Enhanced Reality Showing Long-Lasting Analgesia after Total Knee Arthroplasty: Prospective, Randomized Clinical Trial

Virtual Reality for Postoperative Pain Management: A Review of Current Evidence

PURPOSE OF REVIEW

With the ongoing opioid crisis, there is a continued need to develop multimodal pain management strategies inclusive of non-pharmacological treatments. Virtual reality (VR) offers a non-invasive treatment approach for the management of acute and chronic pain including postoperative pain. The aim of this review is to describe the use of VR and its effect on pain-related outcome measures compared to routine care in various types of surgical procedures.

RECENT FINDINGS

Severe postoperative pain is associated with an increased risk of medical complications and may lead to the development of chronic pain. VR-based interventions are a form of distraction therapy that attenuates pain perception and have been shown to reduce activity in central pain-processing regions. In patients undergoing cardiac surgery, VR may reduce postoperative pain and improve physiological parameters such as heart rate and blood pressure. VR technology was found to have a high satisfaction rate in patients undergoing laparoscopic abdominal surgeries. Three-dimensional (3D) VR interventions may be useful for postoperative pain control in patients undergoing head and neck surgery. VR technology has revealed mixed results for postoperative pain control following orthopedic procedures although it has beneficial effects on functional outcomes during postoperative rehabilitation. In the pediatric population, VR is notable for its applicability in postoperative pain control and anxiety. VR technology is a novel, non-pharmacologic adjunct in the management of postoperative pain. Current studies are limited regarding therapy adaptations for the elderly population. High-quality randomized controlled trials are needed to establish the clinical effectiveness of VR-based therapies in the postoperative setting.

Application of virtual reality technology in postoperative rehabilitation following total knee arthroplasty: A scoping review

BACKGROUND

With the advent of an ageing era, the number of elderly patients undergoing knee joint replacement is increasing. Postoperative long-term standardized functional exercise is a focal point and difficulty in the recovery of joint function for patients after knee replacement. Virtual reality (VR) is increasingly considered a potentially effective option that can provide patients with a relaxed and enjoyable exercise method.

OBJECTIVE

The primary objective of the scoping review to systematically evaluates the impact of virtual reality (VR) technology the movement and functional recovery, psychological state, pain levels, and quality of life of patients after total knee arthroplasty (TKA). It summarises and synthesises VR's effects and feasibility in TKA rehabilitation training, offering a scientific basis and reference for the professional advancement of orthopaedic practice nurses and future research in this domain.

METHODS

We employed the Joanna Briggs Institute's scoping review guidelines as our methodological framework. The literature search spanned from January 2018 to December 31, 2023, encompassing databases such as PubMed, Web of Science, The Cochrane Library, Embase, CNKI, Wanfang, CQVIP, and the China Biomedical Literature Database.

RESULTS

An initial search yielded 2708 articles, with 17 studies meeting the inclusion criteria after stringent screening. The findings indicate that VR equipment primarily comprises VR goggles, handheld controllers, and sensor technology. Interventions typically occurred 3 to 5 times weekly, lasting 20-30 min per session. The principal assessment metrics included pain levels, psychological state, joint function, and quality of life.

CONCLUSION

VR technology proves feasible in the rehabilitation of TKA patients, effectively alleviating pain, enhancing psychological states, and improving joint function and quality of life. However, discrepancies exist regarding VR's effect on bolstering lower limb muscle strength. Future research should focus on evidence-based medical practices, optimising VR intervention strategies, developing customised plans tailored to individual patient differences, and potentially extending intervention durations to amplify VR technology's application effects in TKA patient rehabilitation.

The effectiveness of extended reality on relieving pain after total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Patients with total knee arthroplasty (TKA) often suffer from severe postoperative pain, which seriously hinders postoperative rehabilitation. Extended reality (XR), including virtual reality, augmented reality, and mixed reality, has been increasingly used to relieve pain after TKA. The purpose of this study was to evaluate the effectiveness of XR on relieving pain after TKA.

METHODS

The electronic databases including PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov were searched for studies from inception to July 20, 2023. The outcomes were pain score, anxiety score, and physiological parameters related to pain. Meta-analysis was performed using the Review Manager 5.4 software.

RESULTS

Overall, 11 randomized control trials (RCTs) with 887 patients were included. The pooled results showed XR had lower pain scores (SMD = - 0.31, 95% CI [- 0.46 to - 0.16], P < 0.0001) and anxiety scores (MD = - 3.95, 95% CI [- 7.76 to - 0.13], P = 0.04) than conventional methods. The subgroup analysis revealed XR had lower pain scores within 2 weeks postoperatively (SMD = - 0.49, 95% CI [- 0.76 to - 0.22], P = 0.0004) and XR had lower pain scores when applying XR combined with conventional methods (SMD = - 0.43, 95% CI [- 0.65 to - 0.20], P = 0.0002).

CONCLUSION

This systematic review and meta-analysis found applying XR could significantly reduce postoperative pain and anxiety after TKA. When XR was combined with conventional methods, postoperative pain can be effectively relieved, especially within 2 weeks after the operation. XR is an effective non-pharmacological analgesia scheme.

