Published on 22.04.24 in Vol 12, No 1 (2024): Jan-Dec
Original Paper
Effects of Virtual Reality Therapy Combined With Conventional Rehabilitation on Pain, Kinematic Function, and Disability in Patients With Chronic Neck Pain: Randomized Controlled Trial
ABSTRACT
Background: Neck pain is a common condition that leads to neck motor dysfunction and subsequent disability, with a significant global health care burden. As a newly emerging tool, virtual reality (VR) technology has been employed to address pain and reduce disability among patients with neck pain. However, there is still a lack of high-quality studies evaluating the efficacy of VR therapy combined with conventional rehabilitation for patients with chronic neck pain, particularly in terms of kinematic function.
Objective: This study aims to investigate the effect of VR therapy combined with conventional rehabilitation on pain, kinematic function, and disability in patients with chronic neck pain.
Methods: We conducted an assessor-blinded, allocation-concealed randomized controlled trial. Sixty-four participants experiencing chronic neck pain were randomly allocated into the experimental group that underwent VR rehabilitation plus conventional rehabilitation or the control group receiving the same amount of conventional rehabilitation alone for 10 sessions over 4 weeks. Pain intensity, disability, kinematic function (cervical range of motion, proprioception, and mean and peak velocity), degree of satisfaction, and relief of symptoms were evaluated at 3 timepoints (baseline, postintervention, and at 3 months follow-up). A 2*3 mixed repeated measures analysis of variance was utilized for analyzing the difference across indicators, with a significant difference level of .05.
Results: Both groups demonstrated significant improvements in pain, disability, and kinematic functions (P<.05) at postintervention and at 3-month follow-up. The experimental group showed superior therapeutic outcomes compared to the control group in pain reduction (mean difference from the baseline: 5.50 vs 1.81 at posttreatment; 5.21 vs 1.91 at the 3-month follow-up, respectively; P<.001), disability improvement (mean difference from baseline: 3.04 vs 0.50 at posttreatment; 3.20 vs 0.85 at the 3-month follow-up, respectively; P<.001), and enhanced kinematic functions (P<.05). Moreover, participants in the experimental group reported better satisfaction and relief of symptoms than the control group (P<.05), with better initiative for exercising during the follow-up period. However, there was no between-group difference of improvement in proprioception. No adverse events were reported or observed in our research.
Conclusions: The findings of our study support the efficacy of combining VR therapy with conventional rehabilitation in alleviating pain, enhancing kinematic function, and reducing disability of patients with chronic neck pain. Future research should focus on refining the therapeutic protocols and dosages for VR therapy as well as on optimizing its application in clinical settings for improved convenience and effectiveness.
Trial Registration: Chinese Clinical Trial Registry ChiCTR2000040132; http://www.chictr.org.cn/showproj.aspx?proj=64346
JMIR Serious Games 2024;12:e42829
doi:10.2196/42829
KEYWORDS
Introduction
Chronic neck pain is a prevalent global health issue, with reported prevalence rates ranging from 10% to 24% [
, ]. This condition is closely associated with motor dysfunction in the cervical region, characterized by deficits in various kinematic functions of the neck [ - ]. Cervical kinematic functions can be operationally defined as the capacity of the neck muscles to generate and regulate movement of the head and neck, including range of motion (ROM), which is the degree of movement that can be achieved in various directions of the cervical spine, velocity, coordination, strength, and endurance. These parameters can be quantified through specific evaluations and measurements such as ROM assessments, manual muscle testing, and functional movement tests. Prior studies have proven that motor dysfunction occurs commonly in patients with neck pain [ - ], and these dysfunctions are highly correlated with the level of pain and disability. That is because weakness in neck muscle strength and coordination will provide more unstable support of the neck segments and additional stress on the neck structure, which restricts the patient’s neck movement and results in pain [ ]. These diminished motor dysfunctions as well as worse pain and disability undoubtedly impair a patient’s work performance and quality of life, leading to large economic losses [ ]. Given the abovementioned pivotal role of cervical kinematics in neck pain, interventions aimed at improving motor function hold promise in managing this condition.To date, active exercise is recommended to be a valid therapy for patients with chronic neck pain based on the current clinical guidelines [
, ]. Virtual reality (VR) is a unique form of exercise established by Morton Heiling in 1962 and has been evolving over the past 60 years [ , ]. VR technology commonly generates virtual environments resembling the real world through devices such as computers or head-mounted displays and interacts with patients to enable them to accomplish the targeted therapeutic goals [ , ]. Regarding the economics of VR treatment, studies [ , ] have reported low costs in VR-based treatments. The hardware devices involved in VR therapy are readily available and inexpensive. Additionally, the one-time cost of patient-specific VR software allows for repeated use, making VR applications relatively less expensive in medical settings. VR serves as a valuable assessment and intervention tool in rehabilitation due to its clinical benefits supported by ongoing research [ ], and orthopedic and neurological rehabilitation are the common areas where VR therapy is utilized in clinical practice [ , ]. The potential therapeutic mechanisms of VR include task-oriented repetition, positive feedback, and embodied simulation [ ].As a noninvasive method of pain reduction, VR therapy, both independently and in combination with other interventions, has been investigated in numerous studies. Prior research [
