Patient perspectives on virtual reality-based rehabilitation after knee surgery: Importance of level of difficulty

Virtual reality-based therapy after anterior cruciate ligament injury effectively reduces pain and improves knee function, movement patterns, and dynamic balance: A systematic review and meta-analysis

PURPOSE

Virtual reality-based therapy (VRBT) may be an effective physical therapy complement employed in the rehabilitation of patients with anterior cruciate ligament (ACL) injury. This study aims to assess the effectiveness of VRBT in improving pain, knee function, strength, proprioception, flexion range of motion (ROM), and dynamic balance after ACL injury.

METHODS

We conducted this systematic review with meta-analysis following PRISMA criteria. Since inception to June 2024, we searched in PubMed Medline, WOS, SCOPUS, CINAHL and PEDro without publication date and language restrictions. Randomised controlled trials (RCTs), comprising only patients with ACL injury, that assess the effectiveness of VRBT compared to classical interventions on the outcomes of interest were included. PEDro scale was employed to analyze the methodological quality of the RCTs included. Cohen's standardised mean difference (SMD) and its 95% confidence interval (95% CI) was used to calculate the pooled effect in meta-analyses.

RESULTS

Nine RCTs, providing data from 330 participants (26.96 ± 3.11 years, 85% males) were included. The RCTs included showed good methodological quality (PEDro scale = 6.88 points), being, performance and detection biases, the most common biases reported. Meta-analyses showed that VRBT was more effective than classical interventions in reducing pain (SMD = -1.15; 95% CI -1.85 to -0.45; p = 0.001; I2 = 0%), and increasing knee function (SMD = 1.71; 95% CI 0.93 to 2.5; p < 0.001; I2 = 0%), strength (SMD = 0.82; 95% CI 0.4-1.23; p < 0.001; I2 = 0%) and flexion ROM (SMD = 0.7; 95% CI 0.37-1.01; p < 0.001; I2 = 0%). Additionally, VRBT improved postero-medial (SMD = 0.46; 95% CI 0.01-0.9; p = 0.045; I2 = 15.1%) and postero-lateral CoP excursion (SMD = 0.75; 95% CI 0.3-1.21; p = 0.001; I2 = 0%), being effective in improving dynamic balance.

CONCLUSION

VRBT is an effective physical therapy complement to be included in the ACL's rehabilitation programmes due to reduces pain and increases knee function, strength, ROM and dynamic balance after ACL injury.

LEVEL OF EVIDENCE

Level II evidence.

Recreational cycling provides greater satisfaction and flow in an immersive virtual environment than in real life

BACKGROUND

As the state of satisfaction and flow involved in the physical activity (PA) determines future training commitment, it is undoubtedly very important to study the factors influencing the attractiveness of PA. One of such factors is the usage of virtual reality (VR) technology which creates opportunities for its users to practice various forms of PA in a altered way. It is interesting whether PA practiced in a virtual environment can offer higher levels of satisfaction and flow comparing with PA practiced in the real world. Positive answer to this question support the statement that the use of such technology could contribute to the future commitment in PA. Therefore, in order to find out whether PA in VR can be an attractive alternative towards the PA in a real world, the research should be undertaken to verify if the state of satisfaction and flow involved in the practising certain PA in the VR environment could be higher comparing to the levels of pleasure and flow connected with the same PA carried out in the real world.

OBJECTIVE

The main objective of the study was to assess the level of satisfaction and flow experienced by healthy adults during various cycling conditions: real life (RL), non-immersive and immersive virtual reality (nIVR and IVR). Additionally, questionnaires for assessing satisfaction with PA and flow in RL and VR were also validated in terms of their measurement reliability. The correlation of the results obtained during tests using both measurement tools was also assessed.

METHODS

Forty students were studied, including 20 women (age 22.35 ± 2.32 years) and 20 men (age 22.95 ± 2.19 years). The Physical Activity Enjoyment Scale (PACES) was used to evaluate the enjoyment of cycling. Flow state was assessed using The Flow State Scale (FSS).