The Effectiveness of Virtual Reality, Augmented Reality, and Mixed Reality Rehabilitation in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Extended reality (XR), including virtual reality, augmented reality, and mixed reality, has been increasingly used in postoperative rehabilitation of total knee arthroplasty (TKA). The purpose of this systematic review and meta-analysis was to evaluate the effectiveness of XR-based rehabilitation in TKA compared to conventional rehabilitation.

METHODS

In this study, we searched PubMed (MEDLINE), Embase (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and clinicaltrials.gov from inception to February 15, 2023 for eligible studies. A total of 14 randomized controlled trials with 989 patients were included in our study. The primary outcomes were pain and function. The secondary outcomes were anxiety and quality of life. A systematic review and meta-analysis was performed.

RESULTS

The pooled data indicated XR-based rehabilitation significantly improved the visual analog scale (standardized mean difference [SMD] = -0.31, 95% Confidence Interval [CI] [-0.47 to -0.15], P = .0001), the Western Ontario and McMaster Universities Osteoarthritis Index (SMD = -0.46, 95% CI [-0.86 to -0.06], P = .02), range of motion (SMD = 0.40, 95% CI [0.09 to 0.72], P = .01), and anxiety scores (mean difference = -3.95, 95% CI [-7.76 to -0.13], P = .04) than conventional rehabilitation, but Timed Up and Go test and quality of life were similar in the 2 groups.

CONCLUSION

This systematic review and meta-analysis found XR-based rehabilitation improved pain, function, and anxiety, but not quality of life in TKA compared to conventional rehabilitation within 1 month postoperatively. Based on the pooled results, we suggested that XR-based rehabilitation may have benefit in patients' postoperative rehabilitation in TKA.

Effectiveness of Virtual Reality-Based Rehabilitation Interventions in Improving Postoperative Outcomes for Orthopedic Surgery Patients

PURPOSE OF REVIEW

The surge in orthopedic surgeries strains the US healthcare system, necessitating innovative rehabilitation solutions. This review examines the potential of virtual reality (VR)-based interventions for orthopedic rehabilitation.

RECENT FINDINGS

The effectiveness of VR-based interventions in orthopedic surgery patients is scrutinized. While some studies suggest better patient-reported outcomes and satisfaction, mixed results emerge from others, demonstrating comparable or varied results compared to traditional rehabilitation. The underlying mechanisms of VR-based rehabilitation are elucidated, showing its positive impact on proprioception, pain management, agency, and balance. Challenges of unfamiliarity, patient engagement, and drop-out rates are identified, emphasizing the need for tailored approaches. VR technology's immersive environments and multisensory experiences offer a novel approach to addressing functional deficits and pain post-surgery. The conclusion drawn is that VR-based rehabilitation complements rather than replaces conventional methods, potentially aiding in pain reduction and functional improvement. VR-based rehabilitation holds promise for enhancing orthopedic surgery outcomes, presenting a dynamic approach to recovery. Its potential to reshape healthcare delivery and reimbursement structures underscores its significance in modern healthcare. Overall, VR-based rehabilitation offers a promising avenue for optimizing postoperative recovery in orthopedic surgery patients.

The Effect of a Virtual Reality-Mediated Gamified Rehabilitation Program on Pain, Disability, Function, and Balance in Knee Osteoarthritis: A Prospective Randomized Controlled Study

Background: This prospective randomized controlled study is the first study that evaluates the disease-specific gamification through virtual reality (VR) glasses on pain, disability, functionality, and balance in knee osteoarthritis (OA). Materials and Methods: The demographic data of the patients were recorded. A total of 73 patients were divided into two groups (35 in experimental group and 38 in control group). All patients were evaluated with pain (visual analog scale [VAS]), functionality (Lysholm functional knee score [LFKS], 6 minutes walking test [6MWT]), disability (Western Ontario and McMaster Universities Arthritis Index [WOMAC]), and balance (Berg Balance Scale [BBS]) before treatment, after treatment (3th weeks), and 4 weeks after treatment (7th weeks). In the experimental group, plus the conservative treatment, a total of 15 sessions of a disease-specific gamification through VR glasses were applied. Results: VAS and WOMAC scores of the experimental group were lower at the 3th and 7th weeks than those of the control group (P = 0.005, P = 0.000), (P = 0.000). LFKS of the experimental group was higher at the 3th and 7th weeks than that of the control group (P = 0.005, P = 0.013). No difference was found between the groups in terms of 6MWTs (P > 0.05). BBS score of the experimental group was higher in the 7th week than that of the control group (P = 0.021). Conclusion: In knee OA, the disease-specific gamification through VR glasses added to the conservative treatment has a positive effect on pain, functionality, and balance. Side effects such as mild nausea, headache that did not last long, require additional treatment. In light of this, disease-specific gamification through VR glasses is effective and safe in knee OA, more studies that reveal the long-term effect on structural healing must be planned.

Effects of the Practice of Movement Representation Techniques in People Undergoing Knee and Hip Arthroplasty: A Systematic Review

OBJECTIVE

To analyze the effects of movement representation techniques (MRT) combined with conventional physical therapy (CFT) in people undergoing knee and hip arthroplasty compared to conventional physical therapy alone in terms of results in physical and functionality variables, cognitive function, and quality of life.

