Virtual reality exergame for supplementing multimodal pain therapy in older adults with chronic back pain: a randomized controlled pilot study

Virtual Reality Mental Health Interventions in Geriatric Care for Functional or Well-being Enhancement - A Scoping Review

PURPOSE

It has become common to use Virtual Reality (VR) for mental health interventions; however, its use in care of the elederly is limited, especially regarding mood and well-being. In this review, we summarize the results of current VR-based mental health interventions for this population.

METHODS

Peer-reviewed journal articles on immersive VR mental health intervention in seniors, published until 2022, were included.

RESULTS

There were 2697 results found in the database search, of which 40 articles met the inclusion criteria and were included in the final analysis. Most studies did not use an experimental design with randomized controlled trials and follow-up sessions. Function-oriented and entertainment-oriented intervention studies were categorized. VR-based geriatric mental interventions have grown rapidly since 2018, especially the number of interventions that promote wellbeing. The function-oriented intervention used active interactions with varied devices. Entertainment-oriented interaction was primarily passive, seldomly using hand controllers for moving activities. Generally, VR interventions improved the mental health of older adults.

CONCLUSION

Geriatric rehabilitation can benefit from this innovative technology to maintain cognitive functions and to improve the well-being of seniors. They have potential for use in aging care and in retirement homes. Future VR intervention may also involve promoting social interaction to combat loneliness among seniors.

Limited use of virtual reality in primary care physiotherapy for patients with chronic pain

BACKGROUND

Chronic pain is a disabling condition which is prevalent in about 20% of the adult population. Physiotherapy is the most common non-pharmacological treatment option for chronic pain, but often demonstrates unsatisfactory outcomes. Virtual Reality (VR) may offer the opportunity to complement physiotherapy treatment. As VR has only recently been introduced in physiotherapy care, it is unknown to what extent VR is used and how it is valued by physiotherapists. The aim of this study was to analyse physiotherapists' current usage of, experiences with and physiotherapist characteristics associated with applying therapeutic VR for chronic pain rehabilitation in Dutch primary care physiotherapy.

METHODS

This online survey applied two rounds of recruitment: a random sampling round (873 physiotherapists invited, of which 245 (28%) were included) and a purposive sampling round (20 physiotherapists using VR included). Survey results were reported descriptively and physiotherapist characteristics associated with VR use were examined using multivariable logistic regression analysis.

RESULTS

In total, 265 physiotherapists participated in this survey study. Approximately 7% of physiotherapists reported using therapeutic VR for patients with chronic pain. On average, physiotherapists rated their overall experience with therapeutic VR at 7.0 and "whether they would recommend it" at 7.2, both on a 0-10 scale. Most physiotherapists (71%) who use therapeutic VR started using it less than two years ago and use it for a small proportion of their patients with chronic pain. Physiotherapists use therapeutic VR for a variety of conditions, including generalized (55%), neck (45%) and lumbar (37%) chronic pain. Physiotherapists use therapeutic VR mostly to reduce pain (68%), improve coordination (50%) and increase physical mobility (45%). Use of therapeutic VR was associated with a larger physiotherapy practice (OR = 2.38, 95% CI [1.14-4.98]). Unfamiliarity with VR seemed to be the primary reason for not using VR.

DISCUSSION

Therapeutic VR for patients with chronic pain is in its infancy in Dutch primary care physiotherapy practice as only a small minority uses VR. Physiotherapists that use therapeutic VR are modestly positive about the technology, with large heterogeneity between treatment goals, methods of administering VR, proposed working mechanisms and chronic pain conditions to treat.

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.

Effects of Exergaming on Musculoskeletal Pain in Older Adults: Systematic Review and Meta-analysis

BACKGROUND

Exercise is effective for musculoskeletal pain. However, physical, social, and environmental factors make it difficult for older adults to persist in exercising. Exergaming is a new pathway that combines exercise with gameplay and may be helpful for older adults to overcome these difficulties and engage in regular exercise.

OBJECTIVE

This systematic review aimed to determine the efficacy of exergaming to improve musculoskeletal pain in older adults.

