Virtual reality in pain therapy: a requirements analysis for older adults with chronic back pain

Perspectives and Experiences on eHealth Solutions for Coping With Chronic Pain: Qualitative Study Among Older People Living With Chronic Pain

BACKGROUND

Chronic noncancer pain (CNCP) is a major health issue among the older population, affecting multiple aspects of individual functioning. Recently, the use of eHealth solutions has been proposed in supporting chronic pain self-management even among older adults, although some barriers have emerged. Few qualitative studies, with none conducted in Mediterranean countries, have explored older people's experiences and perceptions regarding the types of strategies used to cope with chronic pain and eHealth tools for chronic pain management.

OBJECTIVE

This study's objectives were to explore the perspectives and experiences of older adults regarding the coping strategies used to manage chronic pain, the use of digital technologies in everyday life, and the potentiality and barriers in using those technologies for health and pain management.

METHODS

A multimethod approach (ie, self-report questionnaires and a semistructured interview) has been adopted targeting older adults (ie, those who are aged 65 to 80 years and presenting different types of CNCP) who are attending a pain therapy center in Italy. Qualitative answers were analyzed using thematic analysis.

RESULTS

Overall, participants reported using a variety of pain coping strategies; however, they showed an attitude of resignation to their CNCP condition. Nearly 70% (12/18) of the interviewees referred to using digital technologies for purposes related to health and pain management, mostly involving very basic management activities. The participants' opinions on the useful functions that need to be incorporated in eHealth tools for chronic pain management have been categorized into four themes: (1) specific pain self-management skills, (2) support in organizing various health-related aspects, (3) sharing experiences with others, and (4) increasing pain-related personal knowledge. Conversely, the following potential barriers to adopting eHealth tools emerged: (1) computer illiteracy, (2) negative effects or risks, (3) impersonal interaction, and (4) physical limitations.

CONCLUSIONS

The use of eHealth solutions still seems low, often being accompanied by a perceived lack of digital skills or attitude among a sample of older adults from Italy with CNCP. Before introducing innovative eHealth solutions, it would be of primary importance to take action to enhance, on the one hand, self-efficacy in pain management and, on the other, the digital literacy level among older people.

Immersive and Nonimmersive Virtual Reality-Assisted Active Training in Chronic Musculoskeletal Pain: Systematic Review and Meta-Analysis

BACKGROUND

Virtual reality (VR) in different immersive conditions has been increasingly used as a nonpharmacological method for managing chronic musculoskeletal pain.

OBJECTIVE

We aimed to assess the effectiveness of VR-assisted active training versus conventional exercise or physiotherapy in chronic musculoskeletal pain and to analyze the effects of immersive versus nonimmersive VR on pain outcomes.

METHODS

This systematic review of randomized control trials (RCTs) searched PubMed, Scopus, and Web of Science databases from inception to June 9, 2024. RCTs comparing adults with chronic musculoskeletal pain receiving VR-assisted training were included. The primary outcome was pain intensity; secondary outcomes included functional disability and kinesiophobia. Available data were pooled in a meta-analysis. Studies were graded using the Cochrane Risk-of-Bias Tool version 2.

RESULTS

In total, 28 RCTs including 1114 participants with some concerns for a high risk of bias were identified, and 25 RCTs were included in the meta-analysis. In low back pain, short-term outcomes measured post intervention showed that nonimmersive VR is effective in reducing pain (standardized mean difference [SMD] -1.79, 95% CI -2.72 to -0.87; P<.001), improving disability (SMD -0.44, 95% CI -0.72 to -0.16; P=.002), and kinesiophobia (SMD -2.94, 95% CI -5.20 to -0.68; P=.01). Intermediate-term outcomes measured at 6 months also showed that nonimmersive VR is effective in reducing pain (SMD -8.15, 95% CI -15.29 to -1.01; P=.03), and kinesiophobia (SMD -4.28, 95% CI -8.12 to -0.44; P=.03) compared to conventional active training. For neck pain, immersive VR reduced pain intensity (SMD -0.55, 95% CI -1.02 to -0.08; P=.02) but not disability and kinesiophobia in the short term. No statistical significances were detected for knee pain or other pain regions at all time points. In addition, 2 (8%) studies had a high risk of bias.

CONCLUSIONS

Both nonimmersive and immersive VR-assisted active training is effective in reducing back and neck pain symptoms. Our study findings suggest that VR is effective in alleviating chronic musculoskeletal pain.