METHODOLOGY

the review was carried out according to the criteria of the PRISMA statement, considering studies in the electronic databases PubMed/Medline, Pubmed Central/Medline, Web of Science, EBSCO, and ScienceDirect.

RESULTS

MRT plus CFT generated therapeutic effects in some aspects of the physical variables: 100% pain (7 of 7 studies); 100% strength (5 out of 5 studies); range of motion 87.5% (7 out of 8 studies); 100% speed (1 of 1 study), functional variables: 100% gait (7 of 7 studies); functional capacity 87.5% (7 out of 8 studies); cognitive variables: 100% motor visualization ability (2 out of 2 studies); cognitive performance 100% (2 of 2 studies); and quality of life 66.6% (2 of 3 studies). When comparing its effects with conventional physical therapy, the variables that reported the greatest statistically significant changes were motor visualization ability, speed, pain, strength and gait. The most used MRT was motor imagery (MI), and the average time extension of therapies was 3.5 weeks.

CONCLUSIONS

movement representation techniques combined with conventional physical therapy are an innocuous and low-cost therapeutic intervention with therapeutic effects in patients with knee arthroplasty (KA) and hip arthroplasty (HA), and this combination generates greater therapeutic effects in physical, functional, and cognitive variables than conventional physical therapy alone.

Post-operative rehabilitation using a digital healthcare system in patients who had undergone rotator cuff repair: protocol for a single-center randomized controlled trial

Background

Operative repair of a rotator cuff tear requires up to 12 weeks of post-operative (post-op) home-based rehabilitation. Maintaining patients’ compliance in the post-op rehabilitation program is a pivotal component for generating successful outcomes. By developing a post-op rehabilitation-oriented digital healthcare system and applying it in patients who had undergone rotator cuff repair, we aim to increase the efficacy of the rehabilitation program and raise patients’ compliance levels. Here, we present a protocol developed for comparing the efficacy of rehabilitation using a newly developed augmented reality (AR)-based digital healthcare system with that of conventional rehabilitation for post-op rehabilitation of rotator cuff repair.

Methods

This study will recruit a total of 115 patients who had undergone rotator cuff repair within 3 days after surgery. Patients will be randomly allocated to rehabilitation using an AR-based digital healthcare system (digital group) or conventional rehabilitation (conventional group). Patients in both groups will perform brochure-based exercises from the immediate post-op period to post-op 6 weeks. From post-op 6 weeks to 12 weeks, patients in the digital group will use the AR-based system for post-op exercises, whereas patients in the conventional group will continue brochure-based rehabilitation exercises. The primary outcome will be scores on the Simple Shoulder Test at post-op 12 weeks. Secondary outcomes include numeric rating scale scores for pain, measures of range of motion and muscle strength of the affected shoulder, grip strength of the affected arm, scores on the Disabilities of the Arm, Shoulder and Hand test, the Shoulder Pain and Disability Index, and the EuroQoL-5D-5L quality-of-life measure. Analyses will be conducted using an intention-to-treat approach.

Discussion

This study will examine the effectiveness of an AR-based digital healthcare system for post-op rehabilitation in the patients after rotator cuff repair. The study will add evidence for the application of digital healthcare systems in post-op rehabilitation.

Trial registration

ClinicalTrials.gov NCT04511377. Registered on 10 August 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06648-4.

"It's Not My Knee": Understanding Ongoing Pain and Discomfort After Total Knee Replacement Through Re-Embodiment

OBJECTIVE

Up to 20% of people who undergo total knee replacement surgery have ongoing pain and discomfort. The aim of this study was to understand what role the concepts of embodiment (of both having a body and experiencing the world through one's body) and incorporation (integrating something into one's body) might have in understanding experiences of pain and discomfort after total knee replacement.

METHODS

We conducted semistructured interviews with 34 people who had received total knee replacement at either of 2 National Health Service hospitals in the UK, and who had chronic postsurgical pain (n = 34, ages 55-93 years). Data were audiorecorded, transcribed, and analyzed thematically.

RESULTS

Two main themes were identified: 1) when describing chronic postsurgical pain, some participants also described sensations of discomfort, including heaviness, numbness, pressure, and tightness associated with the prosthesis; 2) participants reported a lack of felt connection with and agency over their replaced knee, often describing it as alien or other, and lacked confidence in the knee.

CONCLUSION

Participants' experiences indicate that some people do not achieve full incorporation of the prosthesis. Our study emphasizes the importance of physicians treating patients as whole people and moving beyond clinical and procedural ideas of success. Our findings suggest that to optimize postoperative outcomes, rehabilitation must focus not only on strengthening the joint and promoting full recovery to tasks but on modifying a person's relationship to the new joint and managing sensations of otherness to achieve full incorporation of the joint or re-embodiment.

