the literature pertaining to adults report promising results, particularly for acute procedural pain.

OBJECTIVE

This study aimed to (1) summarize the available evidence with respect to feasibility, safety, and effectiveness (pain intensity) of XR for pediatric acute and chronic pain; (2) summarize assessment tools used to measure study outcomes; and (3) identify gaps in evidence to guide future research efforts.

METHODS

This study is a systematic review of the literature. Multiple databases (CINAHL, Cochrane Central, Embase, MEDLINE, PsycINFO) were searched from inception until March 2023. Titles, abstracts, and full-text articles were reviewed by 2 team members to determine eligibility. Articles were included if the (1) participants were aged 0 to 18 years; (2) study intervention was VR or AR; (3) study outcomes included safety, feasibility, acceptability, or effectiveness on the outcome of pain; and (4) study design was observational or interventional. Data were collected on bibliographic information; study characteristics; XR characteristics; outcome domains; outcome measures; and study findings pertaining to safety, feasibility, and effectiveness.

RESULTS

We included 90 articles in the review. All included studies used VR, and 93% (84/90) studied VR in the context of acute pain. Of the 90 studies, 74 studies were randomized trials, and 15 studies were observational. Safety was assessed in 23 studies of acute pain, with 13 studies reporting no adverse events and 10 studies reporting events of low concern. Feasibility was assessed in 27 studies. Of the 84 studies of acute pain, 62% (52/84) reported a positive effect on pain intensity, 21% (18/84) reported no effect, and 13% (11/84) reported mixed effects. All 6 studies of chronic pain reported a positive effect on pain intensity. An evidence gap map was used to illuminate gaps in specific research areas stratified by subtypes of pain. Risk of bias assessment revealed 67 studies had a moderate risk of bias, 17 studies had a high risk, and 5 studies were deemed to be low risk.

CONCLUSIONS

The current body of literature around XR for pediatric pain is focused on acute pain with promising results of safety and effectiveness on pain intensity. The literature pertaining to chronic pain lags behind, limiting our ability to draw conclusions. The risk of bias in studies is problematic in this field, with the inherent challenge of blinding participants and researchers to the intervention. Future research should aim to measure effectiveness beyond pain intensity with a consistent approach to measuring key outcome domains and measures. Current efforts are underway to establish expert consensus on best research practices in this field.

TRIAL REGISTRATION

Prospero CRD42022307153; https://www.crd.york.ac.uk/PROSPERO/view/CRD42022307153.

Are some people more susceptible to placebos? A systematic review and meta-analysis of inter-individual variability in musculoskeletal pain

Existing data suggest placebo responses to treatments are small, but some people may be more likely to respond. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) on interindividual variability in response to placebo interventions MEDLINE, EMBASE, CINAHL, Web of Science Core Collection, CENTRAL, and SPORTDiscus were searched from inception to September 2023. Trial registry searches, citation tracking, and searches for prior systematic reviews were completed. The PEDro scale assessed study quality. Random effects robust variance estimation estimated the log variability ratio (VR), identifying subgroups with varying responses. Twenty-six studies were included, comprising various musculoskeletal pain conditions. Analysis of pain intensity (VR: 1.06, 95%-confidence interval (CI):[0.97; 1.16], 95%-prediction interval (PI):[0.75; 1.51], p = 0.17, k = 26 studies, N = 52 outcomes, GRADE: low), physical function (VR: 1.14, 95%-CI:[0.97; 1.34], 95%-PI:[0.62; 2.11], p = 0.11, k = 19, N = 40, GRADE: low), and health-related quality of life (VR: 1.14, 95%-CI:[0.91; 1.41], 95%-PI:[0.72; 1.80], p = 0.19, k = 7, N = 13, GRADE: low) outcomes revealed minimal, non-statistically significant variability in placebo response compared to control. However, wide prediction intervals suggest uncertainty regarding individual response patterns. There are likely no distinct subgroups of people who are more likely to respond to placebo interventions in musculoskeletal pain; although the available data limits the certainty of this assessment. Future work should consider individual participant data meta-analyses to better elucidate potential responder subgroups and optimize treatment strategies for musculoskeletal pain. PERSPECTIVE: This study systematically reviewed and analyzed RCTs to assess interindividual variability in placebo responses for musculoskeletal pain. Findings suggest minimal variability in placebo response, with no distinct subgroups more likely to respond. Wide prediction intervals indicate uncertainty, highlighting the need for future individual participant data meta-analyses to better elucidate potential responder subgroups.