RESULTS

Based on Friedman's analysis of variance regarding the results obtained for all the respondents, it can be concluded that the conditions of cycling significantly affect their level of satisfaction (χ2 = 85.61(40;3); p < 0.001) and flow (χ2 = 40.52(40;3); p < 0.001). The research participants rated cycling the highest in IVR. Based on the calculated Cronbach's alpha coefficients, high measurement reliability of the questionnaires used in nIVR (PACES, α = 0.94; FFS-2, α = 0.86) and IVR (PACES, α = 0.89; FFS-2, α = 0.91). There was also a significant positive moderate correlation between PA satisfaction and user flow.

CONCLUSIONS

The research is the first attempt to directly compare the sense of satisfaction and flow when practicing cycling in RL and in nIVR and IVR. The greater attractiveness and higher level of flow during PA in IVR compared to a similar traditional form of PA in RL, found on the basis of the conducted research, should prompt reflection by both those involved in planning and promoting PA, as well as the creators of active video games (AVGs). Due to the great attractiveness of PA in IVR and the constant, dynamic development of immersive information technologies, virtual training may, in the near future, become not only an important supplement to conventional forms of exercise, but perhaps even an alternative solution.

Mobile and Computer-Based Applications for Rehabilitation Monitoring and Self-Management After Knee Arthroplasty: Scoping Review

BACKGROUND

Successful post-knee replacement rehabilitation requires adequate access to health information, social support, and periodic monitoring by a health professional. Mobile health (mHealth) and computer-based technologies are used for rehabilitation and remote monitoring. The extent of technology use and its function in post-knee replacement rehabilitation care in low and middle-income settings are unknown.

OBJECTIVE

To inform future mHealth intervention development, we conducted a scoping review to map the features and functionality of existing technologies and determine users' perspectives on telerehabilitation and technology for self-management.

METHODS

We followed the Joanna Briggs Institute methodology for scoping reviews. We searched the Embase, Medline, PsycINFO via OVID, and Cochrane Central Register of Controlled Trials databases for manuscripts published from 2001 onward. We included original research articles reporting the use of mobile or computer-based technologies by patients, health care providers, researchers, or family members. Studies were divided into the following 3 categories based on the purpose: validation studies, clinical evaluation, and end user feedback. We extracted general information on study design, technology features, proposed function, and perspectives of health care providers and patients. The protocol for this review is accessible in the Open Science Framework.

RESULTS

Of the 5960 articles, 158 that reported from high-income settings contributed to the qualitative summary (64 studies on mHealth or telerehabilitation programs, 28 validation studies, 38 studies describing users' perceptions). The highest numbers of studies were from Europe or the United Kingdom and North America regarding the use of a mobile app with or without wearables and reported mainly in the last decade. No studies were from low and middle-income settings. The primary functions of technology for remote rehabilitation were education to aid recovery and enable regular, appropriate exercises; monitoring progress of pain (n=19), activity (n=20), and exercise adherence (n=30); 1 or 2-way communication with health care professionals to facilitate the continuum of care (n=51); and goal setting (n=23). Assessment of range of motion (n=16) and gait analysis (n=10) were the commonly validated technologies developed to incorporate into a future rehabilitation program. Few studies (n=14) reported end user involvement during the development stage. We summarized the reasons for satisfaction and dissatisfaction among users across various technologies.

CONCLUSIONS

Several existing mobile and computer-based technologies facilitate post-knee replacement rehabilitation care for patients and health care providers. However, they are limited to high-income settings and may not be extrapolated to low-income settings. A systematic needs assessment of patients undergoing knee replacement and health care providers involved in rehabilitation, involving end users at all stages of development and evaluation, with clear reporting of the development and clinical evaluation can make post-knee replacement rehabilitation care in resource-poor settings accessible and cost-effective.

Clinical Applications of Virtual Reality in Musculoskeletal Rehabilitation: A Scoping Review

(1) Background: VR is based on a virtual world that creates sounds effects and videos that replace the real environment. Arising literature shows VR efficacy in the field of neurological rehabilitation (NR) and that its use is also taking a place in musculoskeletal rehabilitation (MSR), as a treatment of various disorders that cause disability and chronic pain. (2) Aim: We discuss the role of VR in MSR, presenting its use and development on acute and chronic musculoskeletal disorders, based on the most recent literature. (3) Design and Methods: Literature searches were conducted in the databases Pubmed and Medline up to 30 September 2023. The PRISMA-Scr Checklist was followed. (4) Results: A total of 51 records were included. The analysed studies were conducted within a variety of populations, musculoskeletal disorders, settings, and VR technologies. Only a few studies could statistically affirm the efficacy of VR in MSR, as mentioned for the rehabilitation of the upper limb. Nevertheless, the observed trend is an improvement of the global perceived effect compared to traditional rehabilitation. (5) Conclusion: VR allows for the personalisation of treatment with an adaptable treatment platform, which may improve the participation of the patient and increase acceptability and adherence to long-term rehabilitation programs. We provide recommendations and suggestions for future research and use of VR in musculoskeletal rehabilitation.