TRIAL REGISTRATION

PROSPERO CRD42022302912; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=302912.

eHealth-Integrated Psychosocial and Physical Interventions for Chronic Pain in Older Adults: Scoping Review

BACKGROUND

Chronic noncancer pain (CNCP) is highly present among older adults, affecting their physical, psychological, and social functioning. A biopsychosocial multimodal approach to CNCP management is currently extensively suggested by international clinical practice guidelines. Recently, the growing development and application of eHealth within pain management has yielded encouraging results in terms of effectiveness and feasibility; however, its use among the older population remains underexamined.

OBJECTIVE

The overall aim of this scoping review was to systematically map existing literature about eHealth multimodal interventions (including both physical and psychosocial components) targeting older adults with CNCP.

METHODS

This review adhered to the JBI methodology, a protocol was a priori registered as a preprint on the medRxiv platform, and the results were reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Four electronic databases (PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and PsycINFO) were systematically searched for relevant articles. Studies were included if they reported on multimodal interventions (including both physical and psychosocial components) delivered through any eHealth modality to an older population with any type of CNCP. Two reviewers selected the studies: first by screening titles and abstracts and second by screening full-text articles. The quality of the included studies was evaluated using the Quality Assessment Tool for Studies with Diverse Designs. The results of the studies were summarized narratively.

RESULTS

A total of 9 studies (n=6, 67% published between 2021 and 2023) with quality rated as medium to high were included, of which 7 (78%) were randomized controlled trials (n=5, 71% were pilot and feasibility studies). All the included studies evaluated self-management interventions, most of them (n=7, 78%) specifically designed for older adults. The participants were aged between 65 and 75 years on average (mean 68.5, SD 3.5 y) and had been diagnosed with different types of CNCP (eg, osteoarthritis and chronic low back pain). Most of the included studies (5/9, 56%) involved the use of multiple eHealth modalities, with a higher use of web-based programs and video consulting. Only 1 (11%) of the 9 studies involved a virtual reality-based intervention. The evaluated interventions showed signs of effectiveness in the targeted biopsychosocial outcomes, and the participants' engagement and ratings of satisfaction were generally positive. However, several research gaps were identified and discussed.

CONCLUSIONS

Overall, of late, there has been a growing interest in the potential that eHealth multimodal interventions offer in terms of improving pain, physical, and psychosocial outcomes in older adults with CNCP. However, existing literature on this topic still seems scarce and highly heterogeneous, with few proper randomized controlled trials, precluding robust conclusions. Several gaps emerged in terms of the older population considered and the lack of evaluation of comorbidities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1101/2023.07.27.23293235.

Acceptability and feasibility of virtual reality to promote health literacy in primary care from the health professional's view: A qualitative study

OBJECTIVE

The development of health literacy is important in the management of chronic pain and virtual reality may be an effective medium for its development. This study aims to understand the usability and acceptability of a virtual reality-based pain education system for the facilitation of health literacy.

METHODS

Semi-structured interviews were conducted with health professionals who had used a VR-based pain education system within their clinical practice, to explore perceptions of feasibility. Data collection and analyses were informed by the Unified Theory of Acceptance and Use of Technology and the Integrated Model of Health Literacy.

RESULTS

From 10 participants, the VR-based system was considered feasible in providing immersive experiential learning which addressed patient understanding and health-related communication.

CONCLUSION

VR appears to be perceived as an acceptable and feasible technology to support the development of health literacy in people with chronic pain. Its largest perceived benefit was its capacity to provide an immersive and entertaining alternative to conventional methods of pain education.

PRACTICE IMPLICATIONS

Virtual reality is considered as a feasible method of facilitating patient understanding and health-related communication related to chronic pain. Feasibility of such a tool relies clinically on time available, social expectations of VR, and the role of immersive and experiential learning within the management of chronic pain.

Experiences of physiotherapists considering virtual reality for shoulder rehabilitation: A focus group study

Introduction

Shoulder pain is common and associated with substantial morbidity. Different treatment strategies are being prescribed with equivocal results. Virtual reality (VR) is a novel technology and emerging research suggests that VR may be a promising alternative to current treatments. Prior to effectiveness research or any large-scale introduction, VR-applications require appropriate scrutiny including feasibility- and acceptability of clinicians and patients. Therefore, the aim of this study was to collect experiences of physiotherapists after using immersive VR.

Methods

A qualitative interpretive design was used to explore physiotherapists' experiences related to the use of VR for people with shoulder symptoms. 17 physiotherapists were asked to use VR at home for five days prior to a focus group interview. Data from the focus group interviews were analyzed using a six-phase process of thematic analysis.

