The State of Science in the Use of Virtual Reality in the Treatment of Acute and Chronic Pain: A Systematic Scoping Review

Effectiveness of Virtual Reality Technology in Symptom Management of Patients at the end of life: A Systematic Review and Meta-Analysis

OBJECTIVES

The objective of this review was to explore the effectiveness of virtual reality (VR) technology in symptom management of patients at the end of life.

DESIGN

This is a systematic review and meta-analysis, which has been registered on PROSPERO (CRD42022344679).

SETTING AND PARTICIPANTS

Patients at the end of life.

METHODS

PubMed, Embase, Web of Science, the Cochrane Library, JBI, EBSCO, CNKI, Wanfang, and SinoMed were searched from inception to July 31, 2023. Search terms included "virtual reality" and "end-of-life." Articles were screened according to the inclusion and exclusion criteria. The random effects model was used to calculate the standardized mean difference (SMD), and the fixed effects model was used to calculate the mean difference (MD). The Cochrane Risk of Bias Tool 2.0 and JBI Evaluation tool were used to assess the risk of bias. The I2 statistic was used to measure heterogeneity between studies. Forest plots were used for analysis.

RESULTS

A total of 234 patients at the end of life from 3 randomized controlled trials and 6 quasi-experimental studies were included. Compared with pre-VR intervention, the pain [standardized mean difference (SMD) -0.89, 95% CI -1.29 to -0.48, P < .05], shortness of breath [mean difference (MD) -0.98, 95% CI -0.98-0.51, P < .05], depression (MD -0.62, 95% CI -0.85 to -0.40, P < .05), and anxiety (SMD -0.93, 95% CI -1.50 to 0.36, P < .05) of patients at the end of life was significantly improved after VR intervention. However, there were no significant differences observed in tiredness, drowsiness, nausea, and lack of appetite.

CONCLUSIONS AND IMPLICATIONS

VR technology can be effective in improving pain, shortness of breath, depression, and anxiety in patients at the end of life. For tiredness, drowsiness, nausea, and lack of appetite, further research is required.

The Role of Virtual Reality and Artificial Intelligence in Cognitive Pain Therapy: A Narrative Review

PURPOSE OF REVIEW

This review investigates the roles of artificial intelligence (AI) and virtual reality (VR) in enhancing cognitive pain therapy for chronic pain management. The work assesses current research, outlines benefits and limitations and examines their potential integration into existing pain management methods.

RECENT FINDINGS

Advances in VR have shown promise in chronic pain management through immersive cognitive therapy exercises, with evidence supporting VR's effectiveness in symptom reduction. AI's personalization of treatment plans and its support for mental health through AI-driven avatars are emerging trends. The integration of AI in hybrid programs indicates a future with real-time adaptive technology tailored to individual needs in chronic pain management. Incorporating AI and VR into chronic pain cognitive therapy represents a promising approach to enhance management by leveraging VR's immersive experiences and AI's personalized tactics, aiming to improve patient engagement and outcomes. Nonetheless, further empirical studies are needed to standardized methodologies, compare these technologies to traditional therapies and fully realize their clinical potential.

Virtual reality facilitated exercise improves pain perception: A crossover study

STUDY OBJECTIVE

Both virtual reality (VR) and exercise are recognized for their analgesic and anxiolytic properties. The purpose of this study is to evaluate the ability of VR-facilitated exercise to modulate pain.

DESIGN

Within-subject cross-over clinical trial.

SETTING

The Stanford Chariot Program conducted this study at Lucile Packard Children's Hospital Stanford (LCPHS).

PATIENTS

Healthy participants meeting inclusion criteria were recruited by volunteer solicitation from LCPHS.

INTERVENTIONS

Participants were randomized by hand dominance and subjected to a standardized cold pressor test with no VR or exercise. After a 5-min wash-out period, participants repeated the test on their other hand while experiencing a VR-facilitated exercise condition. Pain sensitivity, pain tolerance, and sympathetic activation data were collected during both conditions.

MEASUREMENTS

Pain sensitivity was scored 0-10 and collected every 30 s. Pain tolerance was recorded as the duration a participant could endure the painful stimuli. Sympathetic activation was measured by skin conductance response density (SCRD) and recorded in 30 s epochs by a biosensor. In all analyses, data were nested by participant.

MAIN RESULTS

Forty-one participants completed both interventions. Pain sensitivity was reduced in the VR-facilitated exercise condition (p < 0.0001). There was no difference in pain tolerance between conditions. While both conditions resulted in an increase in sympathetic activity, SCRD was higher at all time points in the VR-facilitated exercise condition.

CONCLUSIONS

The reduction in pain sensitivity indicates VR-facilitated exercise results in improved pain perception. VR-facilitated exercise may be especially useful for patients with chronic pain or other conditions requiring physical therapy, where pain may be exacerbated by exercise.

Use of Virtual Reality in Interdisciplinary Multimodal Pain Treatment With Insights From Health Care Professionals and Patients: Action Research Study

BACKGROUND

Chronic pain is a widespread global health problem. Interdisciplinary multimodal pain treatment (IMPT) is a treatment option for people with chronic pain. Virtual reality (VR) could be used to broaden IMPT programs. However, despite the advantages of VR, it is rarely used in daily clinical practice.

OBJECTIVE

This research aimed to explore how, when, and with whom VR can be used meaningfully during IMPT, either as an addition or substitution as a component of IMPT.

METHODS

This research used an action research design to help health care professionals and patients learn how, when, and with whom they can use VR. Data were collected through reflection sessions with health care professionals and semistructured interviews with patients in 2 specialized centers that provide IMPT for chronic pain. Two researchers performed direct content analyses.