Comparison between the effect of immersive virtual reality training versus conventional rehabilitation on limb loading and functional outcomes in patients after anterior cruciate ligament reconstruction: A prospective randomized controlled trial

Purpose

Anterior cruciate ligament injury (ACL) commonly occurs during sporting events. It causes pain, instability and reduction in range of movement of the knee which results in altered balance, reduced strength as well as loading to the involved knee. The challenge to get the patient back to competitive sports level much depends on the rehabilitation process. Post ACLR rehabilitation is challenging due to the long rehabilitation time as well as boring repetitive exercises. The aim of this study is to compare between the effectiveness of using immersive virtual reality (PlayStation VR) in addition to the conventional rehabilitation as an aid in rehabilitation of patients after ACLR in terms of objective functional assessment and pain and subjective knee function scoring.

Methods

This randomised controlled trial was undertaken in a tertiary hospital in Malaysia from July 2019 until July 2020. Thirty patients were randomised into a group undergoing purely conventional rehabilitation (Group 1) and a group undergoing both conventional rehabilitation and immersive virtual reality assisted rehabilitation (Group 2). The immersive virtual reality assisted rehabilitation was started at 3 months post operatively for 3 months duration. Limb loading, balance, range of motion, functional hop tests of the knee, pain and subjective scoring of the knee with the International Knee Documentation Committee (IKDC) Scores were measured preoperatively and at 6 months.

Results

There were significant differences in terms of improvement of pain scores (p = 0.012) as well as IKDC Scores (p = 0.024) in Group 2 as compared to Group 1. However, there were no significant differences with regards to limb loading, balance, range of motion and functional hop tests of the knee (p > 0.05). No adverse events were observed during the study period.

Conclusion

Immersive virtual reality can be used as an adjunct in rehabilitation of patients after ACL reconstruction in terms of improving their pain as well as their subjective knee evaluation. Large randomised control trial is recommended to further investigate the efficacy.

The use of virtual reality hypnosis for prostate cancer patients during transperineal biopsy/gold seed implantation: A needs assessment study

BACKGROUND

Patients having radiation therapy treatment to the prostate may require invasive preparation procedures under local anesthesia (LA), such as the insertion of gold seeds into the prostate or targeted biopsies. These procedures can induce pain and anxiety for some patients. Virtual Reality Hypnosis (VRH) is the combination of a 360-degree video display with audio and mental guides for relaxation and distraction during medical procedures. The objective of this research was to assess the level of patient interest in the use of VRH during gold seed insertion and biopsy, and to identify a subset of patients that would be most likely to benefit from the use of VRH.

METHODS

This single arm, prospective pilot study included patients who were receiving biopsy and/or gold seed insertion using a 2-step LA procedure. Participants were asked to complete a questionnaire about their level of knowledge and interest in VRH before and after their procedure. At the same time, pain and anxiety levels were collected before and after the procedure, as well as during each LA step and at the mid-seed drop/biopsy core extraction. A visual analogue scale for pain and the National Comprehensive Cancer Network's Distress Thermometer were used to verbally rate pain and distress respectively. Descriptive statistics and Pearson's correlation coefficient were calculated for all variables of interest.

RESULTS

24 patients were recruited and 1 had their procedure cancelled, so a total of 23 patients completed this study. 74% of patients (n=23) agreed to try VRH before their procedures, whereas 65% of patients (n=23) were willing to try VRH after the procedure. Pain scores were highest at deep LA injection (mean= 5.48, SD= 2.56) and distress scores were also highest at deep LA injection (mean= 4.28, SD= 2.92). After the procedure, 83% of participants with pain scores above the mean at deep LA injection and 80% with anxiety scores above the mean at deep LA injection agreed that they would be willing to try VRH.