Effectiveness of Virtual Reality for Pain Management in Musculoskeletal Disorders Across Anatomical Regions: A Systematic Review and Meta-Analysis

INTRODUCTION

The use of virtual reality (VR) in physiotherapy is expanding across various fields; however, while extensively researched in neurology, its application in musculoskeletal (MSK) disorders remains underexplored. This review aims to evaluate the effectiveness of VR in pain management across different anatomical regions.

MATERIALS AND METHODS

The research was conducted using the MEDLINE (via PubMed), Cochrane Library, Scopus, Web of Science, and Embase databases, including randomized controlled trials that evaluated the effectiveness of VR interventions, encompassing immersive VR, specialised non-immersive VR, and gaming platforms. The primary outcomes focused on pain reduction. Data were extracted from the included studies, and methodological quality was assessed using the Revised Cochrane risk-of-bias tool for Randomized Trials (RoB 2). A meta-analysis was conducted using both fixed- and random-effects models to synthesise the findings.

RESULTS

From 1265 records, 27 articles met the eligibility criteria, comprising a total of 1191 participants. Of these, 20 studies contributed data to the meta-analyses. Significant findings were observed for pain relief in the knee region (SMD = - 0.33; 95% CI: - 0.55 to - 0.10; I2 = 13%, p < 0.004), with particularly notable effects within the subgroup utilising specialised non-immersive VR (SMD = - 0.32; 95% CI: - 0.62 to - 0.03; I2 = 10%, p < 0.003). For other anatomical regions, the heterogeneity was substantial, limiting the strength of recommendations for these areas.

CONCLUSIONS

VR shows potential for managing pain in MSK disorders, particularly knee conditions, with significant effectiveness using specialised non-immersive VR. However, high heterogeneity across other regions limits broader recommendations.

An update on non-pharmacological interventions for pain relief

Chronic pain affects a substantial portion of the population, yet current treatments often fail to provide adequate relief. Non-pharmacological interventions, which target behaviors and brain processes underlying the experience of pain, hold promises in offering relief for people with chronic pain. This review consolidates the current knowledge concerning the efficacy of non-pharmacological interventions for chronic pain. We focus on psychological interventions (e.g., cognitive behavioral therapy-based interventions and emotion-based therapies) that use mental techniques and physical practices (e.g., exercise, massage, acupuncture, and yoga) that use body techniques to reduce pain. The efficacy of neuromodulation is also discussed. Given that placebo and expectation effects may enhance benefits for non-pharmacological interventions, we also discuss placebo interventions and expectation management practices. Finally, we describe digital therapeutics as an emerging approach for managing chronic pain. We argue that non-pharmacological interventions are critical adjunctive or stand-alone interventions for chronic pain conditions.

Integrating Physical Therapy and Virtual Reality to Manage Pain-Related Fear of Movement in Patients With Chronic Pain: A Randomized Controlled Trial

OBJECTIVES

This study aims to investigate the effect of virtual reality (VR) technology and physical therapy on pain-related fear of movement in patients with chronic pain.

METHODS

This randomized controlled trial included 73 patients with chronic pain. All participants underwent measurements using the Tampa Scale for Kinesiophobia (TSK), the Japanese version of the World Health Organization Health and Work Performance Questionnaire (WHO-HPQ), the Pain Self-Efficacy Questionnaire (PSEQ), the Numerical Rating Scale (NRS), the Hospital Anxiety and Depression Scale (HADS), the Pain Catastrophizing Scale (PCS), the International Physical Activity Questionnaire (IPAQ), the EuroQOL 5 Dimensions 5-Level (EQ-5D-5L), quadriceps muscle strength, the Timed Up and Go test (TUG), and the 30-s Chair Stand test (CS-30). The intervention group underwent three months of rehabilitation, incorporating VR and exercises administered by a physical therapist. The control group performed similar exercises guided by a physical therapist, with the only distinction being the absence of VR.

RESULTS

Sixty-six participants (32 males, mean age: 54.7±11.7 years) were included in the analysis. TSK scores improved at one-month post-intervention in the intervention group (ΔTSK: -12.4±2.1) compared to the control group (ΔTSK: -7.8±1.4) (p<0.05). The intervention group predominantly demonstrated improved TSK scores at one-month post-intervention. Multivariate logistic regression analysis at one-month post-intervention revealed significant associations between TSK scores and the intervention, PCS, PSEQ, and IPAQ scores (p<0.05).

