The Effects of VR-based Wii Fit Yoga on Physical Function in Middle-aged Female LBP Patients

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.

Virtual Reality-Based Training in Chronic Low Back Pain: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Low back pain is one of the most prevalent pain conditions worldwide. Virtual reality-based training has been used for low back pain as a new treatment strategy. Present evidence indicated that the effectiveness of virtual reality-based training for people with chronic low back pain is inconclusive.

OBJECTIVE

This study conducted a meta-analysis to evaluate the immediate- and short-term effects of virtual reality-based training on pain, pain-related fear, and disability in people with chronic low back pain.

METHODS

We searched the PubMed, Embase, Web of Science, PEDro, CENTRAL, and CINAHL databases from inception until January 2024. Only randomized controlled trials assessing the effects of virtual reality-based training on individuals with chronic low back pain were selected. The outcomes were focused on pain, pain-related fear measured by the Tampa Scale of Kinesiophobia, and disability measured by the Oswestry Disability Index. The immediate term was defined as the immediate period after intervention, and the short term was defined as 3 to 6 months after intervention. The Cochrane Risk of Bias tool and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach were used to evaluate the quality of the methodology and evidence, respectively.

RESULTS

In total, 20 randomized controlled trials involving 1059 patients were eligible for analysis. Virtual reality-based training showed significant improvements in pain (mean difference [MD] -1.43; 95% CI -1.86 to -1.00; I2=95%; P<.001), pain-related fear using the Tampa Scale of Kinesiophobia (MD -5.46; 95% CI -9.40 to 1.52; I2=90%; P=.007), and disability using the Oswestry Disability Index (MD -11.50; 95% CI -20.00 to -3.01; I2=95%; P=.008) in individuals with chronic low back pain immediately after interventions. However, there were no significant differences observed in pain (P=.16), pain-related fear (P=.10), and disability (P=.43) in the short term.

CONCLUSIONS

These findings indicated that virtual reality-based training can be used effectively for individuals with chronic low back pain in the immediate term, especially to reduce pain, alleviate pain-related fear, and improve disability. However, the short-term benefits need more high-quality trials to be demonstrated.

TRIAL REGISTRATION

PROSPERO CRD42021292633; http://tinyurl.com/25mydxpz.

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.

Exercise intervention for patients with chronic low back pain: a systematic review and network meta-analysis

Purpose

Chronic low back pain (CLBP) is an aging and public health issue that is a leading cause of disability worldwide and has a significant economic impact on a global scale. Treatments for CLBP are varied, and there is currently no study with high-quality evidence to show which treatment works best. Exercise therapy has the characteristics of minor harm, low cost, and convenient implementation. It has become a mainstream treatment method in clinics for chronic low back pain. However, there is insufficient evidence on which specific exercise regimen is more effective for chronic non-specific low back pain. This network meta-analysis aimed to evaluate the effects of different exercise therapies on chronic low back pain and provide a reference for exercise regimens in CLBP patients.

Methods

We searched PubMed, EMBASE, Cochrane Library, and Web of Science from inception to 10 May 2022. Inclusion and exclusion criteria were used for selection. We collected information from studies to compare the effects of 20 exercise interventions on patients with chronic low back pain.

Results

This study included 75 randomized controlled trials (RCTs) with 5,254 participants. Network meta-analysis results showed that tai chi [standardized mean difference (SMD), -2.11; 95% CI, -3.62 to -0.61], yoga (SMD, -1.76; 95% CI -2.72 to -0.81), Pilates exercise (SMD, -1.52; 95% CI, -2.68, to -0.36), and sling exercise (SMD, -1.19; 95% CI, -2.07 to -0.30) showed a better pain improvement than conventional rehabilitation. Tai chi (SMD, -2.42; 95% CI, -3.81 to -1.03) and yoga (SMD, -2.07; 95% CI, -2.80 to -1.34) showed a better pain improvement than no intervention provided. Yoga (SMD, -1.72; 95% CI, -2.91 to -0.53) and core or stabilization exercises (SMD, -1.04; 95% CI, -1.80 to -0.28) showed a better physical function improvement than conventional rehabilitation. Yoga (SMD, -1.81; 95% CI, -2.78 to -0.83) and core or stabilization exercises (SMD, -1.13; 95% CI, -1.66 to -0.59) showed a better physical function improvement than no intervention provided.

Conclusion

Compared with conventional rehabilitation and no intervention provided, tai chi, toga, Pilates exercise, sling exercise, motor control exercise, and core or stabilization exercises significantly improved CLBP in patients. Compared with conventional rehabilitation and no intervention provided, yoga and core or stabilization exercises were statistically significant in improving physical function in patients with CLBP. Due to the limitations of the quality and quantity of the included studies, it is difficult to make a definitive recommendation before more large-scale and high-quality RCTs are conducted.

Effects of exercise therapy on disability, mobility, and quality of life in the elderly with chronic low back pain: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Exercise is an effective treatment in chronic low back pain (CLBP), but there are few studies on CLBP in the elderly, and the intervention effect is controversial. We aimed to compare the efficacy of different exercises therapy on CLBP, dysfunction, quality of life, and mobility in the elderly.

METHODS

We searched Web of Science, MEDLINE, Cochrane Library, Chinese National Knowledge Infrastructure, EMBASE, and PubMed from the database inception till December 31, 2022. The publication languages were Chinese and English. Randomized controlled trials (RCTs) of exercise intervention in the elderly (≥ 60 years) with CLBP were included. Two reviewers independently extracted the data and evaluated them using the Revised Cochrane Risk of Bias Tool for Randomized Trials 2 (RoB2). The pooled effect sizes on different aspects of outcome measures were calculated.

RESULTS

Sixteen articles (18 RCTs) were included, comprising a total of 989 participants. The quality of included studies was relatively high. Meta-analysis results indicated that exercise therapy could improve visual analog scale (VAS) (WMD = - 1.75, 95% CI - 2.59, - 0.92, p < 0.05), Oswestry disability index (ODI) (WMD = - 9.42, 95% CI - 15.04, - 3.79, p < 0,005), short-form 36-item health survey physical composite summary (SF-36PCS) (WMD = 7.07, 95% CI 1.01, 13.14, p < 0.05), short-form 36-item health survey mental composite summary (SF-36MCS) (WMD = 7.88, 95% CI 0.09, 15.67, p < 0.05), and timed up and go test (TUG) (WMD = - 0.92, 95% CI - 2.22, 0.38, p < 0.005).

CONCLUSION

Exercise therapy effectively improved VAS, ODI, and SF-36 indexes in the elderly. Based on the subgroup, when designing the exercise therapy regimen, aerobics, strength, and mind-body exercise (≥ 12 weeks, ≥ 3 times/week, ≥ 60 min) should be considered carefully, to ensure the safety and effectiveness for the rehabilitation of CLBP patients. More high-quality trials are needed in future to confirm the effect of exercise on SF-36 and TUG indexes.

A Systematic Review and Meta-Analysis of the Effects of Rehabilitation Using Digital Healthcare on Musculoskeletal Pain and Quality of Life

Rehabilitation using digital healthcare (DHC) has the potential to enhance the effectiveness of treatment for musculoskeletal disorders (MSDs) and associated pain by improving patient outcomes, while being cost-effective, safe, and measurable. This systematic review and meta-analysis aimed to evaluate the effectiveness of musculoskeletal rehabilitation using DHC. We searched PubMed, Ovid-Embase, Cochrane Library, and PEDro Physiotherapy Evidence Database from inception to October 28, 2022 for controlled clinical trials comparing DHC to conventional rehabilitation. We used a random-effects model for the meta-analysis, pooling the effects of DHC on pain and quality of life (QoL) by calculating standardized mean differences (SMDs) with 95% confidence intervals (CIs) between DHC rehabilitation and conventional rehabilitation (control). Fifty-four studies with 6240 participants met the inclusion criteria. The sample size ranged from 26 to 461, and the average age of the participants ranged from 21.9 to 71.8 years. The majority of the included studies focused on knee or hip joint MSD (n = 23), and the most frequently utilized DHC interventions were mobile applications (n = 26) and virtual or augmented reality (n = 16). Our meta-analysis of pain (n = 45) revealed that pain reduction was greater in DHC rehabilitation than in conventional rehabilitation (SMD: -0.55, 95% CI: -0.74, -0.36), indicating that rehabilitation using DHC has the potential to ameliorate MSD pain. Furthermore, DHC significantly improved health-related QoL and disease-specific QoL (SMD: 0.66, 95% CI: 0.29, 1.03; SMD: -0.44, 95% CI: -0.87, -0.01) compared to conventional rehabilitation. Our findings suggest that DHC offers a practical and flexible rehabilitation alternative for both patients with MSD and healthcare professionals. Nevertheless, further researches are needed to elucidate the underlying mechanisms by which DHC affects patient-reported outcomes, which may vary depending on the type and design of the DHC intervention.