CONCLUSIONS

Patients with higher pain and distress scores had more interest in trying VRH with the standard LA for gold seed insertion/biopsy procedures. Patients with a history of lower pain tolerance or who express having experienced high levels of pain during previous biopsies will be the target population for using VRH in future trials to determine feasibility and effectiveness.

Virtual reality for pain management: an umbrella review

Background and objective

Virtual reality is a promising pain control strategy for various pain conditions. This umbrella review of systematic reviews and meta-analyses aims to evaluate the analgesic effects of virtual reality.

Methods

We searched for the relevant reviews in Scopus, PubMed and Cochrane library. Our primary outcome was pain, with secondary outcomes including disability, general health status, patient satisfaction, depression, balance, fear of movement, and adverse events. The quality of included articles was evaluated using the AMSTAR-2 tool.

Results

21 systematic reviews and meta-analyses with 274 studies and 17,680 patients were included in this review. All the reviews concluded benefits of virtual reality in managing pain conditions, including chronic and pain.

Discussion and conclusions

This umbrella review demonstrates successful application of virtual reality in pain control, including perioperative, periprocedural, and chronic pain settings. Virtual reality can be used as an alternative therapy for pain management in children and adults.

Technical aspects of virtual augmented reality-based rehabilitation systems for musculoskeletal disorders of the lower limbs: a systematic review

INTRODUCTION

Musculoskeletal disorders are one of the most common causes of physical disability. The rehabilitation process after musculoskeletal disorders is long and tedious, and patients are not motivated to follow rehabilitation protocols. Therefore, new systems must be used to increase patient motivation. Virtual reality (VR) and augmented reality (AR) technologies can be used in this regard. In developing such systems, various technologies and methods of movement recognition are used; therefore, this study aims to summarize the technical aspects of using VR/AR in rehabilitation and evaluate and discuss efficient methods of investigating studies using the Statement of Standards for Reporting Implementation Studies (StaRI).

METHODS

Search in four scientific databases was done systematically based on PRISMA through online search engines from inception to June 2021. These databases include Medline (PubMed), Scopus, IEEE, and Web of Science. An updated search was also conducted on 17 December 2021. The research used keywords and MeSH terms associated with VR/AR, musculoskeletal disorder, and rehabilitation. Selected articles were evaluated qualitatively using the Standards for Reporting Implementation Studies (StaRI) statement.

RESULTS

A total of 2343 articles were found, and 20 studies were included. We found that 11 (55%) studies used Kinect technology as input tools, and 15 (75%) studies have described the techniques used to analyze human movements, such as dynamic time warping (DTW) and support vector machines (SVM). In 10 (50%) studies, the Unity game engine was used for visualization. In 8 studies (40%), usability was assessed, and high usability was reported. Similarly, the results of the review of studies according to the StaRI checklist showed poor reporting in the title and discussion of the studies.

CONCLUSIONS

We found that academic studies did not describe the technical aspects of rehabilitation systems. Therefore, a good description of the technical aspects of the system in such studies should be considered to provide repeatability and generalizability of these systems for investigations by other researchers.

Licensing Effect of Pro-Environmental Behavior in Metaverse

The Metaverse is an important virtual venue in people's daily lives. This study examined whether pro-environmental behaviors in the Metaverse with a self-customized avatar lead to licensing effects, thereby reducing pro-environmental intention in reality. In addition, the study examined the mediating effect of self-presence on the relationship between avatar customization and pro-environmental behavior. A laboratory experiment was conducted using ZEPETO, a Metaverse platform. A total of 60 participants were randomly assigned to the self-customized avatar condition or the assigned avatar condition, and they engaged in pro-environmental behaviors on the Metaverse platform. Participants with self-customized avatars had less intention to engage in pro-environmental behavior in reality after engaging in pro-environmental behavior in the Metaverse than those with assigned avatars. Furthermore, self-presence partially mediated the relationship between avatar customization and pro-environmental intention.