Development and Trial of a Prototype Device for Sensorimotor Therapy in Patients with Distal Radius Fractures

This study examined the clinical feasibility of a prototype device (development name: Ghost) for facilitating range of motion (RoM) recovery in the acute phase in patients with distal radius fractures (DRF). The Ghost device involves the administration of a combination of vibratory and visual stimuli. We divided the patients into the Ghost (n = 10) and control group (n = 4; tendon vibration only) groups. The experimental interventions were administered between the day after surgery and day 7 postoperatively. Traditional hand therapy was provided to both groups once daily from day 7 until day 84 postoperatively and once a week from day 84 until the end of the intervention period. Because vibratory stimulation makes the patient focus on wrist flexion, the primary outcome was the arc of wrist flexion-extension on the injured side, which was measured on days 7, 14, 28, 42, 56, 70, and 84. Analysis of covariance was applied using a bootstrap method to evaluate changes over time and compare them between the groups. Analyses was performed after stratification by age and body mass index. Both interventions improved RoM over time in patients with DRF. Results showed that Ghost has greater efficacy for improving wrist RoM in DRF patients than vibration alone. Treatment with Ghost can result in good RoM improvement during the acute phase of DRF in young patients and those with and normal or low body mass index. Further study is needed to verify our findings and assess the extent of RoM recovery.

Effectiveness of Augmented Reality in Stroke Rehabilitation: A Meta-Analysis

Augmented reality (AR)-based rehabilitation shows potential to improve upper and lower limb function after stroke. This study aims to review the effect of AR technology in the recovery of the upper and lower limb function in stroke patients. Published randomized controlled trials and observational investigations with adult stroke patients were retrieved from five electronic databases to analyze the effect of the AR systems in improving motor function and balance and gait function for stroke patients. The treatment effect was estimated by standardized mean difference (SMD) and 95% confidence interval (CI) using a random effect model for motor function outcomes at the body structure and function, body activity and participation level of the International Classification of Functioning, and balance and gait outcomes. In total, 13 investigations (9 for the upper limb and 4 for the lower limb) were identified. AR demonstrated a significant influence on the upper limb function (SMD = 0.657; 95% CI, 0.287 to 1.026; p = 0.000) and the lower limb function (SMD = 0.52; 95% CI, 0.039 to 1.001; p = 0.034). The present analysis suggests that AR applications could offer options for increasing treatment intensity and promoting motor recovery after a stroke. This approach can be used with the conventional rehabilitation methods as a new intervention for recovering upper and lower limb function.

Effectiveness of motor imagery for improving functional performance after total knee arthroplasty: a systematic review with meta-analysis

Background

The aim of this study was to appraise the effects of motor imagery on the functional performance improvement among total knee arthroplasty patients systematically. We hypothesized a relatively greater recovery in the motor imagery group.

Methods

Medline (Ovid), Embase and Cochrane Controlled Register of Trials (CENTRAL) were searched from inception to October 1st, 2021. We included randomized controlled trials evaluating the effects of motor imagery on the functional recovery among total knee arthroplasty patients. Measurements included range of motion, strength intensity, Visual Analogue Scale, Time Up and Go Test, Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index, all of which were evaluated before and after intervention. Mean differences (MD) or standard mean differences (SMD) and 95% confidence intervals (CI) were calculated. The Cochrane risk of bias tool was used to assess the risk of bias.

Results

Six studies with 168 patients were included for the meta-analysis. The SMD of strength intensity was increased (SMD = 0.90, 95% CI = [0.47]–[1.32], P < 0.001). The SMD of Visual Analogue Scale was reduced (SMD =  − 0.91; 95% CI = [− 1.29]–[− 0.52], P < 0.001). The SMD of Time Up and Go Test was reduced (SMD =  − 0.56, 95% CI = [− 0.94]–[− 0.19], P = 0.003). The MD of Oxford Knee Score was slightly increased (MD = 0.79-point, 95% CI = [− 0.31]–[1.88], P = 0.159). The outcomes of range of motion, Western Ontario and McMaster Universities Osteoarthritis Index were described according to the original data.

Conclusion

Compared with control therapy, motor imagery in the intervention group achieved an effective treatment for strength enhancement, pain reduction and physical activities improvement. More large-scale, prospective researches are needed in the future.

Trial registration: The PROSPERO trial registration number is CRD42021250996.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-02946-4.

Using Virtual Reality Exposure Therapy in Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This study aimed to assess the effectiveness of virtual reality (VR) in managing different types of pain in different age groups and to provide evidence for the clinical application of new alternative strategy for pain management.

METHODS

Electronic databases, including the Cochrane Library, PubMed, EMBASE, and the Web of Science, were searched for studies published up to October 2020. Randomized controlled trials that reported on VR for pain management were included.

RESULTS

A total of 31 randomized controlled trials were included. As for the pain intensity, the increase of visual analog scale score in the VR group was 1.62 scores less than that in the control group. In juvenile patients, the VR group had 1.79 scores lower than that in control group. For adult patients, the VR group had 1.34 scores lower than that in control group. As for other pain-related indicators, the VR group had lower levels of anxiety, lower pain unpleasantness, lower pulse rate, and shorter duration of dressing change and spent less time thinking about pain. Nevertheless, there was no statistical difference in pain tolerance. VR can effectively alleviate acute pain. In terms of chronic low back pain and cancer-related pain, there was no statistical difference between VR therapy and standard therapy.