DISCUSSION

This study revealed two significant findings: (i) combining physical therapy with VR effectively reduced pain-related fear of movement in patients at an early stage, and (ii) a change in the kinesiophobia scores in patients with chronic pain was associated with a change in pain catastrophizing, self-efficacy, and VR intervention. TSK scores in the intervention group significantly improved at one-month post-intervention compared to those in the control group. Combining VR with physical therapy effectively mitigated the excessive pain-related fear of movement. In this study, VR provided an exercise experience without physical pain for patients with chronic pain. This was intended to create a calming, distracting environment and thereby reduce the perceived threat of kinesiophobia. Furthermore, it is possible that there was a reduction in central sensitization. Multiple regression analysis revealed that ΔPCS, ΔPSEQ, and intervention were common elements of ΔTSK at one and three months post-intervention. These findings suggest that combined physical therapy with VR and improved PCS and PSEQ scores contributed to improved TSK scores. Therefore, VR could be beneficial in managing pain-related fear of movement by creating the illusion that exercise does not cause pain. This study had several limitations. First, pain assessment was subjective using questionnaires. Second, participants were limited to patients who underwent physical therapy, which may introduce selection bias. Third, findings were derived from a single pain clinic.

CONCLUSION

This study's findings indicated significant differences between the control and intervention groups, which combined physical therapy with VR, particularly in reducing pain-related fear of movement at an early stage.

Navigating virtual realities: identifying barriers and facilitators to implementing VR-enhanced PT for youth with chronic pain

OBJECTIVE

Virtual reality (VR) can enhance engagement in outpatient physical therapy (PT) through distraction and gamification of movement. This study assessed barriers and facilitators to VR-enhanced PT.

METHOD

Data were collected during a feasibility trial of VR-enhanced PT for youth with chronic musculoskeletal pain. Semistructured and informal interviews were conducted with youth participants, their caregivers, and collaborating physical therapists. To analyze transcriptions, content analysis was employed in multiple rounds. Barriers and facilitators to VR implementation were coded using a deductive approach, then an inductive approach was used to identify emergent themes within each deductive code category.

RESULTS

We completed interviews with youth participants (n = 9), caregivers (n = 7), and clinician stakeholders (n = 5). Coded barriers included: (1) participant identity and self-narrative inconsistent with the intervention, (2) system-level, structural constraints of healthcare, (3) lack of guidance and leadership from clinicians around VR use, (4) research burnout, (5) expectation violation and disappointment, and (6) missing the optimal treatment window. Coded facilitators included: (1) viewing VR as a bridge to achieving treatment goals, (2) having access to resources, (3) sustained positive experience and immersion in the game, (4) alignment between identity and the intervention, and (5) champion-level collaborations.

CONCLUSIONS

This study highlights the importance of considering the VR technology, person using the VR, and the context in which VR is being implemented to optimize uptake and acceptability. Adopting an implementation science lens to the field of VR for chronic pain will enhance the applicability and scale of impact.

The Interplay Between Health Disparities and Acceptability of Virtual Reality: A Survey Study

Virtual reality (VR) has emerged as a nonpharmacological adjuvant to manage acute and chronic pain symptoms. The goal of this survey study was to determine the acceptability of VR among chronic pain participants hailing from distressed and prosperous neighborhoods in the state of Maryland. We hypothesized that pain severity and interference vary in groups experiencing health disparities, potentially influencing VR's acceptability. From March 11 to March 15, 2020, we surveyed a cohort of clinically phenotyped participants suffering from chronic orofacial pain. Participants were asked to express their willingness to participate in a longitudinal VR study and their expectation of pain relief from using VR. Seventy out of 350 participants with chronic pain completed the survey (response rate: 20%). There was no difference in the likelihood of responding to the survey based on their neighborhood distress. Among survey respondents and nonrespondents, similar proportions of participants were from distressed neighborhoods. Among the respondents, 63 (90%) and 59 (84.3%) were willing to participate and expected to experience pain relief from the VR intervention, respectively. Age, sex, race, neighborhood distress, severity of pain, and prior VR experience did not influence willingness to participate in the VR trial or the expectations of VR-induced improvement. These findings suggest that VR as an adjuvant intervention is potentially accepted by chronic pain participants, irrespective of neighborhood-level social determinants of health.

Effectiveness of Digital Health Interventions (DHI) in Chronic Pain Management: A Scoping Review of Current Evidence and Emerging Trends