Effectiveness of Early Rehabilitation with Exergaming in Virtual Reality on Gait in Patients after Total Knee Replacement

Total knee replacement (TKR) is the treatment of choice for advanced stages of osteoarthritis but it requires good postoperative rehabilitation. This study aimed to assess the effectiveness of exercises using virtual reality to improve gait parameters in patients after TKR. Fifty-nine patients 7−14 days after TKR surgery were divided into a study group (VRG, n = 38) and a control group (CG, n = 21). Both groups underwent the same 4-week rehabilitation protocol. The VRG group had 12 additional nonimmersive virtual reality game sessions on the Virtual Balance Clinic prototype system at 30 min each, focusing on gait and balance improvement. Spatiotemporal, force and foot plantar pressure parameters were collected on an instrumented treadmill during a 30 s walk. The most significant improvement was in the symmetry indices of forefoot force, maximum forefoot force, loading response time, and preswing time (p < 0.05) in both groups. Gait speed increased by 31.25% and 44% in the VRG and CG groups, respectively (p < 0.005). However, the extra exergaming sessions did not significantly improve rehabilitation outcomes. Therefore, additional VR training does not improve gait better than standard rehabilitation alone, but the improvement of gait, especially its symmetry, is significant within the first six weeks after surgery.

Virtual Reality Game for Physical and Emotional Rehabilitation of Landmine Victims

Landmine victims require an engaging and immersive rehabilitation process to maintain motivation and therapeutic adherence, such as virtual reality games. This paper proposes a virtual reality exercise game called Exogames, which works with Nukawa, a lower limb rehabilitation robot (LLRR). Together, they constitute the general Kina system. The design and development process of Exogames is reported, as well as the evaluation of its potential for physical and emotional rehabilitation. In an initial survey designed ad-hoc, 13 health professionals evaluated compliance with various requirements. They agreed that Exogames would help the user focus on rehabilitation by providing motivation; 92.3% said that the user will feel safe in the virtual world, 66.7% of them agreed or totally agreed that it presents characteristics that may enhance the physical rehabilitation of lower limbs for amputees, 83.3% stated that it would promote the welfare of landmine victims, and 76.9% responded that the graphical interface and data report are useful for real-time assessment, and would be helpful for four interventional areas in all rehabilitation stages. In a second evaluation, using standardized surveys, five physical therapists and one lower limb amputee tried the Kina system as users. They filled out the System Usability Scale (SUS), the Physical Activity Enjoyment Scale (PACES), and the Game Experience Questionnaire (GEQ). The usability of the Kina system overall score was 69 (66, 79) out of 100, suggesting an acceptable though improvable usability. The overall PACES score of 110 (108, 112) out of 126 suggests that users enjoyed the game well. Finally, users indicated a positive effect with a good sense of immersion and smooth of gameplay during the tests, as indicated by the GEQ results. In summary, the evaluations showed that Exogames has the potential to be used as a virtual reality game for the physical and emotional rehabilitation of landmine victims.

Immersive virtual reality is effective in the rehabilitation of older adults with balance disorders: A randomized clinical trial

QUESTION

What are the effects of immersive virtual reality (IVR) training compared to conventional physiotherapy on body balance and risk of falls in older adults with balance disorders?

DESIGN

A randomized controlled trial with two intervention arms, concealed allocation, per-protocol analysis, and blinded assessment.

PARTICIPANTS

Thirty-seven older adults with balance disorders and risk of falling.

INTERVENTION

Participants were randomized into two groups: a control group, which received balance training with conventional physiotherapy using multimodal circuit exercises, and an experimental group, which received balance training using immersive virtual reality. Both groups received 16 individual sessions, twice a week.

OUTCOME MEASURES

The primary outcome was functional balance. Secondary outcomes were static balance, gait speed, functional range, dizziness symptoms, and fear of falling. Safety was ensured by assessing any adverse events during the intervention.

RESULTS

After 16 sessions, in the intragroup analysis, the functional balance score in the experimental group increased by 3.00 (95% CI 1.42 to 4.57) and in the control group by 3.88 (95% CI 2.16 to 5.59). Both groups improved in assessments of sensory interaction and anterior reach. Only the experimental group presented increased mobility and reduced dizziness. After two months, there was a maintenance of gains in functional balance and a reduction of the gains in functional reach for both groups. In the intergroup comparison, there was no significant difference.

CONCLUSION

Immersive Virtual Reality training proved to be effective for balance-related outcomes, although it was not superior to conventional therapy.

TRIAL REGISTRATION

RBR-3tk7fw.

