So some of you that might be reading this (and that know me) are familiar with my fascination of the use of Virtual Reality within a persistent pain setting. I am the first person to admit it is very cool and it is something that I am exploring more clinically. However, I want to put the brakes on, stop and reflect on whether physiotherapists (come on let’s face it, it’s always physiotherapists) will be too quick to jump onto another bandwagon.
I recently wrote about CRPS and what treatment is best (here), highlighting the need for clinical reasoning when it comes to using a particular treatment. It seems that GMI and mirror therapy seems to be the thing that clinicians jump on when we see someone with Complex Regional Pain Syndrome. So first up I am definitely not saying that GMI is ineffective, despite the Cochrane reviews highlighting very low quality evidence (Smart, Wand, & O’Connell, 2016). I’m saying that it needs to be reasoned appropriately. Incidentally, I was discussing manual therapy with a fellow clinician on Facebook and made this comment about manual therapy.
So back to VR. There is a lot of research about its use in managing acute pain, mainly in burn patients (Hoffman et al., 2011; Keefe, Huling, & Coggins, 2012; Malloy & Milling, 2010; Morris, Louw, & Grimmer-Somers, 2009) and chemotherapy (Li, Montaño, Chen, & Gold, 2011; S M Schneider & Workman, 2000; Susan M Schneider, Prince-Paul, Allen, Silverman, & Talaba, 2004), which did prove to be effective in modulating pain.
Chronic Pain and VR
However, chronic pain as we know is far more complex. We have learnt (thanks to the likes of the Body in Mind group, Pain in motion, NOI, Pain-ed) a significant amount about the mechanisms involved in the construct of persistent pain. So, what’s my issue with VR being used in the management of chronic pain? Well, pretty much what I have previously mentioned. VR is cool and groovy and it is certainly showing promise and intrigue in areas of musculoskeletal persistent pain (D. S. Harvie et al., 2015; Daniel S Harvie et al., 2017; Jones, Moore, Rose, & Choo, 2016; Keefe et al., 2012; Lewis & Rosie, 2012; Li et al., 2011).
At present, VR has shown that it could work as an effective means of distraction, particularly towards pain and fear of movement, likely due to its level of immersion (Gupta, Scott, Dukewich, & Wilson, 2017; Keefe, Huling, & Coggins, 2012). In the Gupta, Scott, Dukewich, & Wilson, (2017) special article they discuss the neurophysiological effects beyond distraction in areas of pain tolerance, pain threshold and pain intensity. The results are promising but also equivocal. As such by immersing people in non-threatening environments VR has the potential for exposing people to movements that are commonly painful. Is this Graded Exposure? I am conflicted with this. One reason is that virtual reality is never and will never be representative of real world. You can’t reproduce physical load for example. We might, potentially, possibly, may be able to reproduce the physical sensations that might be associated with lifting load (there are some pretty clever people in Australia like Daniel Harvie and Tasha Stanton working on this kind of stuff). So, at this moment in time there will always be a perceptual gap consciously and sub-consciously as you know that you are immersed in a virtual world and ultimately may reject the idea of the visual stimulus in front of you (https://www.gizmodo.com.au/2015/03/the-neuroscience-of-why-vr-still-sucks/).
Take a chill pill
So, the caveat for clinician’s is don’t be too hasty to jump on the VR bandwagon as we definitely don’t need VR to become the next new fad like pilates and core stability and pain education (although I fear it already will be), resulting in people promoting it like some revolutionary new concept that justifies lots of emptying of punters pockets. It needs to be appropriately reasoned for it to have a place. On top of all that, currently there are not (that I know of) any high-quality studies reporting long term outcomes. If that wasn’t enough VR is still expensive, and with all exposure based programs you need constant reinforcement of the stimulus, so renting out the equipment or getting your patients to buy it will be the only options.