This review aims to address the impact of digital health interventions (DHIs) on chronic pain management, specifically, mHealth, eHealth, wearable devices, virtual reality (VR), and artificial intelligence. The following study identifies and assesses DHIs' efficacy in specific chronic pain conditions and then extrapolates improved outcomes and patient groups that benefit from their use. Using a systematic methodology, this review synthesizes findings that could improve knowledge for patients and practitioners in chronic pain management while also addressing gaps in understanding the impact of DHIs. Sub-questions guide the identification of gaps and recommendations assessing DHIs' effectiveness for pain reduction and improved quality of life. A systematic search across databases (EMBASE, Ovid MEDLINE, CINAHL, Web of Sciences, Cochrane Central) targets original, English-language, peer-reviewed studies (2013-2023). The inclusion criteria cover DHIs in chronic pain management for adults age 18+, excluding non-full texts, reviews, opinion pieces, or unrelated articles. Search terms include "chronic pain management" OR "long-term pain relief strategies" OR "sustained pain alleviation" OR "pain control for chronic conditions" OR "chronic pain" AND "ehealth interventions" OR "mobile health interventions" OR "digital therapy" OR "health informatic solutions" OR "digital health intervention." After applying inclusion criteria, 34 articles from 11 countries are included, with studies conducted primarily in the United States (n = 17), United Kingdom (n = 4), and Australia (n = 3). DHIs are emerging as effective tools in pain management, as they can emphasize patient autonomy and communication with clinicians while enabling medical self-management in diverse populations. These various digital interventions show promise in reducing pharmaceutical usage and deferring surgical procedures, with most studies reporting positive outcomes in pain reduction. DHIs were also associated with positive mental health outcomes; however, some studies found no significant improvement. Additionally, interventions targeting pain catastrophizing showed varied results, with some app-based approaches demonstrating promise. Overall, the review underscores the potential of DHIs in improving chronic pain management outcomes.

Virtual Reality in Acute and Chronic Pain Medicine: An Updated Review

PURPOSE OF REVIEW

This review critically analyzes the recent literature on virtual reality's (VR) use in acute and chronic pain management, offering insights into its efficacy, applications, and limitations.

RECENT FINDINGS

Recent studies, including meta-analyses and randomized controlled trials, have demonstrated VR's effectiveness in reducing pain intensity in various acute pain scenarios, such as procedural/acute pain and in chronic pain conditions. The role of factors such as immersion and presence in enhancing VR's efficacy has been emphasized. Further benefits have been identified in the use of VR for assessment as well as symptom gathering through conversational avatars. However, studies are limited, and strong conclusions will require further investigation. VR is emerging as a promising non-pharmacological intervention in pain management for acute and chronic pain. However, its long-term efficacy, particularly in chronic pain management, remains an area requiring further research. Key findings highlight that VR programs vary in efficacy depending on the specificity of the origin of pain.

Virtual Reality for Subacute Pain After Orthopedic Traumatic Musculoskeletal Injuries: A Mixed Methods Pilot Study

OBJECTIVES

Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (eg, pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed-methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating principles of mindfulness and cognitive-behavioral therapy, for pain self-management at home following orthopedic injury.

METHODS

We enrolled 10 adults with acute orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham health care system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and hypothesized mechanisms (pain self-efficacy, mindfulness, and coping).

RESULTS

The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients.

DISCUSSION

The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries.

Virtual reality-based analgesia: towards a novel framework for the biopsychosocial management of chronic pain

Virtual reality (VR) holds unmeasured potential as a multicomponent tool for managing chronic pain by adapting conventional in-person biopsychosocial pain management strategies into one virtual space. We review recent evidence showcasing the successful integration of cognitive behavioural therapy, mindfulness-based stress reduction, embodiment techniques, and physical therapy into VR environments, demonstrating positive outcomes in patients with chronic pain. We propose that future clinical and basic research build on this by integrating pain neuroscience techniques to help better understand pathophysiological pain mechanisms and treatment response. This could help facilitate early assessment and personalised treatment of chronic pain using a VR-based biopsychosocial approach.

Exploring the potential of virtual reality for the self-management of chronic pain: A scoping review of its use to address health literacy

BACKGROUND

Individuals with low health literacy struggle to manage long-term conditions. Addressing pain-related health competencies is important in the management of chronic pain. Virtual reality may be a useful tool for empowering sustainable health-related stratgies due to its unique ability to engage users in artificial environments.

OBJECTIVES

The aim of this scoping review was to explore existing research on the use of virtual reality as a tool to promote health literacy in people with chronic pain.

DESIGN

Scoping Review guided by framework proposed by Arksey & O'Malley.

METHOD

Articles related to "pain", "virtual reality" and "health literacy" were searched in four electronic databases: CINAHL, PubMed, Embase and PsycINFO using a formal search strategy. Studies were categorised based on intervention content using the Health Literacy Pathway Model which encompasses health knowledge, self-management skills, health communication and information seeking.

RESULTS

Thirteen studies met the inclusion criteria. Several elements of pain related health literacy were not addressed in the research. Interventions addressed health knowledge, self-management skills, decision making and featured content aiming to address emotional barriers to pain-related health literacy. Other components including active information seeking and use, actively communicating with health professionals and seeking and negotiating treatment options, were not explicitly addressed.