Virtual reality therapy for myofascial pain: Evolving towards an evidence-based non-pharmacologic adjuvant intervention

Myofascial pain syndrome (MPS) is a highly prevalent and burdensome cause of pain globally, representing a major focus of chronic pain management. Management of MPS is highly variable, with therapies ranging from interventional approaches to physical therapy. Virtual reality (VR) is a novel form of therapy being actively explored as an adjuvant to procedural sedation in the acute pain setting, and increasingly as a means of chronic pain management through programs that facilitate pain education, physical therapy and mindfulness, among other approaches. However, to date, there are minimal clinical studies assessing VR therapy within the context of MPS treatments. Given the existing volume of work published in the acute pain setting and the translational work exploring VR and neuroplasticity in chronic pain, we make the case here that it is an appropriate time to consider exploring VR therapy as a non-pharmacological adjuvant treatment for MPS.

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.

Long-Term Clinical Outcomes of a Remote Digital Musculoskeletal Program: An Ad Hoc Analysis from a Longitudinal Study with a Non-Participant Comparison Group

Digital solutions have emerged as an alternative to conventional physiotherapy, particularly for chronic musculoskeletal pain (CMP) management; however, its long-term effects remain largely unexplored. This study focuses on patients reporting CMP, assessing 1-year clinical outcomes after a multimodal digital care program (DCP) versus non-participants, who enrolled in the program but never engaged in a single exercise session or partook of the educational content made available to them. In this longitudinal study ad-hoc analysis, pain and functionality outcomes at 1-year reassessment were studied, focusing on the odds of reaching minimal clinically important difference (MCID) and, overall average reduction in both outcomes. Healthcare utilization was additionally studied within the same period. From 867 individuals allocated to the study, 460 completed the 1-year reassessment (intervention group: 310; comparison group: 150). The intervention group presented sustained and greater pain reduction until 1-year reassessment than the comparison group, reflecting greater odds ratio of achieving the MCID both in pain and functionality (1.90 95% CI: 1.27-2.86, p = 0.002 and 2.02 95% CI: 1.31-3.12, p = 0.001, respectively). A lower healthcare utilization during the 1-year follow-up was observed in the intervention group than in the comparison group. This study suggests that a digital CMP program may have a lasting impact on improved pain and functionality in patients with CMP.

Yoga for chronic non-specific low back pain

BACKGROUND

Non-specific low back pain is a common, potentially disabling condition usually treated with self-care and non-prescription medication. For chronic low back pain, current guidelines recommend exercise therapy. Yoga is a mind-body exercise sometimes used for non-specific low back pain.

OBJECTIVES

To evaluate the benefits and harms of yoga for treating chronic non-specific low back pain in adults compared to sham yoga, no specific treatment, a minimal intervention (e.g. education), or another active treatment, focusing on pain, function, quality of life, and adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 31 August 2021 without language or publication status restrictions.

SELECTION CRITERIA

We included randomized controlled trials of yoga compared to sham yoga, no intervention, any other intervention and yoga added to other therapies.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our major outcomes were 1. back-specific function, 2. pain, 3. clinical improvement, 4. mental and physical quality of life, 5. depression, and 6.

ADVERSE EVENTS

Our minor outcome was 1. work disability. We used GRADE to assess certainty of evidence for the major outcomes.

MAIN RESULTS

We included 21 trials (2223 participants) from the USA, India, the UK, Croatia, Germany, Sweden, and Turkey. Participants were recruited from both clinical and community settings. Most were women in their 40s or 50s. Most trials used iyengar, hatha, or viniyoga yoga. Trials compared yoga to a non-exercise control including waiting list, usual care, or education (10 trials); back-focused exercise such as physical therapy (five trials); both exercise and non-exercise controls (four trials); both non-exercise and another mind-body exercise (qigong) (one trial); and yoga plus exercise to exercise alone (one trial). One trial comparing yoga to exercise was an intensive residential one-week program, and we analyzed this trial separately. All trials were at high risk of performance and detection bias because participants and providers were not blinded to treatment, and outcomes were self-assessed. We found no trials comparing yoga to sham yoga. Low-certainty evidence from 11 trials showed that there may be a small clinically unimportant improvement in back-specific function with yoga (mean difference [MD] -1.69, 95% confidence interval [CI] -2.73 to -0.65 on the 0- to 24-point Roland-Morris Disability Questionnaire [RMDQ], lower = better, minimal clinically important difference [MCID] 5 points; 1155 participants) and moderate-certainty evidence from nine trials showed a clinically unimportant improvement in pain (MD -4.53, 95% CI -6.61 to -2.46 on a 0 to 100 scale, 0 no pain, MCID 15 points; 946 participants) compared to no exercise at three months. Low-certainty evidence from four trials showed that there may be a clinical improvement with yoga (risk ratio [RR] 2.33, 95% CI 1.46 to 3.71; assessed as participant rating that back pain was improved or resolved; 353 participants). Moderate-certainty evidence from six trials showed that there is probably a small improvement in physical and mental quality of life (physical: MD 1.80, 95% CI 0.27 to 3.33 on the 36-item Short Form [SF-36] physical health scale, higher = better; mental: MD 2.38, 95% CI 0.60 to 4.17 on the SF-36 mental health scale, higher = better; both 686 participants). Low-certainty evidence from three trials showed little to no improvement in depression (MD -1.25, 95% CI -2.90 to 0.46 on the Beck Depression Inventory, lower = better; 241 participants). There was low-certainty evidence from eight trials that yoga increased the risk of adverse events, primarily increased back pain, at six to 12 months (RR 4.76, 95% CI 2.08 to 10.89; 43/1000 with yoga and 9/1000 with no exercise; 1037 participants). For yoga compared to back-focused exercise controls (8 trials, 912 participants) at three months, we found moderate-certainty evidence from four trials for little or no difference in back-specific function (MD -0.38, 95% CI -1.33 to 0.62 on the RMDQ, lower = better; 575 participants) and very low-certainty evidence from two trials for little or no difference in pain (MD 2.68, 95% CI -2.01 to 7.36 on a 0 to 100 scale, lower = better; 326 participants). We found very low-certainty evidence from three trials for no difference in clinical improvement assessed as participant rating that back pain was improved or resolved (RR 0.97, 95% CI 0.72 to 1.31; 433 participants) and very low-certainty evidence from one trial for little or no difference in physical and mental quality of life (physical: MD 1.30, 95% CI -0.95 to 3.55 on the SF-36 physical health scale, higher = better; mental: MD 1.90, 95% CI -1.17 to 4.97 on the SF-36 mental health scale, higher = better; both 237 participants). No studies reported depression. Low-certainty evidence from five trials showed that there was little or no difference between yoga and exercise in the risk of adverse events at six to 12 months (RR 0.93, 95% CI 0.56 to 1.53; 84/1000 with yoga and 91/1000 with non-yoga exercise; 640 participants).

AUTHORS' CONCLUSIONS

There is low- to moderate-certainty evidence that yoga compared to no exercise results in small and clinically unimportant improvements in back-related function and pain. There is probably little or no difference between yoga and other back-related exercise for back-related function at three months, although it remains uncertain whether there is any difference between yoga and other exercise for pain and quality of life. Yoga is associated with more adverse events than no exercise, but may have the same risk of adverse events as other exercise. In light of these results, decisions to use yoga instead of no exercise or another exercise may depend on availability, cost, and participant or provider preference. Since all studies were unblinded and at high risk of performance and detection bias, it is unlikely that blinded comparisons would find a clinically important benefit.

Optimal modes of mind-body exercise for treating chronic non-specific low back pain: Systematic review and network meta-analysis

Background

There were limited studies that directly compare the outcomes of various mind-body exercise (MBE) therapies on chronic non-specific low back pain (CNLBP).

Objectives

To compare the efficacy of the four most popular MBE modes [Pilates, Yoga, Tai Chi (TC), and Qigong] in clinically CNLBP patients, we conducted a systematic review and network meta-analysis (NMA).

Methods

We searched databases for eligible randomized controlled trials (RCTs) (from origin to July 2022). RCTs were eligible if they included adults with CNLBP, and implemented one or more MBE intervention arms using Pilates, yoga, TC, and qigong. In addition, pain intensity and physical function were evaluated using validated questionnaires.

Results

NMA was carried out on 36 eligible RCTs involving 3,050 participants. The effect of exercise therapy on pain was in the following rankings: Pilates [Surface under cumulative ranking (SUCRA) = 86.6%], TC (SUCRA = 77.2%), yoga (SUCRA = 67.6%), and qigong (SUCRA = 64.6%). The effect of exercise therapy on function: Pilates (SUCRA = 98.4%), qigong (SUCRA = 61.6%,), TC (SUCRA = 59.5%) and yoga (SUCRA = 59.0%).