It could be said that perhaps having exposure to certain movements whilst immersed in virtual reality and not experiencing pain may then help people to reconceptualise movement and pain. However, as I’ve previously stated pain is not just about what’s happening with movement, it’s multi-dimensional and so there are any number of triggers that could contribute towards a person’s pain experience.
Yes, maybe I am trying to burst the VR bubble but this is because we need to accept that one approach does not fit all (N=1) and it’s likely that there will be subgroups that benefit but not everyone will.
So, before you go all crazy about virtual reality, stop and think if a person would benefit just as much from getting out into the environment and being distracted through natural human experiences.
Thanks for having a read
Gupta, A., Scott, K., Dukewich, M., & Wilson, W. (2017). Innovative Technology Using Virtual Reality in the Treatment of Pain: Does It Reduce Pain via Distraction, or Is There More to It? Pain Medicine.
Harvie, D. S., Broecker, M., Smith, R. T., Meulders, A., Madden, V. J., & Moseley, G. L. (2015). Bogus Visual Feedback Alters Onset of Movement-Evoked Pain in People With Neck Pain. Psychological Science, 26(4), 385–392. https://doi.org/10.1177/0956797614563339
Harvie, D. S., Fadiga, L., Smith, R. T., Hunter, E. V, Davis, M. G., Sterling, M., & Lorimer Moseley, G. (2017). Using visuo-kinetic virtual reality to induce illusory spinal movement: the MoOVi Illusion. https://doi.org/10.7717/peerj.3023
Hoffman, H. G., Chambers, G. T., Meyer, W. J., Arceneaux, L. L., Russell, W. J., Seibel, E. J., … Patterson, D. R. (2011). Virtual reality as an adjunctive non-pharmacologic analgesic for acute burn pain during medical procedures. In Annals of Behavioral Medicine (Vol. 41, pp. 183–191). https://doi.org/10.1007/s12160-010-9248-7
Jones, T., Moore, T., Rose, H., & Choo, J. (2016). The impact of virtual reality on chronic pain. Journal of Pain, 17(4), S102–S103. https://doi.org/10.1016/j.jpain.2016.01.319
Keefe, F. J., Huling, D. A., & Coggins, M. J. (2012). Virtual reality for persistent pain: A new Direction for Behavioural Pain Management. Pain, 153(11), 2163–2166. https://doi.org/10.1016/j.pain.2012.05.030.Virtual
Lewis, G. N., & Rosie, J. A. (2012). Virtual reality games for movement rehabilitation. Disability & Rehabilitation, 34(22), 1880–1886. https://doi.org/10.3109/09638288.2012.670036
Li, A., Montaño, Z., Chen, V. J., & Gold, J. I. (2011). Virtual reality and pain management: current trends and future directions. Pain Management, 1(2), 147–157. https://doi.org/10.2217/pmt.10.15.Virtual
Malloy, K. M., & Milling, L. S. (2010). The effectiveness of virtual reality distraction for pain reduction: A systematic review. Clinical Psychology Review. https://doi.org/10.1016/j.cpr.2010.07.001
Morris, L. D., Louw, Q. A., & Grimmer-Somers, K. (2009). The effectiveness of virtual reality on reducing pain and anxiety in burn injury patients: a systematic review. The Clinical Journal of Pain, 25(9), 815–826. https://doi.org/10.1097/AJP.0b013e3181aaa909
Schneider, S. M., Prince-Paul, M., Allen, M. J., Silverman, P., & Talaba, D. (2004). Virtual reality as a distraction intervention for women receiving chemotherapy. Oncology Nursing Forum, 31(1), 81–88. https://doi.org/10.1188/04.ONF.81-88
Schneider, S. M., & Workman, M. L. (2000). Virtual reality as a distraction intervention for older children receiving chemotherapy. Pediatric Nursing, 26, 593–597.
Smart, K. M., Wand, B. M., & O’Connell, N. E. (2016). Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database of Systematic Reviews, 2016(2). https://doi.org/10.1002/14651858.CD010853.pub2