CONCLUSION

There is heterogeneity in existing research exploring the use of VR to support people with chronic pain. Existing VR tools to address pain-related health literacy do not cover several key components of health literacy. More research is required before a robust assessment of efficacy can be undertaken.

Pain Education and Virtual Reality Improves Pain, Pain-related Fear of Movement, and Trunk Kinematics in Individuals With Persistent Low Back Pain

OBJECTIVES

To evaluate the effect of combining pain education and virtual reality (VR) exposure therapy using a cognitive-behavioral therapy-informed approach (virtual reality-based cognitive behavioral therapy [VR-CBT]) on pain intensity, fear of movement, and trunk movement in individuals with persistent low back pain.

MATERIALS AND METHODS

Thirty-seven participants were recruited in a single cohort repeated measures study, attending 3 sessions 1 week apart. The VR-CBT intervention included standardized pain education (session 1) and virtual reality-based exposure therapy (VRET; session 2) incorporating gameplay with mixed reality video capture and reflective feedback of performance. Outcome measures (pain intensity, pain-related fear of movement (Tampa Scale of Kinesiophobia), and trunk kinematics during functional movements (maximum amplitude and peak velocity) were collected at baseline (session 1) and 1 week after education (session 2) and VRET (session 3). One-way repeated measures analysis of variances evaluated change in outcomes from baseline to completion. Post hoc contrasts evaluated effect sizes for the education and VR components of VR-CBT.

RESULTS

Thirty-four participants completed all sessions. Significant ( P < 0.001) reductions were observed in mean (SD) pain (baseline 5.9 [1.5]; completion 4.3 [2.1]) and fear of movement (baseline 42.6 [6.4]; completion 34.3 [7.4]). Large effect sizes (Cohen d ) were observed for education (pain intensity: 0.85; fear of movement: 1.28), whereas the addition of VRET demonstrated very small insignificant effect sizes (pain intensity: 0.10; fear of movement: 0.18). Peak trunk velocity, but not amplitude, increased significantly ( P < 0.05) across trunk movement tasks.

CONCLUSION

A VR-CBT intervention improved pain, pain-related fear of movement, and trunk kinematics. Further research should explore increased VR-CBT dosage and mechanisms underlying improvement.

Clinical improvements due to specific effects and placebo effects in conservative interventions and changes observed with no treatment in randomized controlled trials of patients with chronic nonspecific low back pain: a systematic review and meta-analysis

ABSTRACT

Little is known about the contribution of placebo effects and changes observed with no treatment in interventions for nonspecific low back pain (NSLBP). This systematic review assessed the proportions of the overall treatment effect that may be attributable to specific treatment effects, placebo effects, and changes observed with no treatment in randomized controlled trials (RCTs) in patients with NSLBP. Trials published before 2019 were identified from a published systematic review, and the search was updated in MEDLINE, Embase, and Cochrane Central for trials published between January 2019 and March 2023. Three-arm RCTs comparing the effects of experimental interventions vs placebo control vs no intervention reporting pain intensity, physical function, and/or health-related quality of life (HRQoL) were included. Sixteen RCTs with 1436 adults with chronic NSLBP testing conservative and mainly passive interventions were included. For pain intensity (16 studies), 33%, 18%, and 49% of the overall short-term treatment effect was attributable to specific treatment effects, placebo effects, and changes observed with no treatment, respectively. For physical function (11 studies) and HRQoL (6 studies), these proportions were 34%, 13%, and 53%, and 11%, 41%, and 48%, respectively. These results show that approximately half of the overall treatment effect of conservative and mainly passive interventions for patients with chronic NSLBP is attributable to changes observed with no treatment, rather than specific or placebo effects of treatments. However, the certainty of evidence was very low to low, suggesting that the true effects might be markedly different from the effect sizes underlying these estimates.

Effects of virtual reality on psychophysical measures of pain: superiority to imagination and nonimmersive conditions

ABSTRACT

Virtual reality (VR) has been shown to be effective in pain management. However, to date, little is known about the mechanisms by which immersive experiences influence pain processing. The aim of this study was to investigate the direct effects of an immersive VR environment on the perception of experimental pain in individuals with chronic pain and pain-free controls. The immersion in a VR landscape was compared with mental imagery and a nonimmersive control condition. Using a randomized within-crossover design, pressure pain detection and tolerance thresholds, spatial and temporal summation (SSP, TSP), and conditioned pain modulation (CPM) were measured in 28 individuals with chronic pain and 31 pain-free controls using phasic cuff pressure on the legs. Direct comparison between the groups showed that although individuals with pain had significantly lower pain thresholds, reduced CPM effects, and increased TSP, the VR condition had the same pain-inhibitory effect on pain thresholds as in pain-free controls. Conditioned pain modulation effects were reduced by all conditions compared with baseline. There were no significant differences between conditions and baseline for TSP and SSP. Overall, pain modulatory effects were largest for VR and smallest for imagery. These results demonstrate that immersion in a VR environment has an increasing effect on pain thresholds, reduces pain inhibition in a CPM paradigm, and has no effects on TSP. This applies for participants with chronic pain and pain-free controls. These VR effects exceeded the effects of mental imagery on the nonimmersive control condition. This indicates that VR effectively modulates pain perception in both patients and controls irrespective of differences in pain perception.