Conclusion

Our NMA shows that Pilates might be the best MBE therapy for CNLBP in pain intensity and physical function. TC is second only to Pilates in improving pain in patients with CNLBP and has the value of promotion. In the future, we need more high-quality, long-term follow-up RCTs to confirm our findings.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=306905, identifier: CRD42022306905.

Use of interventions involving virtual reality tasks during the climacteric: a systematic review

Technological advances have been impacting health care worldwide. Our study aimed to research the literature systematically to determine the impact of technological treatments versus conventional treatments on the quality of life of climacteric women. The study was registered on PROSPERO (CRD42021241638). We searched seven databases, including PRISMA, using mesh terms. After screening for eligibility, we selected five clinical trials, and applying the snowball technique we were able to include four more articles, totaling nine articles that used technology-based interventions (virtual reality games) during the climacteric. The total study population consisted of 298 climacteric women. Two studies evaluated a technology-based treatment for pelvic floor, one for urinary incontinence symptoms, three for postural balance, one for cardiorespiratory capacity, one for osteoporosis and one study for lower back pain. The studies showed that the technological treatments improved pelvic floor strength, balance, cardiorespiratory fitness and bone mineral density when compared to conventional treatments. Improvement was linked to adherence to training and a high level of satisfaction during the training sessions. Technology-based treatments appear to be a viable alternative to conventional treatments in improving the quality of health, with benefits for the cardiovascular, genitourinary and skeletal systems, and ultimately for the overall quality of life.

Effect of virtual reality technology as intervention for people with kinesiophobia: A meta-analysis of randomised controlled trials

AIMS AND OBJECTIVE

To explore the effectiveness of Virtual Reality Technology in reducing kinesiophobia in people.

BACKGROUND

Kinesiophobia is an important psychosocial factor affecting the pain experience and has a significant negative impact on rehabilitation. Virtual reality technology has been widely used in the treatment of phobias, mental disorders and anxiety disorders. However, the effect of virtual reality technology on people with kinesiophobia has been reported with inconsistent results.

DESIGN

A meta-analysis of randomised controlled trials.

METHODS

This study systematically searched PubMed, Web of Science, PsycINFO, CINAHL, Embase, Cochrane Library, Medline, Scopus and four Chinese databases. The standardised mean difference (SMD) was calculated using random-effects models, and the Cochrane Collaboration's tool was used to assess the risk of bias in each study. The PRISMA 2020 checklist provided by the EQUATOR network was used.

RESULTS

Eleven randomised controlled trials involving a total of 488 subjects were included. Meta-analysis showed the effect sizes of virtual reality intervention on kinesiophobia (SMD = -0.53, 95% CI [-0.90, -0.17], p = .004). Virtual reality intervention was more effective in reducing kinesiophobia in people with chronic low back pain (SMD = -1.00, 95% CI [-1.71, -0.29], p = .006). Compared with fully immersive virtual reality (SMD = -0.29, 95% CI [-0.62, 0.05], p = 0.09), non-immersive virtual reality was more effective in reducing kinesiophobia (SMD = -0.66, 95% CI [-1.24, -0.09], p = 0.02). Compared with virtual reality intervention alone (SMD = -0.35, 95% CI [-1.40, 0.71], p = 0.52), virtual reality combined with exercise was more effective in reducing kinesiophobia (SMD = -0.59, 95% CI [-0.95, -0.22], p = 0.002).

CONCLUSIONS

Virtual reality technology has the potential to reduce the degree of kinesiophobia in people. In addition, virtual reality technology was more effective in people with chronic low back pain; non-immersive virtual reality was more effective in reducing kinesiophobia; and virtual reality technology combined with exercise was more effective in reducing kinesiophobia than virtual reality intervention alone. Clinical nursing staff should be encouraged to use virtual reality to speed up patient recovery. However, to achieve immersion and apply this technology to different diseases, more studies are required to provide clearer suggestions.

RELEVANCE TO CLINICAL PRACTICE

This study suggests that healthcare staff should pay attention to kinesiophobia, and early identification and intervention of kinesiophobia can help patients recover their health and improve the quality of nursing.

Feedback on Trunk Movements From an Electronic Game to Improve Postural Balance in People With Nonspecific Low Back Pain: Pilot Randomized Controlled Trial

Background

Postural balance is compromised in people with low back pain, possibly by changes in motor control of the trunk. Augmenting exercising interventions with sensor-based feedback on trunk posture and movements might improve postural balance in people with low back pain.

Objective

We hypothesized that exercising with feedback on trunk movements reduces sway in anterior-posterior direction during quiet standing in people with low back pain. Secondary outcomes were lumbar spine and hip movement assessed during box lift and waiter bow tasks, as well as participant-reported outcomes. Adherence to the exercising intervention was also examined.

Methods

A randomized controlled trial was conducted with the intervention group receiving unsupervised home exercises with visual feedback using the Valedo Home, an exergame based on 2 inertial measurement units. The control group received no intervention. Outcomes were recorded by blinded staff during 4 visits (T1-T4) at University Hospital Zurich. The intervention group performed 9 sessions of 20 minutes in the 3 weeks between T2 and T3 and were instructed to exercise at their own convenience between T3 and T4. Postural balance was assessed on a force platform. Lumbar spine and hip angles were obtained from 3 inertial measurement units. The assessments included pain intensity, disability, quality of life, and fear of movement questionnaires.

Results

A total of 32 participants with nonspecific low back pain completed the first assessment T1, and 27 (84%) participants were randomized at T2 (n=14, 52% control and n=13, 48% intervention). Intention-to-treat analysis revealed no significant difference in change in anterior-posterior sway direction during the intervention period with a specified schedule (T2-T3) between the groups (W=99; P=.36; r=0.07). None of the outcomes showed significant change in accordance with our hypotheses. The intervention group completed a median of 61% (55/90; range 2%-99%) of the exercises in the predefined training program. Adherence was higher in the first intervention period with a specified schedule.

Conclusions

The intervention had no significant effect on postural balance or other outcomes, but the wide range of adherence and a limited sample size challenged the robustness of these conclusions. Future work should increase focus on improving adherence to digital interventions.

Trial Registration

ClinicalTrials.gov NCT04364243; https://clinicaltrials.gov/ct2/show/NCT04364243

International Registered Report Identifier (IRRID)

RR2-10.2196/26982

Effects of Gaming on Pain-Related Fear, Pain Catastrophizing, Anxiety, and Depression in Patients with Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

The aim was to systematically review the effects of gaming on pain-related fear, pain catastrophizing, anxiety, and depression in patients with chronic musculoskeletal pain. Databases (Medline, EMBASE, PsycInfo, CINAHL, Cochrane Central Register for Controlled Trials [CENTRAL], Web of Science, and SCOPUS) were searched from inception up to October 2021. Two reviewers independently selected randomized controlled trials that compared the effects of any gaming modality with other interventions or no treatment on pain-related fear, pain catastrophizing, anxiety, and depression. For data synthesis, Standardized Mean Differences (SMDs) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model for meta-analysis according to the outcome of interest, comparison group, and follow-up period. The level of evidence was synthesized using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Thirteen studies were included with a total sample of 680 patients. Gaming was superior to other treatments and no treatment on reducing pain-related fear (SMD: -1.23; 95% CI: -2.02 to -0.44) and anxiety (SMD: -0.55; 95% CI: -1.01 to -0.09), respectively. Gaming was not superior to other treatments on reducing pain catastrophizing, anxiety, and depression, and it was not superior to no treatment on reducing pain-related fear, pain catastrophizing, and depression. Those findings were based on very low or low-quality evidence. In a conclusion, gaming modalities may have positive effects on some mental health outcomes. However, there were conflicting results with low-quality evidence, which indicates that more high-quality randomized controlled trials are needed.

System for Game-like Therapy in Balance Issues Using Audiovisual Feedback and Force Platform

Background: The aim of the work is to verify the usability of a stabilometric platform and audiovisual feedback in the group-based therapy of patients with vertebral algic syndrome, to analyze an immediate effect after a single therapeutic unit, and to analyze differences between male and female probands. Methods: The study included 189 patients (90 male, age 55 ± 12 and 89 female, age 52 ± 12). All patients received group balance therapy with a portable medical device, Homebalance MA. The intervention consisted of measurement of quiet stance and a reference training scene before and after 15 min of game-like balance training with audiovisual feedback. Results: A statistically significantly lower value of the body sway trajectory during quiet stance was detected in men than in women. After a single therapy session, there was a statistically significant improvement in quiet stance with visual feedback, and marginal statistically significant improvement in the time required to complete the reference training scene. Conclusions: Homebalance MA is a utilizable tool for group therapy. The use of group game-like balance training increases the availability of physiotherapeutic intervention for a larger number of patients, while maintaining the positive effect of the therapy.