CONCLUSIONS

VR is a feasible alternative therapy for both juveniles and adults in pain management, and it has a greater potential for juveniles. VR can effectively alleviate acute pain. Nevertheless, VR showed little effectiveness in increasing pain tolerance, which may explain in part the ineffectiveness of VR therapy in pain management for chronic pain.

Virtual reality-based rehabilitation in patients following total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Physical therapy is regarded as an essential aspect in achieving optimal outcomes following total knee arthroplasty (TKA). The coronavirus disease 2019 (COVID-19) pandemic has made face-to-face rehabilitation inaccessible. Virtual reality (VR) is increasingly regarded as a potentially effective option for offering health care interventions. This systematic review and meta-analysis investigate VR-based rehabilitation's effectiveness on outcomes following TKA.

METHODS

From inception to May 22, 2021, PubMed/Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, Scopus, PsycINFO, Physiotherapy Evidence Database, China National Knowledge Infrastructure, and Wanfang were comprehensively searched to identify randomized controlled trials (RCTs) evaluating the effect of VR-based rehabilitation on patients following TKA according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Eight studies were included in the systematic review, and seven studies were included in the meta-analysis. VR-based rehabilitation significantly improved visual analog scale (VAS) scores within 1 month (standardized mean difference [SMD]: -0.44; 95% confidence interval [CI]: -0.79 to -0.08, P = 0.02), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) within 1 month (SMD: -0.71; 95% CI: -1.03 to -0.40, P < 0.01), and the Hospital for Special Surgery Knee Score (HSS) within 1 month and between 2 months and 3 months (MD: 7.62; 95% CI: 5.77 to 9.47, P < 0.01; MD: 10.15; 95% CI: 8.03 to 12.27, P < 0.01; respectively) following TKA compared to conventional rehabilitation. No significant difference was found in terms of the Timed Up and Go (TUG) test.

CONCLUSIONS

VR-based rehabilitation improved pain and function but not postural control following TKA compared to conventional rehabilitation. More high-quality RCTs are needed to prove the advantage of VR-based rehabilitation. As the COVID-19 pandemic continues, it is necessary to promote this rehabilitation model.

Impact of the COVID-19 pandemic on the trauma and orthopaedic department at level one Major Trauma Centre in the republic of Ireland

The Coronavirus Disease (COVID-19) has been identified as the cause of a rapidly spreading respira- tory illness in Wuhan, Hubei Province, China in early December 2019. Since then, the free movement of people has decreased. The trauma-related injuries and the demand on the trauma and orthopaedic service would be expected to fall. The aim of this study to examine the impact of the COVID-19 pandemic on a level 1 Trauma Centre in the Republic of Ireland (ROI). Patients admitted to the Trauma & Orthopaedic (T&O) Department at Cork University Hospital (CUH) and the South Infirmary Victoria University Hospital (SIVUH), and their associated fracture patterns and management, between 01/03/20 and the 15/04/20 were documented and compared to the patient admissions from the same time period one year earlier in 2019. The total number of T&O operations performed decreased by 10.15% (P= 0.03)between the two time periods. The number of paediatric procedures fell by 40.32% (P= 0.15). Adult Distal radius and paediatric elbow fractures (excluding supracondylar fracture) increased by 88% and 13% (P= 0.19), (P= 0.04) respectively. Hip fractures remained the most common fracture-type admitted for surgery. The COVID-19 crisis has to lead to a decrease in the total numbers of trauma surgeries in a major trauma centre in the ROI. This decline is most evident in the number of paediatric and male adult patients presenting with fractures requiring operative management. Interestingly, fractures directly related to solo outdoor activities, such as running or cycling, as well as simple mechanical falls like ankle, distal radius, elbow, and hand fractures all increased. Irish males were more compliant with outdoors restrictions than females.

[Effectiveness evaluation of the psychological support inclusion in the correction of pain syndrome in patients with movement disorders at the stage of medical rehabilitation using the virtual reality technology]

OBJECTIVE

Evaluation of the comparative effectiveness of various methods of psychological support in the correction of pain syndrome in patients with degenerative-dystrophic diseases of big joints and spine in the process of medical rehabilitation.

MATERIAL AND METHODS

In conditions of hospital, the 70 patients with degenerative-dystrophic diseases of the big joints and spine who received drug and non-drug treatment were examined. The dynamics of the psycho-emotional state, subjective assessment of well-being and pain was studied in three groups: the main group (24 patients) where the psycho-correction plan included classes with a medical psychologist using a high-tech VR tool - «Vive Focus Plus EEA virtual reality helmet». A comparison group (24 patients) who received a standard format of psychological support within the patient-centered approach. The control group (22 patients) where only psycho-diagnostic measures were carried out. The «Tamp Kinesiophobia Scale», «Visual Analogue Scale of Well-Being Evaluation», «McGill Pain Questionnaire» were used as diagnostic tools. When comparing the effects of the interventions the nociceptive or mixed nature of pain was taken into account.