Results

Three main themes were identified, each divided into subthemes. The main themes were: 1. VR as an extension of contemporary physiotherapy care: physiotherapists were positive about the potential of VR and its applicability in daily care. 2. Physiotherapist uncertainties of future care using VR: participants expressed concerns about their professional identity, particularly as patients engage in independent home exercises. 3. Physiotherapist's requirements for implementation of VR: participants shared their needs for evidence regarding the effectiveness and parameters such as frequency, dosage and intensity of the VR intervention.

Conclusion

Physiotherapists were positive about VR as an intervention tool. However, they felt more knowledge is needed about parameters of VR. The findings of this study inform researchers and technology developers about optimal design of interventions and applications using VR.

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.

Research Status and Emerging Trends in Virtual Reality Rehabilitation: Bibliometric and Knowledge Graph Study

BACKGROUND

Virtual reality (VR) technology has been widely used in rehabilitation training because of its immersive, interactive, and imaginative features. A comprehensive bibliometric review is required to help researchers focus on future directions based on the new definitions of VR technologies in rehabilitation, which reveal new situations and requirements.

OBJECTIVE

Herein, we aimed to summarize effective research methods for and potential innovative approaches to VR rehabilitation by evaluating publications from various countries to encourage research on efficient strategies to improve VR rehabilitation.

METHODS

The SCIE (Science Citation Index Expanded) database was searched on January 20, 2022, for publications related to the application of VR technology in rehabilitation research. We found 1617 papers, and we created a clustered network, using the 46,116 references cited in the papers. CiteSpace V (Drexel University) and VOSviewer (Leiden University) were used to identify countries, institutions, journals, keywords, cocited references, and research hot spots.

RESULTS

A total of 63 countries and 1921 institutes have contributed publications. The United States of America has taken the leading position in this field; it has the highest number of publications; the highest h-index; and the largest collaborative network, which includes other countries. The reference clusters of SCIE papers were divided into the following nine categories: kinematics, neurorehabilitation, brain injury, exergames, aging, motor rehabilitation, mobility, cerebral palsy, and exercise intensity. The research frontiers were represented by the following keywords: video games (2017-2021), and young adults (2018-2021).

CONCLUSIONS

Our study comprehensively assesses the current research state of VR rehabilitation and analyzes the current research hot spots and future trends in the field, with the aims of providing resources for more intensive investigation and encouraging more researchers to further develop VR rehabilitation.

A Systematic Review and Meta-Analysis of the Effectiveness of Virtual Reality-Based Rehabilitation Therapy on Reducing the Degree of Pain Experienced by Individuals with Low Back Pain

BACKGROUND

The concept of virtual reality (VR)-based rehabilitation therapy for treating people with low back pain is of growing research interest. However, the effectiveness of such therapy for pain reduction in clinical settings remains controversial.

METHODS

The present study was conducted according to the reporting guidelines presented in the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. We searched the PubMed, Embase, CENTRAL, and ProQuest databases for both published and unpublished papers. The Cochrane risk of bias tool (version 2) was used to evaluate the quality of the selected studies. GRADEprofiler software (version 3.6.4) was used to evaluate the level of evidence. We analyzed the included research results using RevMan software (version 5.4.1).

RESULTS

We included a total of 11 articles in the systematic review and meta-analysis, with a total of 1761 subjects. Having assessed the quality of these studies, the risk of bias was generally low with high heterogeneity. The results revealed a small to medium effect (standardized mean difference = ±0.37, 95% confidence interval: 0.75 to 0) based on evidence of moderate overall quality.

CONCLUSION

There is evidence that treatment using VR improves patients' pain. The effect size was small to medium, with the studies presenting evidence of moderate overall quality. VR-based treatment can reduce pain; therefore, it may help in rehabilitation therapy.

Gamification in Musculoskeletal Rehabilitation

PURPOSE OF REVIEW

This study is a narrative review aiming at evaluating the current literature of the last 5 years on gamification and musculoskeletal rehabilitation. The article search involved the following MeSH terms at PubMed: "gamification," "exergaming," and "rehabilitation." Original studies in English language were included.

RECENT FINDINGS

After careful analysis of the search results, 17 articles were included in this review. The use of games for rehabilitation was investigated in musculoskeletal rehabilitation conditions such as shoulder surgery, impingement syndrome, rheumatoid arthritis, osteoarthritis, low back pain, fibromyalgia, fracture, and ligament reconstruction. Results were similar or superior to conventional physical therapy or home-based exercises, with the additional benefit of improving motivation to the exercise program. Improvements in quality of life and perceived health status were also observed. The cost-effectiveness of this type of technology was also mentioned as an advantage of exergames in musculoskeletal rehabilitation. Studies involving gamification in musculoskeletal rehabilitation stress the potential of this resource in several aspects of physical fitness, health, and quality of life, also improving motivation and adherence to the exercise treatment.