Virtual Reality in the Management of Chronic Low Back Pain: A Scoping Review

Virtual reality (VR) is a burgeoning treatment option for chronic pain. Its use has been heterogenous in the literature. This scoping review assesses the current literature for the use of VR in the treatment of chronic low back pain (CLBP). The following themes were identified by the analysis: safety and feasibility of VR, quality of life associated with VR treatment for CLBP, efficacy of VR to treat CLBP, and efficacy of VR to treat functional changes associated with CLBP. Gaps were identified after analysis of the extant literature. Although the nascent research uncovered in this scoping review found good evidence for safety and tolerability of VR, more studies of safety, acceptance, and satisfaction are recommended including focused studies of spinal pain risks specific to use of VR. Overall, the methodological quality of studies reviewed in this scoping review was poor and outcomes were limited to short-term posttreatment outcomes.

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 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.

Effects of Low Back Pain Exercises on Pain Symptoms and Activities of Daily Living: A Systematic Review and Meta-Analysis

Our objective in this paper was to systematically review evaluations of the effects of exercises on pain symptoms and activities of daily living (ADL) in middle-aged and elderly patients with low back pain (LBP). We searched Web of Science, PubMed, EBSCO, and China National Knowledge Internet (CNKI) databases for randomized controlled trials (RCTs) on this topic. We evaluated the methodological quality of included articles using the Physiotherapy Evidence Database (PEDro) scale, and we statistically analyzed these studies using RevMan software. We reviewed 18 RCTs (23 comparison groups) with a total of 910 participants, and our meta-analysis confirmed that exercises significantly improved both pain and ADLs measured on visual analog scales (VAS) (SMD = -0.91, 95% CI: [-1.3, -0.52], p < 0.00001) and on the Oswestry Disability Index (ODI) (SMD = -2.07, 95% CI: [-3.19, -0.96], p < 0.00001). We conclude that exercises can reduce pain severity and improve ADL capacity in middle-aged and elderly persons with LBP, confirming that exercise can serve as a medical intervention for these indivdiuals. However, given the high heterogeneity of responses among individual participants, there remains a need for further study.

The effects of virtual reality training on clinical indices and brain mapping of women with patellofemoral pain: a randomized clinical trial

Background

Virtual reality training (VRT) is a new method for the rehabilitation of musculoskeletal impairments. However, the clinical and central effects of VRT have not been investigated in patients with patellofemoral pain (PFP). To comprehensively assess the effects of VRT on clinical indices and brain function, we used a randomized clinical trial based on clinical and brain mapping assessment.

Methods

Twenty-six women with PFP for more than 6 months were randomly allocated to 2 groups: intervention and control. The intervention consisted of lifestyle education + 8 weeks VRT, in 24 sessions each lasting 40 min of training, whereas the control group just received lifestyle education. The balance was the primary outcome and was measured by the modified star excursion balance test. Secondary outcomes included pain, function, quality of life, and brain function which were assessed by visual analogue scale, step down test and Kujala questionnaire, SF-36, and EEG, respectively. Pre-intervention, post-intervention and follow-up (1 month after the end of the intervention) measurements were taken for all outcome measures except EEG, which was evaluated only at pre-intervention and post-intervention). Analyses of variance was used to compare the clinical outcomes between the two groups. The independent t-test also was used for between group EEG analyses.

Results

Balance score (P < 0.001), function (P < 0.001), and quality of life (P = 0.001) improved significantly at post-intervention and 1 month follow-up in the VRT group compared with the control group. VRT group showed a significantly decreased pain score (P = 0.004). Alpha (P < 0.05) and theta (P = 0.01) power activity also increased in the brain of the VRT group.

Conclusion

This study demonstrated that long term VRT was capable of improving both clinical impairments and brain function in patients with PFP. Therefore, therapists and clinicians can use this method as a more holistic approach in the rehabilitation of PFP.

Trial registration

IRCT, IRCT20090831002391N40. Registered 23 / 10 / 2019.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Virtual reality or isokinetic training; its effect on pain, kinesiophobia and serum stress hormones in chronic low back pain: A randomized controlled trial

BACKGROUND

Evidence on the latest technologies in rehabilitation for reducing pain and altering serum stress hormones in low back pain (LBP) was lacking.

OBJECTIVE

To find the clinical and hormonal effects of virtual reality training (VRT) and isokinetic training (IKT) in chronic LBP patients.

METHODS

Through the simple random sampling method, 60 university football players with chronic LBP were allocated into three groups: NVRT= 20, NIKT= 20 and NCONTROL= 20. The three groups underwent different exercises for 4 weeks. Clinical (pain intensity and kinesiophobia) and hormonal (glucose, insulin, HOMA-IR, growth hormone, prolactin, ACTH and cortisol) values were measured at baseline, after 4 weeks and 6 months.

RESULTS

Four weeks following training, the VRT and IKT groups showed significant changes in pain intensity and kinesiophobia in comparison to the control group (p< 0.05). Hormonal measures also showed significant improvement in the VRT group in comparison to the other two groups (p< 0.05).

CONCLUSION

Training through virtual reality and isokinetic exercise is an effective approach in terms of pain and kinesiophobia. In terms of hormonal analysis, virtual reality shows slightly more improvements than isokinetic training in subjects with chronic LBP.

Yoga for treating low back pain: a systematic review and meta-analysis

ABSTRACT

Yoga is frequently used for back pain relief. However, evidence was judged to be of only low- or moderate. To assess the efficacy and safety of yoga in patients with low back pain a meta-analysis was performed. Therefore Medline/PubMed, Scopus, and the Cochrane Library was searched to May 26 2020. Only randomized controlled trials (RCTs) comparing Yoga with passive control (usual care or waitlist), or an active comparator, for patients with low back pain, that assessed pain intensity or pain-related disability as a primary outcome were considered to be eligible. Two reviewers independently extracted data on study characteristics, outcome measures, and results at short-term and long-term follow-up. Risk of bias was assessed using the Cochrane Risk of Bias Tool. 30 articles on 27 individual studies (2702 participants in total) proved eligible for review. Compared to passive control, yoga was associated with short-term improvements in pain intensity (15 RCTs; Mean Difference (MD)=-0.74 points on a numeric rating scale; 95%CI=-1.04,-0.44; Standardized Mean Difference (SMD)=-0.37 95%CI=-0.52,-0.22), pain-related disability (15 RCTs; MD=-2.28; 95%CI=-3.30,-1.26; SMD=-0.38 95%CI=-0.55,-0.21), mental health (7 RCTs; MD=1.70; 95%CI=0.20,3.20; SMD=0.17 95%CI=0.02,0.32) and physical functioning (9 RCTs; MD=2.80; 95%CI=1.00,4.70; SMD=0.28 95%CI=0.10,0.47). Except for mental health all effects sustained long-term. Compared to an active comparator, yoga was not associated with any significant differences in short- or long-term outcomes.In conclusion, yoga revealed robust short- and long-term effects for pain, disability, physical function and mental health, when compared to non-exercise controls. However these effects were mainly not clinically significant.

Horse-riding simulators in treatment of chronic low back pain: A meta-analysis

BACKGROUND

The use of horse-riding simulators in the treatment of chronic low back pain has drawn considerable attention for its efficacy and acceptability to reduce chronic low back pain; because of the similarities in movements provided by equine-assisted therapies and the possible accessibility advantages. However, the results are conflicting. This study aimed to perform a meta-analysis of randomised controlled trials to assess the impact of treatments based on horse-riding simulators on chronic low back pain.

METHODS

A systematic literature search up to January 2021 was performed and 11 studies were detected with 543 subjects with chronic low back pain at the baseline of the study, 257 of them were using horse-riding simulators, and 255 of them were inactive control group who continued their usual care, and similar kind of physical therapy (control). They reported a comparison between horse-riding simulators and control to reduce chronic low back pain. Mean differences (MD) with 95% confidence intervals (CIs) were calculated assessing the impact of treatments based on horse-riding simulators on chronic low back pain using the continuous method with a random or fixed-effect model.

RESULTS

Significantly higher change-from-baseline pain outcomes was observed in Visual Analogue Scale (MD, -4.36; 95% CI, -6.24 to -2.30, P < .001), and Roland Morris Disability Questionnaire change-from-baseline (MD, -2.32; 95% CI, -3.52 to -1.12, P < .001) with horse-riding simulators compared with control.

CONCLUSIONS

Using horse-riding simulators may lower the risk of chronic low back pain. This relationship forces us to recommend the use of horse-riding simulators to avoid any complications that could occur with chronic low back pain.