RESULTS AND CONCLUSION

It has been shown that psychological support improves the effectiveness of pain therapy while the inclusion of a high-tech VR tool in psycho-correctional programs is expedient for overcoming the fear of movement and pain of neuropathic and mixed genesis but ineffective for relieving nociceptive pain, i.e. pain where there is no psychological component.

The Effectiveness of Virtual Reality Rehabilitation in Patients with Knee and Hip Osteoarthritis

Osteoarthritis (OA) is a common health problem leading to pain, limitation in physical function, a decrease in the quality of life and disability. OA affects 60-70% of the population above 65 years of age all over the world, and is associated with a high cost of healthcare. The main method of treatment of OA, apart from pharmacotherapy and surgery, is comprehensive rehabilitation. Advances in medical technology have resulted in the possibility of using computer-assisted interventions in rehabilitation. The present narrative review is aimed at investigating the effectiveness of virtual reality (VR) in the rehabilitation of elderly patients with knee or hip osteoarthritis, including patients after arthroplasty. This literature review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was carried out in five databases: PubMed, Medline, Web of Science, Scopus and PEDro. It includes ten randomized controlled trials focused on the application of games and biofeedback in the rehabilitation of patients with knee and hip osteoarthritis. There are no conclusive reports that interventions based on VR are more effective than standard physical therapy. Moreover, evidence regarding patients after total hip arthroplasty (THA) is very scarce. The effectiveness of VR-based rehabilitation is unclear, although interventions based on VR are promising in view of pain management, postural and proprioception training. However, this evidence is not sufficient to create clinical guidelines and further high-quality studies are needed.

The influence of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty

Our aim was to assess the effect of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty (TKA). We searched studies on the effect of perioperative interventions focused on psychological distress used in conjunction with TKA on pain, function, and quality of life (QoL) on PubMed, Embase.com, PsycINFO/OVID, CENTRAL, the Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We included 40 studies (22 RCTs, ten cohort studies, and eight quasi-experimental studies) with a total of 3846 patients. We graded the quality of evidence as low for pain and function and as moderate for QoL. Patients receiving music, education, cognitive behavioural therapy, guided imagery, pain coping skills training, Reiki, occupational therapy with self-monitoring, and biofeedback-assisted progressive muscles relaxing training had lower pain scores or declined opioid prescriptions after TKA. Pain coping skills training, audio recording-guided imagery scripts, video promoting self-confidence, psychological therapies by video, Reiki, music, occupational therapy with self-monitoring, education, and psychotherapy improved postoperative functional outcome. Education through an app improved QoL after TKA. The studies in our systematic review show that perioperative interventions targeting psychological distress for patients receiving TKA seem to have a positive effect on postoperative pain, function, and QoL. RCTs with strict methodological safeguards are still needed to determine if perioperative interventions focused on psychological distress should be used in conjunction with TKA. These studies should also assess which type of intervention will be most effective in improving patient-reported outcome measures and declining opioid prescriptions.

How the COVID-19 pandemic is affecting paediatric orthopaedics practice: a preliminary report

PURPOSE

Since the state of alarm was decreed in Spain on 14 March 2020, the coronavirus disease 2019 (COVID-19) pandemic has had an extraordinary impact in paediatric hospitals. This study shows the effect of the pandemic on our practice in paediatric orthopaedics in a referral third level paediatric hospital.

METHODS

We performed a single-centre retrospective review of the official census from a third level paediatric hospital from 14 March to 14 April for the years 2018, 2019 and 2020.

RESULTS

The patients seen in our clinic during this period in 2020 decreased in by 82% (p < 0.001) compared with 2018 and 2019, however, the number of telemedicine consultations increased by 90.21% (p < 0.001). The total number of patients attending the clinic (including onsite and virtual) was reduced by 54.25% (p < 0.001). The total surgeries performed plummeted by 81% in this period in 2020 (p < 0.001) due to a reduction in elective cases of 94.6% (p < 0.001). No significant decrease was found in the number of urgent surgical cases per day in 2020 (p = 0.34). Finally, the number of orthopaedic patients admitted to our emergency department dropped by 78.6% during the state of alarm (p < 0.001).

CONCLUSION

According to our results, the pandemic has significantly affected our daily practice by decreasing elective surgeries and onsite clinics, but other activities have increased. As we have implemented telemedicine and new technologies to adapt to this setback, we should take advantage of the situation to change our practice in the future to better allocate our health resources and to anticipate outbreaks.

Published without peer review.

LEVEL OF EVIDENCE

IV.