METHODS

The search was performed in 5 databases (PubMed, Embase, CINAHL, Web of Science, and Cochrane Library). The risk of bias for randomized controlled studies was assessed using the revised Cochrane Risk of Bias tool in randomized trials (RoB 2), and the methodological quality was assessed using the Physiotherapy Evidence-Based Database scale. Standardized mean difference and 95% CI were calculated using fixed-effects model meta-analyses in the Review Manager version 5.3 (RevMan 5.3).

RESULTS

Seven randomized controlled studies were included, which contained 264 older adults. Three of the 7 studies reported significant improvements in pain after the exergaming intervention, but only 1 reported a significant difference between groups after adjustment for baseline (P<.05), and another reported a significant improvement in thermal pain between the 2 groups (P<.001). The results of the meta-analysis of the 7 studies showed no statistically significant improvement in pain compared to the control group (standardized mean difference -0.22; 95% CI -0.47 to 0.02; P=.07).

CONCLUSIONS

Although the effects of exergames on musculoskeletal pain in older adults are unknown, exergame training is generally safe, fun, and appealing to older adults. Unsupervised exercise at home is feasible and cost-effective. However, most of the current studies have used commercial exergames, and it is recommended that there should be more cooperation between industries in the future to develop professional rehabilitation exergames that are more suitable for older adults. The sample sizes of the studies included are small, the risk of bias is high, and the results should be interpreted with caution. Further randomized controlled studies with large sample sizes, high quality, and rigor are needed in the future.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022342325; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=342325.

Acceptability, Feasibility, and Effectiveness of Immersive Virtual Technologies to Promote Exercise in Older Adults: A Systematic Review and Meta-Analysis

CONTEXT

This review aimed to synthesize the literature on the acceptability, feasibility, and effectiveness of immersive virtual technologies to promote physical exercise in older people.

METHOD

We performed a literature review, based on four databases (PubMed, CINAHL, Embase, and Scopus; last search: 30 January 2023). Eligible studies had to use immersive technology with participants aged 60 years and over. The results regarding acceptability, feasibility, and effectiveness of immersive technology-based interventions in older people were extracted. The standardized mean differences were then computed using a random model effect.

RESULTS

In total, 54 relevant studies (1853 participants) were identified through search strategies. Concerning the acceptability, most participants reported a pleasant experience and a desire to use the technology again. The average increase in the pre/post Simulator Sickness Questionnaire score was 0.43 in healthy subjects and 3.23 in subjects with neurological disorders, demonstrating this technology's feasibility. Regarding the effectiveness, our meta-analysis showed a positive effect of the use of virtual reality technology on balance (SMD = 1.05; 95% CI: 0.75-1.36; p < 0.001) and gait outcomes (SMD = 0.7; 95% CI: 0.14-0.80; p < 0.001). However, these results suffered from inconsistency and the number of trials dealing with these outcomes remains low, calling for further studies.

CONCLUSIONS

Virtual reality seems to be well accepted by older people and its use with this population is feasible. However, more studies are needed to conclude its effectiveness in promoting exercise in older people.

Deep Reinforcement Learning-Based iTrain Serious Game for Caregivers Dealing with Post-Stroke Patients

This paper describes a serious game based on a knowledge transfer model using deep reinforcement learning, with an aim to improve the caretakers’ knowledge and abilities in post-stroke care. The iTrain game was designed to improve caregiver knowledge and abilities by providing non-traditional training to formal and informal caregivers who deal with stroke survivors. The methodologies utilized professional medical experiences and real-life evidence data gathered during the duration of the iTrain project to create the scenarios for the game’s deep reinforcement caregiver behavior improvement model, as well as the design of game mechanics, game images and game characters, and gameplay implementation. Furthermore, the results of the game’s direct impact on caregivers (n = 25) and stroke survivors (n = 21) in Lithuania using the Geriatric Depression Scale (GDS) and user experience questionnaire (UEQ) are presented. Both surveys had favorable outcomes, showing the effectiveness of the approach. The GDS scale (score 10) revealed a low number of 28% of individuals depressed, and the UEQ received a very favorable grade of +0.8.