Effects of Nintendo Ring Fit Adventure Exergame on Pain and Psychological Factors in Patients with Chronic Low Back Pain

Objective: In recent years, there has been an increase in research on the therapeutic effects of exergaming, but there have been few studies on these types of interventions for chronic low back pain. In this study, we hypothesized that the Nintendo Ring Fit Adventure (RFA) exergame would be effective for patients with chronic low back pain, and we conducted a randomized prospective longitudinal study. Materials and Methods: Patients with chronic low back pain were included in this study. Twenty randomly selected patients (9 males and 11 females, mean age 49.3 years) were included in the RFA group, and RFA exergaming was performed once a week for 40 minutes for 8 weeks. Twenty patients (12 males and 8 females, mean age 55.60 years) served as the control group and received oral treatment for 8 weeks. Pain and psychological scores (pain self-efficacy, pain catastrophizing, and kinesiophobia) were measured and analyzed before and after 8 weeks of treatment in both groups. Results: In the RFA group, low back pain, buttock pain, and pain self-efficacy were significantly improved after 8 weeks of RFA exergaming, but there was no significant improvement in lower limb numbness, pain catastrophizing, or kinesiophobia. In the control group, no significant improvement was observed after 8 weeks of oral treatment. Conclusion: RFA exergaming increased pain self-efficacy and reduced pain in patients with chronic low back pain. Future treatment protocols should be developed to improve pain self-efficacy. Approval code: 2894, School of Medicine, Chiba University.

The effects of exergaming on pain, postural control, technology acceptance and flow experience in older people with chronic musculoskeletal pain: a randomised controlled trial

BACKGROUND

Older people with chronic musculoskeletal pain are at risk of falls. This study aimed to investigate the effects of exergaming on pain and postural control in older people with chronic musculoskeletal pain. Secondary outcomes were technology acceptance, flow experience, perceived physical exertion, expended mental effort and heart rate.

METHODS

Fifty four older adults (age: 71 ± 5 years) with chronic musculoskeletal pain were randomised into 2 groups. Group 1 received exergaming training using the Interactive Rehabilitation and Exercise System (IREX®). Group 2 undertook traditional gym-based exercise (TGB). Both groups completed twice weekly 40-min exercise sessions for 6 weeks. Perceived pain was measured using a numeric pain rating scale and the Multidimensional Affect and Pain Survey questionnaire. Postural control was measured as sway using a Kistler™ force platform. Technology acceptance was measured with the Unified Theory of Acceptance and Use of Technology questionnaire and flow experience with the Flow State Scale. Physiological measures of perceived physical exertion, expended mental effort and heart rate were recorded during all sessions.

RESULTS

The exergaming group demonstrated significant reductions in pain intensity and thermal pain including a near significant approach in physical engagement in comparison to TGB group. Although no intervention effects on postural control were found, the exergaming group showed significant improvements in three sway measures (AP SD, ML SD and AP range) over time whereas significant improvements in ML range were found in the TGB group. Relating to technology acceptance, significant intervention effects on social influence and behavioural intention were found in the TGB group instead, although both groups demonstrated increases of acceptance over time. Regarding flow experience, concentration at task was significantly influenced in the TGB group and significant increases in flow variables over time were observed in both groups. Significant increases over time in perceived physical exertion and expended mental effort were found in both groups.

CONCLUSION

Our findings support the potential of exergaming to alleviate pain and improve balance in older people with chronic musculoskeletal pain. Both forms of exercise are acceptable, intrinsically motivating and show evidence of benefit to older people with chronic musculoskeletal pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04029285 (retrospectively registered, July 23, 2019).

Comparative effects of virtual reality training and sensory motor training on bone morphogenic proteins and inflammatory biomarkers in post-traumatic osteoarthritis

The objective of this study is to compare the effects of virtual reality training (VRT) and sensory-motor training (SMT) in bone morphogenetic proteins (BMP) and inflammatory biomarkers expression in post-traumatic osteoarthritis (PTOA) after the anterior cruciate ligament injury. Through a simple random sampling method, 60 eligible participants were allocated into VRT (n = 20), SMT (n = 20), and control groups (n = 20). They underwent training programs for 4 weeks. Clinical (pain intensity and functional disability) and biochemical (bone morphogenic proteins and inflammatory biomarkers) values were measured at baseline, after 4 weeks, 8 weeks and 3 months follow up. Four weeks following training, the VRT group shows more significant changes in pain intensity and functional disability than SMT and control groups (P < 0.001). Bone morphogenic protein (BMP) measures such as BMP 2, 4, 6, and 7 don’t show any significant changes between the groups. But at the same time, the VRT group shows positive improvement in inflammatory biomarkers (CRP, TNF-α, IL-2, IL-4, IL-6) analysis than the other two groups (P < 0.001). Our study suggests that including virtual reality training in PTOA shows beneficial changes in pain, functional disability, and modification of inflammatory biomarkers than sensory-motor training, but at the same time it shows a negligible effect on bone morphogenic proteins.

Effectiveness of walking versus mind-body therapies in chronic low back pain: A systematic review and meta-analysis of recent randomized controlled trials

PURPOSE

Walking and mind-body therapies (MBTs) are commonly recommended to relieve pain and improve function in patients with chronic low back pain (CLBP). The purpose of this study was to compare the effectiveness of walking and MBTs in CLBP.

METHODS

We included randomized controlled trials (RCTs) comparing walking or MBTs to any other intervention or control in adults with CLBP. Studies were identified through PubMed, Cochrane Library, PsycINFO, Scopus, and ScienceDirect databases. The research was limited to studies published in English and French between January 2008 and December 2018. Two reviewers independently selected the studies, extracted data, and assessed studies quality using the Physiotherapy Evidence Database (PEDro) scale. Statistical analyses were performed under a random-effects model. We analyzed pain and activity limitation, with the calculation of standardized mean differences and 95% confidence intervals for the different treatment effects.

RESULTS

Thirty one randomized controlled trials involving 3193 participants were analyzed. Walking was as effective as control interventions in the short-term and slightly superior in the intermediate term with respect to pain (Standardized mean differences (SMD)  = -0.34; 95% CI, -0.65 to -0.03; P = .03) and activity limitation (SMD = -0.30; 95% CI, -0.50 to -0.10; P = .003). In contrast, yoga was more effective than control interventions in the short term in terms of pain (SMD = -1.47; 95% CI, -2.26 to -0.68; P = .0003) and activity limitation (SMD = -1.17; 95% CI, -1.80 to -0.55; P = .0002). Yoga was no longer superior to the control interventions for pain at the 6-month follow-up.

CONCLUSION

MBTs, especially yoga, seem to be more effective in the short term, and walking seems to be more effective in the intermediate term, for the relief of pain and activity limitation in patients with CLBP. A combination of walking and MBTs fits the biopsychosocial model and might be valuable therapy for CLBP throughout follow-up due to combined effects.

Effects of core stability exercise combined with virtual reality in collegiate athletes with nonspecific low back pain: a randomized clinical trial

Background

Nonspecific low back pain (LBP) in collegiate athletes is shown to be accompanied by poor core endurance. Consequently, trunk muscle stabilization exercises for lumbar instability are widely used. Virtual reality (VR) training can activate the cerebral cortex and enhance the cortex to control balance and improve motion function. The purpose of the study was to assess the effect of combined core stability exercises (CSE) and VR training in improving body balance and function in collegiate male athletes with nonspecific low back pain (LBP).

Results

The post-values of the experimental group were significantly higher than that of the control group for the dynamic balance in anterior (p = 0.031), posterolateral (p = 0.034), and posteromedial (p = 0.037) directions. Moreover, there was a significant difference in the post-values of both groups regarding reducing the Micheli Functional Scale in favor of the experimental group (p = 0.012).

Conclusions

CSE training plus virtual reality is more effective than CSE training alone in improving total body balance and dysfunction level in collegiate male athletes with nonspecific LBP. It is recommended that clinicians consider CSE combined with VR to maximize the improvement in overall body balance when developing rehabilitation programs for collegiate athletes with nonspecific low back pain.

Trial registration

Pan African Clinical Trial Registry, PACTR201907749053096. Retrospectively registered on 15 April 2019. https://pactr.samrc.ac.za/Researcher/ManageTrials.aspx

The Effectiveness of Virtual Reality in Patients With Spinal Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Virtual reality (VR) technologies have been shown to be beneficial in various areas of health care; to date, there are no systematic reviews examining the effectiveness of VR technology for the treatment of spinal pain.

PURPOSE

To investigate the effectiveness of VR technology in the management of individuals with acute, subacute, and chronic spinal pain.

METHODS

Six electronic databases were searched until November 2019. Randomized controlled trials (RCTs) assessing the effectiveness of VR were eligible for inclusion. Two independent reviewers extracted the data and assessed the risk of bias for each study and the overall quality of evidence. Mean differences of outcomes were pooled as appropriate using random-effects models.