Virtual Reality-Based Training in Chronic Low Back Pain: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Low back pain is one of the most prevalent pain conditions worldwide. Virtual reality-based training has been used for low back pain as a new treatment strategy. Present evidence indicated that the effectiveness of virtual reality-based training for people with chronic low back pain is inconclusive.

OBJECTIVE

This study conducted a meta-analysis to evaluate the immediate- and short-term effects of virtual reality-based training on pain, pain-related fear, and disability in people with chronic low back pain.

METHODS

We searched the PubMed, Embase, Web of Science, PEDro, CENTRAL, and CINAHL databases from inception until January 2024. Only randomized controlled trials assessing the effects of virtual reality-based training on individuals with chronic low back pain were selected. The outcomes were focused on pain, pain-related fear measured by the Tampa Scale of Kinesiophobia, and disability measured by the Oswestry Disability Index. The immediate term was defined as the immediate period after intervention, and the short term was defined as 3 to 6 months after intervention. The Cochrane Risk of Bias tool and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach were used to evaluate the quality of the methodology and evidence, respectively.

RESULTS

In total, 20 randomized controlled trials involving 1059 patients were eligible for analysis. Virtual reality-based training showed significant improvements in pain (mean difference [MD] -1.43; 95% CI -1.86 to -1.00; I2=95%; P<.001), pain-related fear using the Tampa Scale of Kinesiophobia (MD -5.46; 95% CI -9.40 to 1.52; I2=90%; P=.007), and disability using the Oswestry Disability Index (MD -11.50; 95% CI -20.00 to -3.01; I2=95%; P=.008) in individuals with chronic low back pain immediately after interventions. However, there were no significant differences observed in pain (P=.16), pain-related fear (P=.10), and disability (P=.43) in the short term.

CONCLUSIONS

These findings indicated that virtual reality-based training can be used effectively for individuals with chronic low back pain in the immediate term, especially to reduce pain, alleviate pain-related fear, and improve disability. However, the short-term benefits need more high-quality trials to be demonstrated.

TRIAL REGISTRATION

PROSPERO CRD42021292633; http://tinyurl.com/25mydxpz.

Virtual Reality Therapy for the Management of Chronic Spinal Pain: Systematic Review and Meta-Analysis

BACKGROUND

The effectiveness of virtual reality (VR) therapy in adults with chronic spinal pain (CSP) is unclear.

OBJECTIVE

This study was conducted to compare the effectiveness of VR therapy and other therapies in adults with CSP, especially patients with inflammation-related pain.

METHODS

PubMed, Web of Science, Cochrane Library, Embase, and CINAHL databases were searched up to November 11, 2023. Randomized controlled trials (RCTs) comparing adults with CSP receiving VR therapy with those receiving other therapies were included. The trial registration platform as well as the reference lists of included studies and previous systematic reviews and meta-analyses were manually searched. Two independent reviewers performed study selection, data extraction, risk-of-bias assessment, and evaluation of the quality of the evidence. The weighted mean difference (WMD) was used as the effect size used to synthesize the outcome measure.

RESULTS

In total, 16 RCTs involving 800 participants were included in this meta-analysis. The pooled data from 15 (94%) RCTs including 776 (97%) participants showed that VR therapy was superior in improving pain intensity (WMD=-1.63, 95% CI -2.11 to -1.16, P<.001, I2=90%) and reducing inflammatory markers, including C-reactive protein (WMD=-0.89, 95% CI -1.07 to -0.70, P<.001, I2=0%), tumor necrosis factor-alpha (WMD=-6.60, 95% CI -8.56 to -4.64, P<.001, I2=98%), and interleukin-6 (WMD=-2.76, 95% CI -2.98 to -2.53, P<.001, I2=0%). However, no significant differences were found in terms of the spinal range of motion (ROM), disability level, or fear of movement. In addition, 10 (63%) of the included RCTs had a high risk of bias.

CONCLUSIONS

VR therapy may be an effective and safe intervention for reducing symptoms in patients with CSP, as it is shown to exert significant analgesic effects and beneficial improvements in inflammatory factor levels. However, this approach may not have significant effects on the spinal ROM, disability level, or fear of movement. Notably, the quality of the evidence from the RCTs included in this study ranged from moderate to low. Therefore, we recommend that readers interpret the results of this study with caution.