Recommendation to Optimize Safety of Elective Surgical Care While Limiting the Spread of COVID-19: Primum Non Nocere

COVID-19 has drastically altered our lives in an unprecedented manner, shuttering industries, and leaving most of the country in isolation as we adapt to the evolving crisis. Orthopedic surgery has not been spared from these effects, with the postponement of elective procedures in an attempt to mitigate disease transmission and preserve hospital resources as the pandemic continues to expand. During these turbulent times, it is crucial to understand that while patient and care-providers safety is paramount, canceling or postponing essential surgical care is not without consequences, and may be irreversibly detrimental to a patient's health and quality of life in some cases. The optimal solution of how to effectively balance the resumption of standard surgical care while doing everything possible to limit the spread of COVID-19 is undetermined, and could include strategies such as social distancing, screening forms and tests including temperature screening, segregation of inpatient and outpatient teams, proper use of protective gear, and the use of ambulatory surgery centers (ASCs) to provide elective, yet ultimately essential, surgical care while conserving resources and protecting the health of patients and health-care providers. Of importance, these recommendations do not and should not supersede evolving United States Centers for Disease Control and Prevention (CDC), and relevant federal, state and local public health guidelines. Level of Evidence: Level V.

Virtual reality in the correction of pain syndrome in patients with degenerative-dystrophic joints and spine diseases

Musculoskeletal system diseases require active motor rehabilitation, as a rule, but presence of severe pain syndrome might become a barrier, leading to the development of kinesiophobia and reducing motivation for treatment in patients. In recent decades, non-invasive methods of pain control, in particular virtual reality (VR) and augmented reality (AR) have been commonly used on a par with drug therapy. The purpose of this study is to provide a scientific base for the effectiveness of including a high-tech VR device (Vive Focus Plus EEA Virtual Reality Helmet), in to psychological rehabilitation of a pain syndrome in patients with chronic degenerative-dystrophic diseases of major joints and spine. The study involved 84 patients (24 men and 60 women aged 56±14.4) of a rehabilitation hospital with a severe pain syndrome and motor disorders corresponding to ICF Class 1 or 2. To analyse the characteristics of the subjective pain perception, the method of multidimensional semantic description based on the adapted Russian version of the McGill Pain Questionnaire was applied, and the Tampa Scale was used to kinesiophobia assessment. The VR technology was implemented via usage of the Vive Focus Plus EEA Virtual Reality Helmet tool (10 procedures). The effectiveness of using VR technology was evaluated through monitoring of pain dynamics and the kinesiophobia level prior to the study onset and at the end of hospitalization. As a result, the study has shown that there was no nosological specificity in the description of pain, or the differences in its verbal characteristics representing nociceptive and neuropathic components. Technology of ‘virtual immersion in 3D reality’ makes it possible to influence effectively on pathophysiological mechanisms links in the development of chronic psychologically determined, neuropathic and mixed-origin pain.

Effects of early virtual reality-based rehabilitation in patients with total knee arthroplasty: A randomized controlled trial

BACKGROUND

Virtual reality (VR)-based rehabilitation is a promising approach for improving recovery in many conditions to optimize functional results, enhancing the clinical and social benefits of surgery.

OBJECTIVE

To assess the efficacy of an early rehabilitation performed by the VR-based rehabilitation versus the traditional rehabilitation provided by physical therapists after primary total knee arthroplasty (TKA).

METHODS

In this randomized controlled clinical trial, 85 subjects met the inclusion criteria and were randomized 3 to 4 days after TKA to an inpatient VR-based rehabilitation and a traditional rehabilitation. Participants in both groups received 60 minutes/day sessions until discharge (around 10 days after surgery). The primary outcome was the pain intensity. The secondary outcomes were: the disability knee, the health related quality of life, the global perceived effect, the functional independent measure, the drugs assumption, the isometric strength of quadriceps and hamstrings, the flexion range of motion, and the ability to perform proprioception exercises. Outcomes were assessed at baseline (3-4 days after TKA) and at discharge.

RESULTS

VR-based or traditional rehabilitation, with 13% of dropout rate, shown no statistically significant pain reduction between groups (P = .2660) as well as in all other outcomes, whereas a statistically significant improvement was present in the global proprioception (P = .0020), in favor of the VR-based rehabilitation group.

CONCLUSIONS

VR-based rehabilitation is not superior to traditional rehabilitation in terms of pain relief, drugs assumptions and other functional outcomes but seems to improve the global proprioception for patients received TKA.

LEVEL OF EVIDENCE

Therapy, level 1b. CONSORT-compliant.

TRIAL REGISTRATION

http://www.clinicaltrials.gov, ClinicalTrials.gov, NCT02413996.

Body-Self Unity With a New Hip or Knee: Understanding Total Joint Replacement Within an Embodiment Framework

Medical research increasingly makes use of embodiment concepts to understand how illness disrupts unity of body and self. However, few have applied embodiment concepts in total joint replacement (TJR), an effective treatment for end‐stage arthritis. In considering why a troubling proportion of TJR recipients have continued pain and functional limitation, we ask: what role might be played by the embodied experience of living with an implant? Relevant theoretical models and prior research on embodiment in musculoskeletal health and transplantation are reviewed. Our findings suggest a research agenda with implications for addressing suboptimal outcomes in TJR.