RESULTS

Seven RCTs with high risk of bias met review criteria. Quality of evidence ranged from very low to low quality. In patients with chronic neck pain, VR improved global perceived effect (GPE), satisfaction, and general health at short-term follow-up, as well as general health and balance at intermediate-term follow-up compared to kinematic training. VR improved pain intensity and disability at short-term and long-term follow-up compared to conventional proprioceptive training in patients with chronic neck pain. In patients with either subacute or chronic low back pain (LBP), VR improved pain, disability, and fear of movement compared to lumbar stabilization exercises and improved pain compared to conventional physical therapy (at short-term follow-up). In patients with chronic LBP, VR improved pain compared to lumbar stabilization exercises and improved fear of movement compared to conventional physical therapy (at short-term follow-up).

CONCLUSION

VR's potential for improvement in outcomes for spinal pain that demonstrated statistical and/or clinical significance (pain intensity, disability, fear of movement, GPE, patient satisfaction, general health status, and balance) highlights the need for more focused, higher-quality research on the efficacy and effectiveness of VR for treatment of patients with spinal pain.

Is Xbox 360 Kinect-based virtual reality training as effective as standard physiotherapy in patients undergoing breast cancer surgery?

PURPOSE

Breast cancer surgery may be associated with pain and physical symptoms in the upper limbs. Functional impairment and pain-related avoidance of movement may further increase disability level. This study aimed to investigate the potential effects of early postoperative virtual reality (VR) therapy on pain, range of motion (ROM), muscle strength, functionality, and fear of movement.

METHODS

Forty women with breast cancer who had undergone unilateral mastectomy with axillary lymph node dissection and who were receiving adjuvant therapy were included in the study and randomly assigned to two groups: the Kinect-based rehabilitation group (KBRG) and the standardized physical therapy group (SPTG). The KBRG (n = 20) received VR therapy using Xbox Kinect-based games and the SPTG (n = 20) received standard physiotherapy. Study subjects were assessed at baseline and after the 6-week treatment. Outcome measures were pain (visual analogue scale), grip strength (dynamometer), functionality (disabilities of the arm shoulder and hand questionnaire), muscle strength (handheld dynamometer), ROM (digital goniometer), and fear of movement (Tampa kinesiophobia scale (TKS)).

RESULTS

Both groups detected significant changes in pain, ROM, muscle strength, grip strength, functionality, and TKS scores after the treatment (p < 0.01). Fear of movement was significantly improved in the KBRG and the SPTG displayed more improvement in functionality (p < 0.05). There were no differences in ROM, muscle strength, grip strength, and pain between the groups after the treatment (p > 0.05).

CONCLUSION

Kinect-based VR therapy resulted in significant outcomes that were comparable to those obtained under standard physiotherapy in the early postoperative phase in patients who had undergone breast cancer surgery.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov ( ClinicalTrials.gov identifier: NCT03618433).

Is Virtual Reality Effective in Orthopedic Rehabilitation? A Systematic Review and Meta-Analysis

BACKGROUND

Virtual reality (VR) is an interactive technology that allows customized treatment and may help in delivering effective person-centered rehabilitation.

PURPOSE

The purpose of this review was to systematically review and critically appraise the controlled clinical trials that investigated VR effectiveness in orthopedic rehabilitation.

DATA SOURCES

Pubmed, CINAHL, Embase, PEDro, REHABDATA, and Sage publications were searched up to September 2018. In addition, manual searching and snowballing using Scopus and Web of Science were done.

STUDY SELECTION

Two reviewers screened studies for eligibility first by title and abstract and then full text.

DATA EXTRACTION

Articles were categorized into general or region-specific (upper limbs, lower limbs, and spine) orthopedic disorders. Study quality was assessed using the Evaluation Guidelines for Rating the Quality of an Intervention Study scoring. Meta-analysis quantified VR effectiveness, compared with no treatment, in back pain.

DATA SYNTHESIS

Nineteen studies were included in the quality assessment. The majority of the studies were of moderate quality. Fourteen studies showed that VR did not differ compared with exercises. Compared with the no-treatment control, 5 studies favored VR and 3 other studies showed no differences. For low back pain, the meta-analysis revealed no significant difference between VR and no-treatment control (n = 116; standardized mean difference = -0.21; 95% confidence interval = -0.58 to 0.15).

LIMITATIONS

Limitations included heterogeneity in interventions and the outcome measures of reviewed studies. Only articles in English were included.

CONCLUSION

The evidence of VR effectiveness is promising in chronic neck pain and shoulder impingement syndrome. VR and exercises have similar effects in rheumatoid arthritis, knee arthritis, ankle instability, and post-anterior cruciate reconstruction. For fibromyalgia and back pain, as well as after knee arthroplasty, the evidence of VR effectiveness compared with exercise is absent or inconclusive.

State-of-the-Art Exercise Concepts for Lumbopelvic and Spinal Muscles - Transferability to Microgravity

Low back pain (LBP) is the leading cause of disability worldwide. Over the last three decades, changes to key recommendations in clinical practice guidelines for management of LBP have placed greater emphasis on self-management and utilization of exercise programs targeting improvements in function. Recommendations have also suggested that physical treatments for persistent LBP should be tailored to the individual. This mini review will draw parallels between changes, which occur to the neuromuscular system in microgravity and conditions such as LBP which occur on Earth. Prolonged exposure to microgravity is associated with both LBP and muscle atrophy of the intrinsic muscles of the spine, including the lumbar multifidus. The finding of atrophy of spinal muscles has also commonly been reported in terrestrial LBP sufferers. Studying astronauts provides a unique perspective and valuable model for testing the effectiveness of exercise interventions, which have been developed on Earth. One such approach is motor control training, which is a broad term that can include all the sensory and motor aspects of spinal motor function. There is evidence to support the use of this exercise approach, but unlike changes seen in muscles of LBP sufferers on Earth, the changes induced by exposure to microgravity are rapid, and are relatively consistent in nature. Drawing parallels between changes which occur to the neuromuscular system in the absence of gravity and which exercises best restore size and function could help health professionals tailor improved interventions for terrestrial populations.

Benefits of 24-Week Exergame Intervention on Health-Related Quality of Life and Pain in Women with Fibromyalgia: A Single-Blind, Randomized Controlled Trial

Objective: To evaluate the effects of 24-week exergame-based intervention on health-related quality of life (HRQoL) and pain in patients with fibromyalgia as well as to analyze the effectiveness of the intervention in subgroups of patients with different pain intensity levels. Design: Single-blinded, randomized controlled trial. Setting: University facilities Participants: Fifty-five women with fibromyalgia participated in the study. Intervention: The exercise group (EG) completed 24 weeks of exergames focused on mobility, postural control, upper and lower limbs coordination, aerobic fitness, and strength. A total of 120 minutes per week, divided into two sessions of 60 minutes, was completed. Main outcome measures: The Euroqol-5 Dimensions-5 Levels (EQ-5D-5L) was used to assess the HRQoL. In addition, pain intensity was measured using a visual analog scale (VAS). Results: Twenty-five out of 28 women allocated to the EG completed the intervention, which means an 89.29% of adherence. They were randomly divided into an exercise (age = 54.04 [8.45]) and a control group (52.72 [9.98]). Significant effects on the perceived health status and pain intensity (P < 0.05) were found. K-means clustering procedure revealed two groups with different response to the intervention. The respond group obtained significant effects of the exergame intervention in EQ-5D-5L, pain VAS, and VAS-EQ, compared with those who did not respond. Conclusions: Exergames could be a useful tool to improve perceived health status and pain intensity level in women with fibromyalgia with a reduced health-related quality of life.

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.

Yoga: Can it be integrated with treatment of neuropathic pain?

Background

Neuropathic pain (NP) is a debilitating condition that may result from spinal cord injury (SCI). Nearly 75% of all SCI results in NP affecting 17,000 new individuals in the United States every year, and an estimated 7–10% of people worldwide. It is caused by damaged or dysfunctional nerve fibers sending aberrant signals to pain centers in the central nervous system causing severe pain that affects daily life and routine. The mechanisms underlying NP are not fully understood, making treatment difficult. Identification of specific molecular pathways that are involved in pain syndromes and finding effective treatments has become a major priority in current SCI research. Yoga has therapeutic applications may prove beneficial in treating subjects suffering chronically with SCI induced NP, chronic back and associated pains if necessary experimental data is generated

Summary

This review aims to discuss the implications of various mechanistic approaches of yoga which can be tested by new study designs around various nociceptive molecules including matrix metalloproteinases (MMPs), cation-dependent chloride transporter (NKCC1) etc in SCI induced NP patients.