TRIAL REGISTRATION

PROSPERO CRD42022382331; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=382331.

Virtual reality is effective in the management of chronic low back ache in adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Chronic low back ache (CLBA) is a common condition that is conventionally managed with physical therapy and analgesics. Recently, virtual reality-based interventions have been tried out in the management of CLBA. Their effectiveness, however has not been established. This meta-analysis aims to find out if the application of VR will lead to better pain relief, as compared to conventional techniques in adults with CLBA.

METHODS

The literature search was carried out in three online databases for potential randomized controlled trials that compared VR-based interventions with conventional treatment in CLBA. Data on outcome parameters were recorded. Meta-analysis was carried out with the help of appropriate software.

RESULTS

Seven studies having data on 507 subjects were included in the meta-analysis. Their mean ages were 48.4 years. There were 252 subjects in the VR group and 255 in the control group. VR-based interventions were found to have a statistically significant improvement in the pain intensity compared with conventional techniques (p - 0.005).

CONCLUSION

VR-based interventions are effective in the management of CLBA in the short term. Further research with longer follow-up is required to evaluate if these improvements are persistent in the long term.

Development of a Multimodal, Personalized Intervention of Virtual Reality Integrated Within Physiotherapy for Patients With Complex Chronic Low-Back Pain

Background

Chronic low-back pain (CLBP) is the leading cause of years lived with disability. Physiotherapy is the most common treatment option for CLBP, but effects are often unsatisfactory. Virtual reality (VR) offers possibilities to enhance the effectiveness of physiotherapy treatment. Primary aim was to develop and test a personalized VR intervention integrated within a physiotherapy treatment for patients with CLBP.

Methods

This study describes an intervention development process using mixed methods design that followed the Medical Research Council (MRC) framework. This involved a cocreation process with patients, physiotherapists, and researchers. A draft intervention was constructed based on a literature review and focus groups, and subsequently tested in a feasibility study and evaluated in focus groups. Focus group data were analyzed using thematic analysis. This intervention development process resulted in a final intervention.

Results

Focus group data showed that VR and physiotherapy can strengthen each other when they are well integrated, and that VR needs to be administered under the right conditions including flawless technology, physiotherapists with sufficient affinity and training, and the right expectations from patients. The draft intervention was considered feasible after evaluation by four patients and three physiotherapists and was further complemented by expanding the training for physiotherapists and improving the protocols for physiotherapists and patients. The final intervention consisted of a 12-week physiotherapy treatment with three integrated VR modules: pain education, physical exercise, and relaxation.

Conclusion

Using the MRC framework in cocreation with the end users, a personalized VR intervention integrated within a physiotherapy treatment for patients with CLBP was developed. This intervention was found to be feasible and will subsequently be evaluated for (cost-)effectiveness in a cluster randomized controlled trial.

Ethical Challenges of Virtual Reality Technology Interventions for the Vulnerabilities of Patients With Chronic Pain: Exploration of Technician Responsibility

Chronic pain, a common disease, is a crucial global public health concern. Approximately 20% of the worldwide population is affected by chronic pain, which accounts for 15% to 20% of hospital visits. In Canada, approximately 7.6 million people-or 1 in 5 people-experience chronic pain. Among this population, 60% has either lost their employment or experienced a reduction in income as a result of their pain. The proportion of older people (aged ≥65 years) with chronic pain is high, comprising one-third of the total older population. In addition, the causes of chronic pain and its cures are unknown, and treatment is limited by these unknowns and the dangers of opioids. These essential factors make patients with chronic pain one of the most vulnerable populations. The use of emerging virtual reality (VR) technology as an intervention for chronic pain has consistently demonstrated early effectiveness and has been termed as a "nonpharmacological analgesic." Nevertheless, we must remain vigilant about the potential ethical risks of VR interventions, as inappropriate VR interventions may exacerbate the vulnerabilities of patients. Currently, a central challenge for VR developers is the ambiguity of patient vulnerability and the unpredictability of ethical dilemmas. Therefore, our paper focused on the vulnerability and ethical dilemmas faced by patients with chronic pain in VR interventions. Through an experience-based, prospective ethical examination, we have identified both existing and potential new vulnerabilities and specific manifestations that patients with chronic pain may encounter in VR interventions. Our aim was to highlight the ethical risks that may be present in VR interventions. On one hand, this can help raise awareness among technology developers regarding the vulnerabilities of patients with chronic pain and mitigate technological ethical risks. In addition, it can assist technology developers in determining the priorities for VR technology interventions. These efforts collectively lay a solid foundation for the comprehensive realization of responsible VR technology interventions.