Wrist Rehabilitation System Using Augmented Reality for Hemiplegic Stroke Patient Rehabilitation: A Feasibility Study

Objective: Our objective was to investigate the effect of the rehabilitation system using augmented reality (AR) on upper extremity motor performance of patients with stroke. Methods: The system using AR applying mirror therapy mechanism provides the intervention protocol for the patient with hemiplegia after stroke. The system consists of a patient positioning tool (a chair), a white surface table, an image acquisition unit, an image processing unit, an image displaying unit, an arm holder, a Velcro-strap, and two blue circle stickers. To assess the feasibility of our system in motor function recovery, a stroke patient was recruited to receive the AR intervention. The treatment was performed two times a day for ten minutes over two weeks (ten days of treating weeks), except for the time of installation, calibration, and three minute breaks. Jebsen Taylor hand function test and Arm Motor Fugl-Meyer assessment were used as primary and secondary outcome measures, respectively, to evaluate the effect of motor function recovery. Additionally, stroke impact scale, Korean version-Modified Barthel Index (K-MBI), active range of motion of wrist joint (ROM), and the grasp force in Newtons were measured. Participants’ feedback and adverse effects were recorded as well. Results: Motor function improvements were exhibited in wrist and hand subtest of Arm Motor Fugl-Meyer (baseline: 19; post-intervention: 23), proximal arm subtest of Fugl-Meyer (baseline: 31; post-intervention: 34), ROM (extending ROM: 10° and 3° for flexion and extension, repeatedly), stroke impact scale (baseline: 46; post-intervention: 54), K-MBI (baseline: 92; post-intervention: 95), nine-hole pegboard (baseline: 30 s; post-intervention: 25 s), and grasp force in Newtons (baseline: 12.7; post-intervention: 17.7). However, the adverse effects were reported after the intervention. Conclusion: The system using AR applying mirror therapy mechanism demonstrated the feasibility in motor function recovery for the stroke patient.

A Scoping Review of The Efficacy of Virtual Reality and Exergaming on Patients of Musculoskeletal System Disorder

To assess the effects of virtual reality on patients with musculoskeletal disorders by means of a scoping review of randomized controlled trials (RCTs). The databases included PubMed, IEEE, and the MEDLINE database. Articles involving RCTs with higher than five points on the Physiotherapy Evidence Database (PEDro) scale were reviewed for suitability and inclusion. The methodological quality of the included RCT was evaluated using the PEDro scale. The three reviewers extracted relevant information from the included studies. Fourteen RCT articles were included. When compared with simple usual care or other forms of treatment, there was significant pain relief, increased functional capacity, reduced symptoms of the disorder, and increased joint angles for the virtual reality treatment of chronic musculoskeletal disorders. Furthermore, burn patients with acute pain were able to experience a significant therapeutic effect on pain relief. However, virtual reality treatment of patients with non-chronic pain such as total knee replacement, ankle sprains, as well as those who went through very short virtual reality treatments, did not show a significant difference in parameters, as compared with simple usual care and other forms of treatment. Current evidence supports VR treatment as having a significant effect on pain relief, increased joint mobility, or motor function of patients with chronic musculoskeletal disorders. VR seems quite effective in relieving the pain of patients with acute burns as well.

Effects of Enhanced Recovery After Surgery in Total Knee Arthroplasty for Patients Older Than 65 Years

OBJECTIVES

To explore the safety and efficacy of the enhanced recovery after surgery (ERAS) program for elderly total knee arthroplasty (TKA) patients.

METHODS

A prospective controlled study was conducted for patients older than 65 years, who would undergo unilateral TKA with a minimum follow-up of 2 years. Patients were divided into an ERAS group (n = 106) and a traditional group (n = 141) based on the patients' willingness to participate in the ERAS program. Baseline parameters of American Society of Anesthesiologists classification and comorbidity were recorded. Complication, mortality, knee function assessment using knee society score and knee range of motion, and perioperative clinical outcomes were compared between the two groups.

RESULTS

There were no significant differences between the two groups in terms of baseline parameters. Although no significant differences were found in postoperative nausea and vomiting, urinary tract infection, deep venous thrombosis, pulmonary embolism, wound delayed healing, superficial infection, and deep infection, there were significantly fewer total complications in the ERAS group (26/106 vs 52/141; P = 0.039). No significant difference was found in short-term mortality (1/106 vs 3/141; P = 0.836) between the two groups. There were no significant differences in preoperative visual analogue scale (VAS), knee society score (KSS), and range of motion (ROM) between the two groups. Lower VAS scores were found in the ERAS group at time of postoperative day (POD) 1 (P = 0.012) and POD 5 (P = 0.020); no significant differences were observed at time of postoperative month (POM) 1 and final follow-up. Higher KSS scores were found in the ERAS group at time of POD 1 (P = 0.013), and POD 5 (P = 0.011), no significant differences were observed at time of POM 1 and final follow-up. Increased ROM degree was found in the ERAS group at time of POD 1 (P = 0.021); no significant differences were observed at time of POD 5, POM 1 and final follow-up. Decreased intraoperative blood loss (P < 0.001), total blood loss (P < 0.001), transfusion rate (P = 0.004), and length of stay (P < 0.001) were found in the ERAS group; no significant differences were found in operative time and hospitalization costs between the two groups.

CONCLUSION

The ERAS program is safer and more efficacious in elderly TKA patients compared to the traditional pathway. It could effectively relieve perioperative pain and improve joint function, and reduce blood transfusion, length of stay, and total complications without increasing short-term mortality.