Key messages

Thus, yogic practices could be used in managing SCI induced NP pain by regulating the action of various mechanisms and its associated molecules. Modern prescriptive treatment strategies combined with alternative approaches like yoga should be used in rehabilitation centers and clinics in order to ameliorate chronic NP. We recommend practical considerations of careful yoga practice as part of an integrative medicine approach for NP associated with SCI.

Video-Game-Based Exercises for Older People With Chronic Low Back Pain: A Randomized Controlledtable Trial (GAMEBACK)

Background

Video game technology increases adherence to home exercise and could support self-management for older people with chronic low back pain (LBP).

Objective

The objective was to investigate the effects of home-based video game exercises on pain self-efficacy and care-seeking in older people with chronic LBP.

Design

The study was a randomized controlled trial.

Setting

The setting was a community and waiting list.

Participants

Sixty participants, aged > 55 years with chronic LBP, were randomized (1:1) to Wii Fit U exercises or to continue their usual activities for 8 weeks.

Intervention

The intervention was home-based Wii Fit U flexibility, strengthening, and aerobic exercises for 60 minutes, 3 times per week, with fortnightly calls from a physical therapist.

Measurements

Measurements included pain self-efficacy and care-seeking (primary outcomes), and physical activity, pain, function, disability, fear of movement/reinjury, falls efficacy, recruitment and response rates, adherence, experience with the intervention, and adverse events (secondary outcomes).

Results

The mean age of participants was 67.8 (standard deviation = 6.0) years. Adherence to the total recommended exercise time was 70.8%, and no adverse events were reported. Participants completing Wii Fit U exercises had significantly higher pain self-efficacy at 6 months, but not immediately postintervention or at 3 months; there were no between-group differences in care-seeking. Compared with the control group, participants completing Wii Fit U exercises demonstrated significantly greater improvements in pain and function at 8 weeks and were more likely to engage in flexibility exercises at 6 months. There were no significant between-group differences for the remaining outcomes.

Limitations

Participants and therapists were not blinded.

Conclusions

Wii Fit U exercises improved pain self-efficacy at 6 months, and pain and function immediately postintervention in older people with chronic LBP, but the clinical importance of these changes is questionable. Wii Fit U exercises had no effect on care-seeking, physical activity, disability, fear of movement/reinjury, or falls efficacy.

Effects of Mantra Meditation versus Music Listening on Knee Pain, Function, and Related Outcomes in Older Adults with Knee Osteoarthritis: An Exploratory Randomized Clinical Trial (RCT)

OBJECTIVE

Disease-modifying treatments for OA remain elusive, and commonly used medications can have serious side effects. Although meditation and music listening (ML) have been shown to improve outcomes in certain chronic pain populations, research in OA is sparse. In this pilot RCT, we explore the effects of two mind-body practices, mantra meditation (MM) and ML, on knee pain, function, and related outcomes in adults with knee OA.

METHODS

Twenty-two older ambulatory adults diagnosed with knee OA were randomized to a MM (N=11) or ML program (N=11) and asked to practice 15-20 minutes, twice daily for 8 weeks. Core outcomes included knee pain (Knee Injury and Osteoarthritis Outcome Score [KOOS] and Numeric Rating Scale), knee function (KOOS), and perceived OA severity (Patient Global Assessment). Additional outcomes included perceived stress (Perceived Stress Scale), mood (Profile of Mood States), sleep (Pittsburgh Sleep Quality Index), and health-related quality of life (QOL, SF-36). Participants were assessed at baseline and following completion of the program.

RESULTS

Twenty participants (91%) completed the study (9 MM, 11 ML). Compliance was excellent; participants completed an average of 12.1±0.83 sessions/week. Relative to baseline, participants in both groups demonstrated improvement post-intervention in all core outcomes, including knee pain, function, and perceived OA severity, as well as improvement in mood, perceived stress, and QOL (Physical Health) (p's≤0.05). Relative to ML, the MM group showed greater improvements in overall mood and sleep (p's≤0.04), QOL-Mental Health (p<0.07), kinesiophobia (p=0.09), and two domains of the KOOS (p's<0.09).

CONCLUSIONS

Findings of this exploratory RCT suggest that a simple MM and, possibly, ML program may be effective in reducing knee pain and dysfunction, decreasing stress, and improving mood, sleep, and QOL in adults with knee OA.

The contribution of Nintendo Wii Fit series in the field of health: a systematic review and meta-analysis

Background

Wii Fit was originally designed as a health and fitness interactive training experience for the general public. There are, however, many examples of Wii Fit being utilized in clinical settings. This article aims to identify the contribution of Wii Fit in the field of health promotion and rehabilitation by: (1) identifying the health-related domains for which the Wii Fit series has been tested, (2) clarifying the effect of Wii Fit in those identified health-related domains and (3) quantifying this effect.

Method

A systematic literature review was undertaken. The MEDLINE database and Games for Health Journal published content were explored using the search term “Wii-Fit.” Occurrences resulting from manual searches on Google and material suggested by experts in the field were also considered. Included articles were required to have measurements from Wii Fit activities for at least one relevant health indicator. The effect of Wii Fit interventions was assessed using meta-analyses for the following outcomes: activity-specific balance confidence score, Berg balance score (BBC) and time-up-and-go test (TUG).

Findings

A total of 115 articles highlighted that the Wii Fit has been tested in numerous healthy and pathological populations. Out of these, only a few intervention studies have focused on the prevention of chronic diseases. A large proportion of the studies focus on balance training (N = 55). This systematic review highlights several potential benefits of Wii Fit interventions and these positive observations are supported by meta-analyses data (N = 25). For example, the BBC and the TUG respond to a similar extend to Wii Fit interventions compared with traditional training.

Conclusion

Wii Fit has the potential to be used as a rehabilitation tool in different clinical situations. However, the current literature includes relatively few randomized controlled trials in each population. Further research is therefore required.

Effects of Exergames on Quality of Life, Pain, and Disease Effect in Women With Fibromyalgia: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effects of an exergame-based intervention on a population sample of women with fibromyalgia.

DESIGN

Single-blinded, randomized controlled trial with 8-week intervention.

SETTING

Fibromyalgia center.

PARTICIPANTS

Participants (all women) (N=83) were divided into 2 groups: an exercise group (n=42; mean age ± SD, 52.52±9.73y) and a nonexercise group (n=41; mean age ± SD, 52.47±8.75y).

INTERVENTIONS

Women in the exercise group completed an 8-week exergame-based training program, which was focused on postural control and coordination of the upper and lower limbs, aerobic conditioning, strength, and mobility. Women (groups of 3) were encouraged to exercise for 120 minutes (over 2 sessions) per week.

MAIN OUTCOME MEASURES

Main outcome measures included pain and disease effect, which were assessed with the Fibromyalgia Impact Questionnaire (FIQ), a specific measure for fibromyalgia. Secondary outcome measure included quality of life, which was assessed with the EuroQoL-5 Dimensions-5 Levels (EQ-5D-5L) generic instrument.

RESULTS

The results showed that 97.62% of participants in the exercise group completed the 8-week intervention. The exercise group showed a significant improvement (P<.05) in the EQ-5D-5L utility index, and in 3 of 5 dimensions. For the FIQ, significant improvements were observed in the dimensions of pain, stiffness, anxiety, and feel good. The FIQ score was also reduced. The mean between-group improvement was 8.25 (95% confidence interval, 2.85-13.65).

CONCLUSIONS

The results and levels of compliance/adherence suggest this exergame-based training program is an effective intervention for reducing pain and increasing health-related quality of life in women with fibromyalgia.

Support of mathematical thinking through embodied cognition: Nondigital and digital approaches

Research on mathematics education has shown that learners’ actions can influence how they think and vice versa. Much of this work has been rooted in the use of manipulatives, gestures, and body movements. Our article dissects the mechanisms that underscore the impact of embodied activities and applies this lens to explore how to harness the affordances of new technology to enhance mathematical thinking. This is especially crucial given the increasing accessibility of technology—such as digital touch devices, 3D printers, and location sensors—for constructing embodied experiences. Providing guidance for incorporating those tools, we focus on the role that embodied cognition can play in communicating mathematical concepts as well as in allowing learners to experiment and evolve their ideas. To inspire future integration of theory in the development of technologically enhanced embodied mathematics experiences, we provide examples of how this can be done. Finally, we outline future directions in the areas of design, implementation, and assessment of embodied learning of mathematics.

Yoga treatment for chronic non-specific low back pain

BACKGROUND

Non-specific low back pain is a common, potentially disabling condition usually treated with self-care and non-prescription medication. For chronic low back pain, current guidelines state that exercise therapy may be beneficial. Yoga is a mind-body exercise sometimes used for non-specific low back pain.

