Could Virtual Reality Dodgeball motivate fear-avoidant CLBP patients to move? Implications for future treatment.

Chronic low back pain (CLBP) is one of the most common musculoskeletal conditions health care professionals encounter. Unfortunately, despite ever increasing costs in regards to clinical management, the results remain underwhelming[1,2] giving CLBP an enigmatic nature. As a masters student I am interested in understanding how the neuromodulatory mechanisms can be targeted in chronic pain patients to improve CLBP management.

Scrolling through the Journal of Pain website the other day, an article by Thomas et al[3] caught my attention. In this study they investigated if a Virtual Reality (VR) Dodgeball game that used principles of graded exposure could encourage movement of the lumbar spine in highly avoidant and fearful CLBP patients. The article is interesting because the theory underlying the proposed VR paradigm is coherent, namely that:

1) High pain-related fear has been shown to mediate treatment efficacy for CLBP patients[4], in addition: high pain-related fear (and catastrophization) are among the strongest predictors of persisting pain and disability for patients with CLBP[5,6,7].

2) Cognitive-behavioral approaches using graded exposure has been shown effective in managing CLBP patients with high pain-related fear[8], and,

3) Visual feedback during movement training has been shown to reduce pain and increase functional capacity in patients with CLBP[9,10].

The aim of the study was to investigate whether Virtual Reality Dodgeball is a feasible and safe approach for CLBP patients with high levels of pain-related fear avoidance and whether this treatment changed pain/harm expectancies and/or increased trunk range of movement outside of game play sessions. To evaluate this, they randomized 52 participants (48% females) into one of two groups: one group received a 15 minute VR intervention over 3 consecutive days and the second group was a no-treatment control group. In the Virtual Reality Dodgeball group, researchers specifically utilized a graded exposure therapy approach to encourage movement of the lumbar spine in participants, in a fun, encouraging, and distracting context. By manipulating the impact height of the launched virtual balls they finely tuned the amount of spinal flexion elicited with game play. Further, they increased the demands of lumbar flexion by 5% in the 2nd session and by 10% in the 3rd session, thus gradually exposing participants to increased back-specific motion. A strength of this study was that they specifically measured back movement through game play.

While the study found that the VR Dodgeball game did not increase back range of movement tested out of the game play session (versus control group), it did successfully increase back movement tested during game play, thus exposing participants to increased ranges of movement that were feared. Further, the VR dodgeball game did not decrease expectations of harm with movement in the VR group (vs control), but it did decrease expectations of pain over time. In terms of feasibility and safety, the participants found the game to be engaging, easy to learn, and said that they would recommend it to others with back pain and there were no adverse events associated with VR game-play.

It is interesting to consider that increases in movement elicited by the VR Dodgeball intervention may also play a role in the way movement is mapped in the brain in chronic pain. There is growing body of evidence that brain areas that code for movement in CLBP patients are dysfunctional (e.g., impaired motor imagery performance that is specific to the back[11]). Additionally, visual feedback of movement may play an important role in perception: i.e. whether visual feedback could re-calibrate potential incongruence between actual movement and perceived movement in chronic pain conditions. While the evidence for incongruence of real and perceived movement as cortical driver of pain is conflicting, it is relevant to consider as a hypothesis. Regardless, cortical reorganization is thought to be an important aspect of the chronification process. Retraining the brain’s ability to accurately code for movement show promising results for CLBP management [12,13,14,15,16,17].

It is interesting to speculate whether an increased dosage of VR training could lead to sustained cognitive and behavioral changes for patients with high pain-related fears. In the study by Thomas et al, participants only received 3 sessions of training. As the authors point out in their paper, graded exposure is usually applied over 8-12 sessions. Perhaps with more sessions, the range of motion increases attained during VR game-play would transfer over to everyday life situations.

Future research in this field will hopefully provide more feasible and safe treatment options for the highly fear-avoidant patients with CLBP. It would be interesting to see whether Virtual Reality could enhance compliance to treatment in CLBP patients, given that CLBP often has high rate of recurrent episodes and poor adherence to exercise regimens. Further, it would be relevant to see if VR could re-train disrupted body representation and ownership properties as seen in many chronic pain conditions (e.g., perceive the painful body part as smaller or larger, poor at localizing the body part, disown or neglect the affected limb) and whether this would relate to the level of fear present during movement. Virtual Reality games would certainly only be a part of a multidimensional biopsychosocial framework, but I wonder whether the intervention can help patients encode multisensory information more accurately (i.e. Imprecision Hypothesis[18]). Could it reduce a facilitated pain output and protective fear response in patients with high pain-related fear and CLBP? Further, in a larger dosage could it downscale expectancy of harm and therefore perception of danger?

The findings by Thomas et al. clearly show the potential of VR to get participants with CLBP to actively engage in movements that may otherwise be avoided due to fear of harm. But more research is obviously needed, especially considering the very brief exposure to the intervention. At the end of the day, Thomas et al’s results suggest that VR could be an exciting future tool for physiotherapy treatment.