The Management of Chronic Pain: Re-Centring Person-Centred Care

The drive for a more person-centred approach in the broader field of clinical medicine is also gaining traction in chronic pain treatment. Despite current advances, a further departure from 'business as usual' is required to ensure that the care offered or received is not only effective but also considers personal values, goals, abilities, and day-to-day realities. Existing work typically focuses on explaining pain symptoms and the development of standardised interventions, at the risk of overlooking the broader consequences of pain in individuals' lives and individual differences in pain responses. This review underscores the importance of considering additional factors, such as the influence of chronic pain on an individual's sense of self. It explores innovative approaches to chronic pain management that have the potential to optimise effectiveness and offer person-centred care. Furthermore, it delves into research applying hybrid and individual formulations, along with self-monitoring technologies, to enhance pain assessment and the tailoring of management strategies. In conclusion, this review advocates for chronic pain management approaches that align with an individual's priorities and realities while fostering their active involvement in self-monitoring and self-management.

Physiotherapy with integrated virtual reality for patients with complex chronic low back pain: protocol for a pragmatic cluster randomized controlled trial (VARIETY study)

BACKGROUND

Chronic low back pain (CLBP) is the most common chronic pain condition worldwide. Currently, primary care physiotherapy is one of the main treatment options, but effects of this treatment are small. Virtual Reality (VR) could be an adjunct to physiotherapy care, due to its multimodal features. The primary aim of this study is to assess the (cost-)effectiveness of physiotherapy with integrated multimodal VR for patients with complex CLBP, compared to usual primary physiotherapy care.

METHODS

A multicenter, two-arm, cluster randomized controlled trial (RCT) including 120 patients with CLBP from 20 physiotherapists will be conducted. Patients in the control group will receive 12 weeks of usual primary physiotherapy care for CLBP. Patients in the experimental group will receive treatment consisting of 12 weeks of physiotherapy with integrated, immersive, multimodal, therapeutic VR. The therapeutic VR consists of the following modules: pain education, activation, relaxation and distraction. The primary outcome measure is physical functioning. Secondary outcome measures include pain intensity, pain-related fears, pain self-efficacy and economic measures. Effectiveness of the experimental intervention compared to the control intervention on primary and secondary outcome measures will be analyzed on an intention-to-treat principle, using linear mixed-model analyses.

DISCUSSION

This pragmatic, multicenter cluster randomized controlled trial, will determine the clinical and cost-effectiveness of physiotherapy with integrated, personalized, multimodal, immersive VR in favor of usual physiotherapy care for patients with CLBP.

TRIAL REGISTRATION

This study is prospectively registered at ClinicalTrials.gov (identifier: NCT05701891).

Body movement as a biomarker for use in chronic pain rehabilitation: An embedded analysis of an RCT of a virtual reality solution for adults with chronic pain

Introduction

Chronic low back pain (CLBP) is a major public health problem. Reliably measuring the effects of chronic pain on movement and activity, and any changes due to treatment, is a healthcare challenge. A recently published paper demonstrated that a novel digital therapeutic (DTxP) was efficacious in reducing fear of movement and increasing the quality of life of adult patients with moderate to severe CLBP. In this paper, we report a study of how data from wearable devices collected in this study could be used as a digital measure for use in studies of chronic low back pain.

Methods

Movement, electrodermal recording, general activity and clinical assessment data were collected in a clinical trial of a novel digital therapeutic intervention (DTxP) by using the sensors in commercial Garmin Vivosmart 4, Empatica Embrace2 and Oculus Quest wearables. Wearable data were collected during and between the study interventions (frequent treatment sessions of DTxP). Data were analyzed using exploratory statistical analysis.

Results

A pattern of increased longitudinal velocity in the movement data collected with right-hand, left-hand, and head sensors was observed in the study population. Correlations were observed with the changes in clinical scales (Tampa Scale of Kinesiophobia, EQ5D Overall health VAS, and EQ5D QoL score). The strongest correlation was observed with the increased velocity of head and right-hand sensors (Spearman correlation with increasing head sensor velocity and Tampa Scale of Kinesiophobia -0.45, Overall health VAS +0.67 and EQ5D QoL score -0.66). The sample size limited interpretation of electrodermal and general activity data.

Discussion/Conclusion

We found a novel digital signal for use in monitoring the efficacy of a digital therapeutics (DTxP) in adults with CLBP. We discuss the potential use of such movement based digital markers as surrogate or additional endpoints in studies of chronic musculoskeletal pain.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT04225884?cond=NCT04225884&draw=2&rank=1, identifier: NCT04225884.