OBJECTIVES

To assess the effects of yoga for treating chronic non-specific low back pain, compared to no specific treatment, a minimal intervention (e.g. education), or another active treatment, with a focus on pain, function, and adverse events.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and four trials registers to 11 March 2016 without restriction of language or publication status. We screened reference lists and contacted experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials of yoga treatment in people with chronic non-specific low back pain. We included studies comparing yoga to any other intervention or to no intervention. We also included studies comparing yoga as an adjunct to other therapies, versus those other therapies alone.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected studies, extracted outcome data, and assessed risk of bias. We contacted study authors to obtain missing or unclear information. We evaluated the overall certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 12 trials (1080 participants) carried out in the USA (seven trials), India (three trials), and the UK (two trials). Studies were unfunded (one trial), funded by a yoga institution (one trial), funded by non-profit or government sources (seven trials), or did not report on funding (three trials). Most trials used Iyengar, Hatha, or Viniyoga forms of yoga. The trials compared yoga to no intervention or a non-exercise intervention such as education (seven trials), an exercise intervention (three trials), or both exercise and non-exercise interventions (two trials). All trials were at high risk of performance and detection bias because participants and providers were not blinded to treatment assignment, and outcomes were self-assessed. Therefore, we downgraded all outcomes to 'moderate' certainty evidence because of risk of bias, and when there was additional serious risk of bias, unexplained heterogeneity between studies, or the analyses were imprecise, we downgraded the certainty of the evidence further.For yoga compared to non-exercise controls (9 trials; 810 participants), there was low-certainty evidence that yoga produced small to moderate improvements in back-related function at three to four months (standardized mean difference (SMD) -0.40, 95% confidence interval (CI) -0.66 to -0.14; corresponding to a change in the Roland-Morris Disability Questionnaire of mean difference (MD) -2.18, 95% -3.60 to -0.76), moderate-certainty evidence for small to moderate improvements at six months (SMD -0.44, 95% CI -0.66 to -0.22; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -2.15, 95% -3.23 to -1.08), and low-certainty evidence for small improvements at 12 months (SMD -0.26, 95% CI -0.46 to -0.05; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -1.36, 95% -2.41 to -0.26). On a 0-100 scale there was very low- to moderate-certainty evidence that yoga was slightly better for pain at three to four months (MD -4.55, 95% CI -7.04 to -2.06), six months (MD -7.81, 95% CI -13.37 to -2.25), and 12 months (MD -5.40, 95% CI -14.50 to -3.70), however we pre-defined clinically significant changes in pain as 15 points or greater and this threshold was not met. Based on information from six trials, there was moderate-certainty evidence that the risk of adverse events, primarily increased back pain, was higher in yoga than in non-exercise controls (risk difference (RD) 5%, 95% CI 2% to 8%).For yoga compared to non-yoga exercise controls (4 trials; 394 participants), there was very-low-certainty evidence for little or no difference in back-related function at three months (SMD -0.22, 95% CI -0.65 to 0.20; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.99, 95% -2.87 to 0.90) and six months (SMD -0.20, 95% CI -0.59 to 0.19; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.90, 95% -2.61 to 0.81), and no information on back-related function after six months. There was very low-certainty evidence for lower pain on a 0-100 scale at seven months (MD -20.40, 95% CI -25.48 to -15.32), and no information on pain at three months or after seven months. Based on information from three trials, there was low-certainty evidence for no difference in the risk of adverse events between yoga and non-yoga exercise controls (RD 1%, 95% CI -4% to 6%).For yoga added to exercise compared to exercise alone (1 trial; 24 participants), there was very-low-certainty evidence for little or no difference at 10 weeks in back-related function (SMD -0.60, 95% CI -1.42 to 0.22; corresponding to a change in the Oswestry Disability Index of MD -17.05, 95% -22.96 to 11.14) or pain on a 0-100 scale (MD -3.20, 95% CI -13.76 to 7.36). There was no information on outcomes at other time points. There was no information on adverse events.Studies provided limited evidence on risk of clinical improvement, measures of quality of life, and depression. There was no evidence on work-related disability.

AUTHORS' CONCLUSIONS

There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months. Yoga may also be slightly more effective for pain at three and six months, however the effect size did not meet predefined levels of minimum clinical importance. It is uncertain whether there is any difference between yoga and other exercise for back-related function or pain, or whether yoga added to exercise is more effective than exercise alone. Yoga is associated with more adverse events than non-exercise controls, but may have the same risk of adverse events as other back-focused exercise. Yoga is not associated with serious adverse events. There is a need for additional high-quality research to improve confidence in estimates of effect, to evaluate long-term outcomes, and to provide additional information on comparisons between yoga and other exercise for chronic non-specific low back pain.

Motor Ingredients Derived from a Wearable Sensor-Based Virtual Reality System for Frozen Shoulder Rehabilitation

Objective. This study aims to extract motor ingredients through data mining from wearable sensors in a virtual reality goal-directed shoulder rehabilitation (GDSR) system and to examine their effects toward clinical assessment. Design. A single-group before/after comparison. Setting. Outpatient research hospital. Subjects. 16 patients with frozen shoulder. Interventions. The rehabilitation treatment involved GDSR exercises, hot pack, and interferential therapy. All patients first received hot pack and interferential therapy on the shoulder joints before engaging in the exercises. The GDSR exercise sessions were 40 minutes twice a week for 4 weeks. Main Measures. Clinical assessments included Constant and Murley score, range of motion of the shoulder, and muscle strength of upper arm as main measures. Motor indices from sensor data and task performance were measured as secondary measures. Results. The pre- and posttest results for task performance, motor indices, and the clinical assessments indicated significant improvement for the majority of the assessed items. Correlation analysis between the task performance and clinical assessments revealed significant correlations among a number of items. Stepwise regression analysis showed that task performance effectively predicted the results of several clinical assessment items. Conclusions. The motor ingredients derived from the wearable sensor and task performance are applicable and adequate to examine and predict clinical improvement after GDSR training.

Video-game based exercises for older people with chronic low back pain: a protocol for a feasibility randomised controlled trial (the GAMEBACK trial)

OBJECTIVES

To investigate the feasibility of implementing a video-game exercise programme for older people with chronic low back pain (LBP).

DESIGN

Single-centred single-blinded randomised controlled trial (RCT).

SETTING

Physiotherapy outpatient department in a public hospital in Western Sydney, Australia.

PARTICIPANTS

We will recruit 60 participants over 55 years old with chronic LBP from the waiting list.

INTERVENTIONS

Participants will be randomised to receive video-game exercise (n=30) or to remain on the waiting list (n=30) for 8 weeks, with follow up at 3 and 6 months. Participants engaging in video-game exercises will be unsupervised and will complete video-game exercise for 60minutes, 3 times per week. Participants allocated to remain on the waiting list will be encouraged to maintain their usual levels of physical activity.

MAIN OUTCOME MEASURE

The primary outcomes for this feasibility study will be study processes (recruitment and response rates, adherence to and experience with the intervention, and incidence of adverse events) relevant to the future design of a large RCT. Estimates of treatment efficacy (point estimates and 95% confidence intervals) on pain self-efficacy, care seeking, physical activity, fear of movement/re-injury, pain, physical function, disability, falls-efficacy, strength, and walking speed, will be our secondary outcome measures.

RESULTS

Recruitment for this trial began in November 2015.

CONCLUSION

This study describes the rationale and processes of a feasibility study investigating a video-game exercise programme for older people with chronic LBP. Results from the feasibility study will inform on the design and sample required for a large multicentre RCT.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12615000703505.

A systematic review and meta-analysis on the effects of yoga on weight-related outcomes

INTRODUCTION

Overweight and obesity are among the most important modifiable risk factors for chronic diseases and premature death. The aim of this review was to systematically assess and analyze the effects of yoga on weight-related outcomes.

METHODS

Medline/PubMed, Scopus, and the Cochrane Library were screened through March 2015 for randomized controlled trials on yoga for weight-related outcomes in the general population or overweight/obese individuals. Risk of bias was assessed using the Cochrane risk of bias tool on the following domains: selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias.

RESULTS

Out of 445 records identified during literature search, 30 trials with a total of 2173 participants were included. No effects on weight, body mass index, body fat percentage or waist circumference were found. In studies with healthy adult participants an effect of yoga compared to usual care was found regarding waist/hip ratio (SMD=--1.00; 95% CI=--1.44, -0.55; p<0.001). In studies with overweight/obese participants only, effects relative to usual care were found for body mass index (SMD=-0.99; 95% CI=-1.67, -0.31; p=0.004). Effects however were not robust against selection bias; and publication bias could not be ruled out. No intervention-related adverse events were reported.

CONCLUSIONS

Despite methodological drawbacks, yoga can be preliminarily considered a safe and effective intervention to reduce body mass index in overweight or obese individuals.