- ] has demonstrated the potential of VR therapy to alleviate pain and disability in patients with orthopedic conditions such as rheumatoid arthritis, shoulder impingement syndrome, and low back pain. However, to date, there is still less research exploring the effects of VR therapy or combined treatment on individuals with chronic neck pain, particularly in terms of improving the cervical motor function [ , ]. Mukherjee et al [ ] investigated the efficacy of VR therapy in the treatment of cervical spondylosis. Their findings revealed that patients who underwent VR therapy along with conventional physiotherapy demonstrated notable improvements in pain intensity and active cervical ROM (CROM) compared to those who underwent conventional therapy alone in the short-term period (P<.05). However, another study [ ] reported that after receiving 4 weeks of VR training, patients with neck pain exhibited significant improvement in mean and maximal velocity, with no observed improvement in CROM indicators compared with the control group. A recent meta-analysis [ ] consisting of 2 randomized controlled trials (RCTs) suggested that VR therapy combined with kinematic training could enhance the global perceived effect, patient satisfaction, and general health of patients with neck pain compared to treatment with kinematic training alone. However, evidence supporting the efficacy of VR therapy in strengthening cervical kinematic function remains inconclusive. Given the current gaps in research and the conflicting findings, further high-quality studies are warranted to ascertain the therapeutic effectiveness of VR therapy or combined treatments for individuals with chronic neck pain. Therefore, this RCT aims to evaluate the effects of VR therapy combined with conventional rehabilitation on pain, kinematic functions, and disability in patients with chronic neck pain.Methods
Study Design and Ethics Approval
This study was designed as an assessor-blinded, allocation-concealed RCT (
). Ethics approval for this study was obtained from the West China Hospital Clinical Trials and Biomedical Ethics Committee of Sichuan University (approval: HX-IRB-AF-18-2021-1102). This trial was registered in the Chinese Clinical Trial Registry (ChiCTR2000040132) on November 22, 2020. This study conformed to the Declaration of Helsinki, and all patients provided written consent after recruitment.Participants
This study was conducted at the Department of Rehabilitation Medicine in West China Hospital. Patients were recruited through various channels such as social networks, posters, and brochures from October to December 2021. Inclusion criteria included age of 18 years and older, a diagnosis of chronic neck pain (>3 months) by a physician, reported pain intensity ≥3 on the numeric rating scale (NRS), and disability ≥6 on the neck disability index. Exclusion criteria included existing vestibular pathology, cervical fracture/dislocation, whiplash injuries, neurological/cardiovascular/respiratory disorders affecting patients’ physical performance, inability to provide informed consent, and pregnancy.
Randomization
Randomization was performed using a computer-generated sequence from Randomization.com, with a researcher not involved in treatment overseeing the process. Patients were allocated to either the experimental group or control group based on the odd or even nature of the assigned number within sealed opaque envelopes to ensure blind allocation. Although a blinded researcher assessed the patients during the trial, blinding was not feasible for participants or therapists due to the layout of the VR therapy.
Intervention
VR Treatment
The VR equipment that we used included several hardware and software (Chengdu Feiming Technology Co, Ltd). Hardware included a Pico G2 4k head-mounted VR glass, monitor screen, and optical motion capture camera. Patients wearing VR glasses sat at a distance of 100 cm from the front of the monitor screen. The monitor will display the real-time virtual images that patients see during the experimental process. Therapists can assess the patient's real-time treatment stage by looking at the monitor screen and provide corresponding assistance. During treatment, the optical motion capture camera and customized software collected and analyzed the cervical movement trajectories. Meanwhile, considering the requirement of fully immersive VR therapy, a specific shoulder strap was designed for patient safety during treatment.
In VR therapy, 3 modules (ROM, proprioception, and velocity modules) were designed to enhance the specific kinematic functions of individuals experiencing chronic neck pain. These modules involved patients engaging in targeted cervical movements to attain therapeutic objectives through visual cues. Prior to the beginning of the treatment, each patient underwent a practice trial to mitigate any potential learning biases. Throughout the VR session, patients were fully immersed in a virtual setting resembling a living room, where they could manipulate virtual objects to interact with designated targets. The VR equipment incorporated visual and auditory feedback to augment the interactive and engaging nature of the therapy. The detailed descriptions of the 3 modules are provided below.
In the ROM module, a virtual flying bird is manipulated by the patients’ cervical movement. Patients could move birds by neck flexion, extension, lateral flexion, and rotation movement to catch gold or avoid the fire rings appearing in the scene. The placement of the gold items and fire rings was based on baseline kinematic data, with the game’s difficulty adjusted continuously to facilitate gradual improvements in CROM across all movement directions (
).