Effects of an 8-Week Virtual Reality Training Program on Pain, Fall Risk, and Quality of Life in Elderly Women with Chronic Low Back Pain: Double-Blind Randomized Clinical Trial

Objective: Low back pain (LBP) and falls are among the major problems experienced by the elderly population. The present study investigated the effectiveness of an 8-week virtual reality training (VRT) program in helping relieve pain, minimize fall risk, and improve quality of life (QoL) in elderly women suffering from chronic LBP (CLBP). Materials and Methods: Twenty-five elderly women (VRT/intervention group = 13, control group = 12) with CLBP and aged 65 to 75 years were recruited. The VRT involved three 30-minute weekly sessions of exercises that were carried out using the Xbox Kinect headset. Pain intensity, fall risk, and QoL were assessed via the Visual Analog Scale, the Biodex Balance System, and the 36-Item Short Form Health Survey, respectively. Results: The outcomes of a one-way analysis of covariance indicated that the pain intensity score of the intervention group significantly decreased after participation in the VRT program (P = 0.001). The intervention group also showed reduced fall risk (P = 0.001) and elevated QoL (P = 0.001). Conclusion: The results confirmed that the VRT program can be regarded as a valid therapeutic intervention that helps reduce patients' symptoms and increase the effectiveness of exercises in the elderly by teaching pain-related insight as well as enhancing QoL and reduce fall risk through various movements.

Virtual Reality Aided Therapy towards Health 4.0: A Two-Decade Bibliometric Analysis

Health 4.0 aligns with Industry 4.0 and encourages the application of the latest technologies to healthcare. Virtual reality (VR) is a potentially significant component of the Health 4.0 vision. Though VR in health care is a popular topic, there is little knowledge of VR-aided therapy from a macro perspective. Therefore, this paper was aimed to explore the research of VR in aiding therapy, thus providing a potential guideline for futures application of therapeutic VR in healthcare towards Health 4.0. A mixed research method was adopted for this research, which comprised the use of a bibliometric analysis (a quantitative method) to conduct a macro overview of VR-aided therapy, the identification of significant research structures and topics, and a qualitative review of the literature to reveal deeper insights. Four major research areas of VR-aided therapy were identified and investigated, i.e., post-traumatic stress disorder (PTSD), anxiety and fear related disorder (A&F), diseases of the nervous system (DNS), and pain management, including related medical conditions, therapies, methods, and outcomes. This study is the first to use VOSviewer, a commonly used software tool for constructing and visualizing bibliometric networks and developed by Center for Science and Technology Studies, Leiden University, the Netherlands, to conduct bibliometric analyses on VR-aided therapy from the perspective of Web of Science core collection (WoSc), which objectively and visually shows research structures and topics, therefore offering instructive insights for health care stakeholders (particularly researchers and service providers) such as including integrating more innovative therapies, emphasizing psychological benefits, using game elements, and introducing design research. The results of this paper facilitate with achieving the vision of Health 4.0 and illustrating a two-decade (2000 to year 2020) map of pre-life of the Health Metaverse.

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

Immersive Virtual Reality (VR) with head-mounted displays (HMD) can be a promising tool for increasing adherence to exercise in older adults. However, there is little known about the effectiveness of an interactive multimodal therapy in VR for older chronic back pain (CBP) patients. The aim of the exploratory randomized controlled trial was to examine the preliminary effectiveness of a VR multimodal therapy for older adults with CBP in a laboratory setting over a period of four weeks. The intervention group (IG; n = 11) received a multimodal pain therapy in VR (movement therapy and psychoeducation) and the control group (CG; n = 11) received a conventional multimodal pain therapy (chair-based group exercises and psychoeducation in a group setting). Although the VR therapy (IG) did not reach the pain intensity reduction of the CG (IG: MD = 0.64, p = .535; CG: MD = 1.64, p = .07), both groups showed a reduction in pain intensity on the Numeric Rating Scale. The functional capacity in the IG improved from Visit 1, x ¯ = 73.11% to Visit 2, x ¯ = 81.82% (MD = 8.71%; p = .026). In the changes of fear avoidance beliefs and general physical and mental health, no significance was achieved in either group. Although the IG did not reach a significant pain intensity reduction compared to the CG, the results of the present study showed that a pain intensity reduction can be achieved with the current VR application.