Introducing the newest member of BiM: Maja Sigerseth

maja-sigersethMaja is a Norwegian physiotherapist who graduated from Saxion University, Netherlands in 2015. After working in a private clinic for one year, she started a master degree with the University of Bergen, Norway (under Dr Kjartan Fersum) and Body in Mind research group at UniSA (with Dr Tasha Stanton). Maja grew up playing football and training martial arts, and has been on the national team of ITF Taekwon-Do for many years. If you ever need a bodyguard at any research conference, she’s got your back! She has 5x gold medals from the national championship and 1 gold medal from the European Championship in ITF Taekwon-Do. Her masters thesis involves investigating neuromodulatory mechanisms in chronic pain. In addition to her interest in clinical and cognitive neuroscience, Maja loves travelling, outdoorsy adventures in beautiful scenery, and can’t wait to explore more of Australia (i.e. visit Kangaroo Island!) in the future.

References

[1] Kamper Steven J, Apeldoorn A T, Chiarotto A, Smeets R, Ostelo R, Guzman J et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ. 2015;350:h444

[2] Foster N: Barriers and progress in the treatment of low back pain. BMC Medicine 2011, 9;108.

[3] Thomas JS, France CR, Applegate ME, Leitkam ST, Walkowski S, Feasibility and Safety of a Virtual Reality Dodgeball Intervention for Chronic Low Back Pain: A Randomized Clinical Trial, Journal of Pain (2016).

[4] Wertli MM,Rasmussen-Barr E,Held U, Weiser S, Bachmann LM, Brunner F. Fear-avoidance beliefs – a moderator of treatment efficacy in patients with low back pain: a systematic review. Spine J. 2014 Nov 1;14(11):2658-78.

[5] Rainville J, Smeets RJ, Bendix T, Tveito TH, Poiraudeau S, Indahl AJ. Fear-avoidance beliefs and pain avoidance in low back pain–translating research into clinical practice. Spine J.2011 Sep;11(9):895-903.

[6] Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85:317–32.

[7] Koleck M, Mazaux J, Rascle N, Bruchon-Schweitzer M. Psychosocial factors and coping strategies as predictors of chronic evolution and quality of life in patients with low back pain: a prospective study. Eur J Pain 2006;10:1–11.

[8 López-de-Uralde-Villanueva I,Muñoz-García D,Gil-Martínez A, Pardo-Montero J, Muñoz-Plata R, Angulo-Díaz-Parreño S, Gómez-Martínez M, La Touche R. A Systematic Review and Meta-Analysis on the Effectiveness of Graded Activity and Graded Exposure for Chronic Nonspecific Low Back Pain. Pain Med. 2016 Jan;17(1):172-88.

[9] Wand BM, Tulloch VM, George PJ, Smith AJ, Goucke R, O’Connell NE, Moseley GL. Seeing it helps: Movement-related back pain is reduced by visualization of the back during movement. Clin J Pain. 2012;28:602–608.

[10] Trapp, W., Weinberger, M., Erk, S., Fuchs, B., Mueller, M., Gallhofer, B., Hajak, G., Kübler, A., and Lautenbacher, S. (2015). A brief intervention utilising visual feedback reduces pain and enhances tactile acuity in CLBP patients. J. Back Musculoskelet. Rehabil. 28, 651–660

[11] Bowering, K.J., Butler, D.S., Fulton, I.J., and Moseley, G.L. (2014). Motor imagery in people with a history of back pain, current back pain, both, or neither. Clin. J. Pain 30, 1070–1075.

[12] Wand, B. M., O’Connell, N. E., Di Pietro, F., & Bulsara, M. (2011). Managing Chronic Nonspecific Low Back Pain With a Sensorimotor Retraining Approach: Exploratory Multiple-Baseline Study of 3 Participants. Physical Therapy, 91(4), 535-546.

[13] Wand BM, Parkitny L, O’Connell NE, Luomajoki H, McAuley JH, Thacker M, Moseley GL (2011) Cortical changes in chronic low back pain: current state of the art and implications for clinical practice. Manual Therapy 16(1): 15-20.

[14] Louw, A., Farrell, K., Wettach, L., Uhl, J., Majkowski, K., and Welding, M. (2015b). Immediate effects of sensory discrimination for chronic low back pain: a case series. N. Z. J. Physiother. 43.

[15] Daffada PJ, Walsh N, McCabe CS, Palmer S. The impact of cortical remapping interventions on pain and disability in chronic low back pain: a systematic review. Physiotherapy 101 (2015) 25-33.

[16] Kählin S. What is the effect of sensory discrimination training on chronic low back pain? A systematic review. BMC Musculoskeletal Disorders (2016) 17:143

[17] Kregel, J., Meeus, M., Malfliet, A., Dolphens, M., Danneels, L., Nijs, J., and Cagnie, B. (2015). Structural and functional brain abnormalities in chronic low back pain: A systematic review. Semin. Arthritis Rheum. 45, 229–237.

[18] Moseley, G. L., & Vlaeyen, J. W. S. (2015). Beyond nociception: the imprecision hypothesis of chronic pain. Pain, 156, 35–38.