RESULTS

In total, 4 physiotherapists, 1 occupational therapist, 3 psychologists, and 22 patients participated in this research. Three iteration cycles, including 9 reflection sessions and 8 semistructured interviews, were performed. Both health care professionals and patients considered VR to be useful in therapy as an addition but not a substitution. VR was used as a diagnostic and intervention tool with all patients at the rehabilitation center or home. VR was used to gain insight into patients' pain beliefs, cognitions, and irrational cognitions about additional damage and physical abilities. Considering VR as an intervention tool, the health care professionals had 3 goals: balancing relaxation and competition, grading activities, and exposure in vivo.

CONCLUSIONS

VR could be a valuable addition to IMPT for both patients with chronic pain and health care professionals. More research should be performed to assess the additional effects of VR on patients' participation in daily life.

Sensorimotor Uncertainty of Immersive Virtual Reality Environments for People in Pain: Scoping Review

INTRODUCTION

Decision making and action execution both rely on sensory information, and their primary objective is to minimise uncertainty. Virtual reality (VR) introduces uncertainty due to the imprecision of perceptual information. The concept of "sensorimotor uncertainty" is a pivotal element in the interplay between perception and action within the VR environment. The role of immersive VR in the four stages of motor behaviour decision making in people with pain has been previously discussed. These four processing levels are the basis to understand the uncertainty that a patient experiences when using VR: sensory information, current state, transition rules, and the outcome obtained.

METHODS

This review examines the different types of uncertainty that a patient may experience when they are immersed in a virtual reality environment in a context of pain. Randomised clinical trials, a secondary analysis of randomised clinical trials, and pilot randomised clinical trials related to the scope of Sensorimotor Uncertainty in Immersive Virtual Reality were included after searching.

RESULTS

Fifty studies were included in this review. They were divided into four categories regarding the type of uncertainty the intervention created and the stage of the decision-making model.

CONCLUSIONS

Immersive virtual reality makes it possible to alter sensorimotor uncertainty, but studies of higher methodological quality are needed on this topic, as well as an exploration into the patient profile for pain management using immersive VR.

Virtual Reality-Based Exercise Therapy for Patients with Chronic Musculoskeletal Pain: A Scoping Review

This scoping review aimed to identify interventions utilizing virtual-reality-based exercise therapy in patients with chronic musculoskeletal pain. Searches were conducted in four databases using descriptors related to virtual reality, exercise, and chronic musculoskeletal pain. Two reviewers screened the titles and abstracts of the studies to assess eligibility, with a third author resolving any discrepancies. Data were extracted and summarized in a narrative format by three independent raters. Clinical trials were evaluated using the PEDro scale to assess the effectiveness of virtual-reality-based exercise therapy in chronic musculoskeletal pain patients. A total of 162 articles were identified from the databases. After applying the inclusion criteria, nine articles were considered suitable for analysis, including six randomized clinical trials. The selected articles were categorized based on study characteristics, virtual-reality-based exercise therapy interventions (including technologies and equipment used), exercise interventions, outcome measures, and effectiveness. The findings indicate that virtual-reality-based exercise therapy shows promising results in reducing pain, improving disability, enhancing range of motion, and increasing treatment satisfaction in patients with chronic musculoskeletal pain. However, it is not possible to conclude that virtual-reality-based exercise therapy is superior to other treatments due to the limited number of available studies, heterogeneity in application protocols, and varying methodological quality. Further research is needed to draw more definitive conclusions.

Improving Adherence to a Home Rehabilitation Plan for Chronic Neck Pain through Immersive Virtual Reality: A Case Report

Idiopathic chronic neck pain is a highly disabling musculoskeletal condition. Immersive virtual reality shows a promising efficacy in the treatment of chronic cervical pain through the mechanism of distraction from the pain. This case report describes the management of C.F., a fifty-seven-year-old woman, who suffered from neck pain for fifteen months. She had already undergone a cycle of physiotherapy treatments including education, manual therapy, and exercises, following international guidelines. The patient's poor compliance did not allow adherence to the exercise's prescription. Home exercise training through virtual reality was therefore proposed to the patient to improve her adherence to the treatment plan. The personalization of the treatment allowed the patient to resolve in a short time period her problem and return to live with her family peacefully.

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).

The Feasibility and Effectiveness of Virtual Reality Meditation on Reducing Chronic Pain for Older Adults with Knee Osteoarthritis

There is an urgent need for safe and effective non-pharmacologic approaches to treat chronic knee pain in older adults. Although virtual reality (VR) has shown some effectiveness for acute pain, there is limited evidence on the effects of VR on chronic pain particularly with older adult populations. This single application, within-subject pilot study evaluated the feasibility and effectiveness of VR as a clinical treatment for older adults with chronic osteoarthritis knee pain. Nineteen participants aged 60+ years old participated in a 10-minute VR meditation program. Data on pain and affect were collected immediately prior to, post, and 24-48 hours after the VR. Results suggest that VR meditation had significant moderate-large analgesic effects on knee pain intensity, primarily during VR (d = 1.10) and post VR (d = .99), with some lasting effects into next day (d = .58). The findings also suggest VR meditation intervention had a positive effect on affect, with a significant large decrease in negative affect scores pre to post VR (d = 1.14). The significant moderate to large decreases in pain interference for normal work (d = .71), mood (d = .53), sleep (d = .67), and enjoyment of life (d = .72) suggest that older adults may have a higher ability to participate in meaningful daily activities up to 24-48 hours after VR meditation. VR appears to be a feasible and effective nonpharmacological tool for older adults to treat chronic overall & knee-specific pain.