Designing the Optimal Digital Health Intervention for Patients' Use Before and After Elective Orthopedic Surgery: Qualitative Study

Background

Health behavior changes made by patients during the perioperative period can impact the outcomes and success of elective surgeries. However, there remains a limited understanding of how best to support patients during this time, particularly through the use of digital health interventions. Recognizing and understanding the potential unmet needs of elective orthopedic surgery patients is central to motivating healthier behavior change, improving recovery, and optimizing overall surgical success in the short and long term.

Objective

The aim of this study is to explore patient perspectives on technology features that would help support them to change their lifestyle behaviors during the pre- and postoperative periods, and that could potentially maintain long-term healthy lifestyles following recovery.

Methods

Semistructured interviews with pre- and postoperative elective orthopedic patients were conducted between May and June 2020 using telephone and video call–based software. Patient perspectives on the use of digital technologies to complement current surgical care and support with lifestyle behavior changes were discussed. Interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data, with QSR NVivo software (version 12) facilitating data management. Ethical approval was obtained from the National Health Service Health Research Authority.

Results

A total of 18 participants were interviewed. Four themes were developed from the data regarding the design and functionality of digital technologies to best support the perioperative journey. These center around an intervention’s ability to incorporate interactive, user-centered features; direct a descriptive and structured recovery; enable customizable, patient-controlled settings; and deliver both general and specific surgical advice in a timely manner. Interventions that are initiated preoperatively and continued postoperatively were perceived as beneficial. Interventions designed with personalized milestones were found to better guide patients through a structured recovery. Individualized tailoring of preparatory and recovery information was desired by patients with previously high levels of physical activity before surgery. The use of personalized progression-based exercises further encouraged physical recovery; game-like rewards and incentives were regarded as motivational for making and sustaining health behavior change. In-built video calling and messaging features offered connectivity with peers and clinicians for supported care delivery.

Conclusions

Specific intervention design and functionality features can provide better, structured support for elective orthopedic patients across the entire surgical journey and beyond. This study provides much-needed evidence relating to the optimal design and timing of digital interventions for elective orthopedic surgical patients. Findings from this study suggest a desire for personalized perioperative care, in turn, supporting patients to make health behavior changes to optimize surgical success. These findings should be used to influence future co-design projects to enable the design and implementation of patient-focused, tailored, and targeted digital health technologies within modern health care settings.

Assessment of the Effectiveness of Rehabilitation after Total Knee Replacement Surgery Using Sample Entropy and Classical Measures of Body Balance

Exercises in virtual reality (VR) have recently become a popular form of rehabilitation and are reported to be more effective than a standard rehabilitation protocol alone. The aim of this study was to assess the efficacy of adjunct VR training in improving postural control in patients after total knee replacement surgery (TKR). Forty-two patients within 7-14 days of TKR were enrolled and divided into a VR group and a control group (C). The C group underwent standard postoperative rehabilitation. The VR group additionally attended twelve 30-min exercise sessions using the Virtual Balance Clinic prototype system. Balance was assessed on the AMTI plate in bipedal standing with and without visual feedback before and after the four-week rehabilitation. Linear measures and sample entropy of CoP data were analyzed. After four weeks of rehabilitation, a significant reduction in parameters in the sagittal plane and ellipse area was noted while the eyes remained open. Regression analysis showed that sample entropy depended on sex, body weight, visual feedback and age. Based on the sample entropy results, it was concluded that the complexity of the body reaction had not improved. The standing-with-eyes-closed test activates automatic balance mechanisms and offers better possibilities as a diagnostic tool.

Digital and Mobile Technologies to Promote Physical Health Behavior Change and Provide Psychological Support for Patients Undergoing Elective Surgery: Meta-Ethnography and Systematic Review

BACKGROUND

Digital technology has influenced many aspects of modern living, including health care. In the context of elective surgeries, there is a strong association between preoperative physical and psychological preparedness, and improved postoperative outcomes. Health behavior changes made in the pre- and postoperative periods can be fundamental in determining the outcomes and success of elective surgeries. Understanding the potential unmet needs of patients undergoing elective surgery is central to motivating health behavior change. Integrating digital and mobile health technologies within the elective surgical pathway could be a strategy to remotely deliver this support to patients.

OBJECTIVE

This meta-ethnographic systematic review explores digital interventions supporting patients undergoing elective surgery with health behavior changes, specifically physical activity, weight loss, dietary intake, and psychological support.

