Virtual Reality Graded Exposure Therapy as Treatment for Pain-Related Fear and Disability in Chronic Pain

The effects of virtual reality training on postural sway and physical function performance on older women with chronic low back pain: A double-blind randomized clinical trial

BACKGROUND

Chronic low back pain (CLBP) is known as an important debilitating health condition among older women.

OBJECTIVE

This study aimed to evaluate the effects of eight-week virtual reality training (VRT) exercises on postural sway and physical function performance (PFP) among older women suffering from CLBP.

METHODS

Twenty-seven older women presenting with CLBP were randomized into experimental and control groups. The experimental group was instructed to perform 30-minute VRT exercises three times a week for eight weeks. Plantar pressure variables [sway velocity (SV) and anterior-posterior (AP) and medial-lateral (ML) fluctuations of the center of pressure (CoP)], 30-second chair stand test (30CST), and timed up and go (TUG) test were recorded.

RESULTS

The VRT group exhibited significant decreases in SV (p= 0.002), AP (p= 0.008), and ML (p= 0.02) fluctuations. Also, the performance of the VRT group in the 30CST and TUG tests significantly improved after the exercises (P< 0.001).

CONCLUSION

According to the results, VRT and the program used in this study should be used to enhance balance and PFP in older women with CLBP who mostly prefer activities that are accessible and feasible in low-risk environments.

Virtual reality and chronic low back pain

AIM

Chronic low back pain (CLBP) is a highly prevalent and significant cause of disability which is often resistant to pharmacological management. Virtual reality (VR) is an emerging technology with the potential to influence CLBP, and has been suggested as an alternative to opioids for pain management. VR is a goalfocused, computer-simulated reality allowing modification of the user's experience of their perceived world.

MATERIALS/METHODS

A narrative review of peer-reviewed literature using a systematic search strategy, and sole reviewer for data extraction.

CONCLUSIONS

VR has demonstrated effectiveness in reducing acute, experimental and chronic pain. This review describes the theoretical basis of the therapeutic effects of VR on CLBP via three distinct mechanisms: distraction, neuromodulation and graded exposure therapy. Furthermore, clinical application will be considered, including discussion of ethical issues associated with the technology.Implications for rehabilitationVirtual reality (VR) is suggested as an alternative for opioids in the management of acute and chronic pain.The therapeutic mechanisms of VR in chronic low back pain (CLBP) are equivocal but include distraction, neuromodulation of body perception and graded exposure therapy.VR may show greater efficacy in patients with CLBP with associated kinesiophobia.VR may show greater effect with increased immersion.

Virtual Reality as a Therapy Adjunct for Fear of Movement in Veterans With Chronic Pain: Single-Arm Feasibility Study

Background

Virtual reality (VR) has demonstrated efficacy for distraction from pain-related thoughts and exposure to feared movements. Little empirical VR research has focused on chronic pain management.

Objective

The purpose of this study was to examine the feasibility of VR as an adjunctive intervention for Veterans with chronic pain. We designed a hierarchy ranging from low-intensity pain distraction to high-intensity movement-based exposure for this purpose. VR apps were mapped onto the hierarchy.

Methods

Sixteen Veterans receiving inpatient chronic pain rehabilitation participated in daily VR sessions over a 3-week period. Trajectories across the distraction-to-exposure hierarchy and Veteran-reported intensity ratings were described and evaluated over time. Minimum clinically important differences (MCIDs), pre-post effect sizes, and 95% confidence intervals were examined for fear of movement using the Fear of Daily Activities Questionnaire (FDAQ) and Pain Outcomes Questionnaire-VA (POQ-VA; fear scale). This approach was applied to secondary outcomes: POQ-VA (pain intensity, interference, negative affect), Pain Catastrophizing Scale, and Patient-Specific Functioning Scale (PSFS). Session attendance, completion, and VR experiences were described.

Results

Ten of 14 Veterans (71%) who participated in three or more VR sessions completed the distraction-to-exposure hierarchy. Only three trajectories emerged more than once. Due to high completion rates, Veterans that completed the hierarchy could self-select nonhierarchy apps. Veterans rated all hierarchy levels (low, medium, high) near medium intensity. Self-selected activities were rated as high intensity. For kinesiophobia, six Veterans (38%) exceeded the MCID on the FDAQ and a small effect size improvement was observed (Cohen d=−0.35). The confidence interval (95% CI −0.71 to 0.01) indicated the possibility of a null effect. The POQ-VA fear scale yielded no effect (Cohen d=0.06, 95% CI −0.43 to 0.54). For secondary outcomes, Veterans exceeding MCID were calculated with complete data: pain intensity (1/15, 7%), pain catastrophizing (5/14, 36%), and patient-specific functioning (10/15, 67%). Effect sizes were large for patient-specific functioning (Cohen d=1.14, 95% CI 0.50-1.78), medium for mobility interference (Cohen d=−0.56, 95% CI −0.96 to −0.16), and small for pain intensity (Cohen d=−0.40, 95% CI −0.69 to −0.12) and catastrophizing (Cohen d=−0.41, 95% CI −0.79 to −0.02). No effects were observed for interference in daily activities (Cohen d=0.10, 95% CI −0.27 to 0.47) and negative affect (Cohen d=0.07, 95% CI −0.26 to 0.40). Veterans attended 85.2% (98/108) of VR sessions and completed 95% (93/96) of sessions attended. Twenty-minute sessions were rated as too short. No significant adverse events were reported.

Conclusions

Findings support the feasibility of VR as an adjunct for Veterans with chronic pain. However, the hierarchy will require modification, as evidenced by homogeneous intensity ratings. Veteran-selected activities presented the highest intensity ratings, largest outcome effect size (PSFS), and MCID. This highlights the important role of utilizing Veteran stakeholders in hierarchy modification, design of VR interventions, and outcome selection.

Neuroscience of Virtual Reality: From Virtual Exposure to Embodied Medicine

Is virtual reality (VR) already a reality in behavioral health? To answer this question, a meta-review was conducted to assess the meta-analyses and systematic and narrative reviews published in this field in the last twenty-two months. Twenty-five different articles demonstrated the clinical potential of this technology in both the diagnosis and the treatment of mental health disorders: VR compares favorably to existing treatments in anxiety disorders, eating and weight disorders, and pain management, with long-term effects that generalize to the real world. But why is VR so effective? Here, the following answer is suggested: VR shares with the brain the same basic mechanism: embodied simulations. According to neuroscience, to regulate and control the body in the world effectively, the brain creates an embodied simulation of the body in the world used to represent and predict actions, concepts, and emotions. VR works in a similar way: the VR experience tries to predict the sensory consequences of an individual's movements, providing to him/her the same scene he/she will see in the real world. To achieve this, the VR system, like the brain, maintains a model (simulation) of the body and the space around it. If the presence in the body is the outcome of different embodied simulations, concepts are embodied simulations, and VR is an embodied technology, this suggests a new clinical approach discussed in this article: the possibility of altering the experience of the body and facilitating cognitive modeling/change by designing targeted virtual environments able to simulate both the external and the internal world/body.