A social VR-based collaborative exergame for rehabilitation: codesign, development and user study

Immersive virtual reality (VR)-based exercise video games (exergames) are increasingly being employed as a supportive intervention in rehabilitation programs to promote engagement in physical activity, especially for elderly users. A multifaceted and iterative codesign process is essential to develop sustainable exergaming solutions. The social aspect is considered one of the key motivating factors in exergames; however, research on the social aspect of VR exergames has been limited. Previous studies have relied on competitiveness in exergames, but research has shown that competition can lead to adverse effects on users. With the aim of motivating elderly individuals to participate in physical exercise and improving social connectedness during rehabilitation, this work presents a social VR-based collaborative exergame codesigned with elderly participants and therapists. This exergame stimulates full-body exercise and supports social collaboration among users through a collaborative game task. Furthermore, this article presents a user study based on a mixed-methods approach to gather user feedback on exergame design and the effect of social collaboration versus playing alone in a VR exergame in terms of physical exertion and motivation. This study spanned five weeks (99 exergaming sessions) with 14 elderly participants divided into two groups, one playing collaboratively and the other playing individually. Between-group comparisons were performed at baseline (first week) and in the fourth week, and within-group comparisons were performed in the fifth week, when the participants played the exergame in counterbalanced order. In contrast to the first week, the participants exergaming collaboratively in the fourth week reported significantly higher intrinsic motivation on all subscales (enjoyment: p < 0.02, effort: p < 0.002, usefulness: p < 0.01) and physical exertion (p < 0.001) than those playing alone. Thereafter, exergaming in counterbalanced order during the fifth week resulted in significant differences (medium to large effect size) within groups. The participants found the social VR gameplay enjoyable and agreed that collaboration played a vital role in their motivation. They reported various health benefits, a minimal increase in symptoms of simulator sickness, and excellent usability scores (83.75±13.3). In this work, we also identify various key design principles to support healthcare professionals, researchers and industrial experts in developing ergonomic and sustainable VR-based exergames for senior citizens.

What Is New in Classification, Diagnosis and Management of Chronic Musculoskeletal Pain: A Narrative Review

Chronic musculoskeletal pain (CMP) is the most common type of chronic pain, defined as persistent or recurrent pain condition deriving from musculoskeletal structures such as muscles, joints or bones that lasts for more than 3 months. CMP is multifactorial and severely affects people's quality of life. CMP may be influenced by a number of factors, including contextual factors, the presence of comorbidities, arthritis coping efficacy and access to CMP care. To deepen the comprehensive understanding of CMP, this narrative review provides the latest literature on disease classification, clinical diagnosis, treatment and basic research. In terms of the classification of the disease, here we introduce the 11th edition of the International Classification of Diseases (IDC-11), in which CMP is divided into chronic primary musculoskeletal pain and chronic secondary musculoskeletal pain. In the clinical diagnosis section, the progress of central sensitization in the diagnosis of CMP will also be summarized. In addition, we summarize some recent advances in clinical treatment and basic research.

Evaluation of MyRelief Serious Game for Better Self-Management of Health Behaviour Strategies on Chronic Low-Back Pain

Low back pain is a leading cause of disability worldwide, putting a significant strain on individual sufferers, their families, and the economy as a whole. It has a significant economic impact on the global economy because of the costs associated with healthcare, lost productivity, activity limitation, and work absence. Self-management, education, and adopting healthy lifestyle behaviors, such as increasing physical activity, are all widely recommended treatments. Access to services provided by healthcare professionals who provide these treatments can be limited and costly. This evaluation study focuses on the application of the MyRelief serious game, with the goal of addressing such challenges by providing an accessible, interactive, and fun platform that incorporates self-management, behavior change strategies, and educational information consistent with recommendations for managing low-back pain, based on self-assessment models implemented through ontology-based mechanics. Functional disability measured using the Oswestry Disability Questionnaire showed the statistically significant (p < 0.001) improvement in subjects’ self-evaluation of their health status. System Usability Scale (SUS) test score of 77.6 also suggests that the MyRelief serious game can potentially influence patient enablement.