METHODS

A literature search was conducted in October 2019 across 6 electronic databases (International Prospective Register of Systematic Reviews [PROSPERO]: CRD42020157813). Qualitative studies were included if they evaluated the use of digital technologies supporting behavior change in adult patients undergoing elective surgery during the pre- or postoperative period. Study quality was assessed using the Critical Appraisal Skills Programme tool. A meta-ethnographic approach was used to synthesize existing qualitative data, using the 7 phases of meta-ethnography by Noblit and Hare. Using this approach, along with reciprocal translation, enabled the development of 4 themes from the data.

RESULTS

A total of 18 studies were included covering bariatric (n=2, 11%), cancer (n=13, 72%), and orthopedic (n=3, 17%) surgeries. The 4 overarching themes appear to be key in understanding and determining the effectiveness of digital and mobile interventions to support surgical patients. To successfully motivate health behavior change, technologies should provide motivation and support, enable patient engagement, facilitate peer networking, and meet individualized patient needs. Self-regulatory features such as goal setting heightened patient motivation. The personalization of difficulty levels in virtual reality-based rehabilitation was positively received. Internet-based cognitive behavioral therapy reduced depression and distress in patients undergoing cancer surgery. Peer networking provided emotional support beyond that of patient-provider relationships, improving quality of life and care satisfaction. Patients expressed the desire for digital interventions to be individually tailored according to their physical and psychological needs, before and after surgery.

CONCLUSIONS

These findings have the potential to influence the future design of patient-centered digital and mobile health technologies and demonstrate a multipurpose role for digital technologies in the elective surgical pathway by motivating health behavior change and offering psychological support. Through the synthesis of patient suggestions, we highlight areas for digital technology optimization and emphasize the importance of content tailored to suit individual patients and surgical procedures. There is a significant rationale for involving patients in the cocreation of digital health technologies to enhance engagement, better support behavior change, and improve surgical outcomes.

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Therapy, level 1b. CONSORT-compliant.

TRIAL REGISTRATION

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

Using video simulations and virtual reality to improve decision-making skills in basketball

A large body of literature supports the effectiveness of using video simulations to improve decision-making skills in invasion sports. However, whether these improvements are transferable (from the laboratory to the court/field) and generalizable (from trained to untrained plays) remains unknown. In addition, it remains to be determined whether presenting the video simulations using virtual reality provides an added-value. To investigate these questions, varsity-level basketball players underwent four training sessions during which they observed video clips of basketball plays presented either on a computer screen (CS group) or using a virtual reality headset (VR group). A third group watched footage from NCAA playoff games on a computer screen (CTRL group). Decision-making was assessed on-court before and after the training sessions using two types of plays: "trained" plays (presented during the CS and VR training sessions) and "untrained" plays (presented only during the on-court tests). When facing the trained plays in the posttest, both VR and CS groups significantly outperformed the CTRL group. In contrast, when facing the untrained plays, the VR group outperformed both the CS and CTRL groups. Our results indicate that CS training leads to transferable but non-generalized decision-making gains while VR training leads to transferable and generalized gains.

Infection prevention and control challenges of using a therapeutic robot

This work was part of a National Institute for Health Research participatory action research and practice development study, which focused on the use of a therapeutic, robotic baby seal (PARO, for personal assistive robot) in everyday practice in a single-site dementia unit in Sussex. From the beginning of January 2017 until the end of September 2017, the cleaning and cleanliness of PARO was monitored through a service audit process that focused on the cleaning, amount of use and testing of contamination of PARO being used in everyday clinical practice with individuals and in group sessions. Its use and cleaning followed protocols developed by the study team, which incorporated hand hygiene and standard precaution policies. Its cleanliness was determined using an adenosine triphosphate (ATP) luminometer, with a benchmark of 50 relative light units (RLU). A reading of ATP below 50RLU is the level of cleanliness recommended for social areas in hospital settings. Throughout the study period, monitoring showed that all swab zones on PARO were within the benchmark of the 50RLU threshold for cleanliness. PARO has an emerging evidence base as a useful therapeutic device. However, introducing such devices into clinical practice may encounter barriers or concerns from an infection prevention and control (IPC) perspective. This study of PARO in clinical practice aims to address the IPC concerns raised and offers cleaning and testing protocols and results.