Published on 27.04.24 in Vol 1, No 1 (2024): Jan-Dec
Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/53129, first published Sep 27, 2023.
Original Paper
Barriers and Facilitators to the Implementation of Virtual Reality Interventions for People With Chronic Pain: Scoping Review
ABSTRACT
Background: Chronic pain is a growing health problem worldwide with a significant impact on individuals and societies. In regard to treatment, there is a gap between guideline recommendations and common practice in health care, especially concerning cognitive and psychological interventions. Virtual reality (VR) may provide a way to improve this situation. A growing body of evidence indicates that VR therapy has positive effects on pain and physical function. However, there is limited knowledge about barriers and facilitators to the implementation of VR interventions for people with chronic pain in health care settings.
Objective: The aim of this study was to identify and analyze the barriers and facilitators involved in implementing VR interventions for people with chronic pain.
Methods: We conducted a scoping review of the German and English literature using the MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, PEDro, LILACS, and Web of Science (inception to November 2023) databases, including quantitative, qualitative, and mixed methods studies reporting barriers and facilitators to the implementation of VR interventions for people with chronic pain, as reported by patients or health care professionals. Two reviewers systematically screened the abstracts and full texts of retrieved articles according to the inclusion criteria. All mentioned barriers and facilitators were extracted and categorized according to the Theoretical Domains Framework (TDF).
Results: The database search resulted in 1864 records after removal of duplicates. From the 14 included studies, 30 barriers and 33 facilitators from the patient perspective and 2 facilitators from the health care professional perspective were extracted. Barriers reported by people with chronic pain were most frequently assigned to the TDF domains environmental context (60%) and skills (16.7%). Most facilitators were found in three domains for both the patients and health care professionals: beliefs about consequences (30.3%), emotions (18.2%), and environmental context (18.2%).
Conclusions: The findings of this review can inform the development of strategies for future implementations of VR interventions for people with chronic pain. Additionally, further research should address knowledge gaps about the perspective of health care professionals regarding the implementation of VR interventions for people with chronic pain.
JMIR XR Spatial Comput 2024;1:e53129
doi:10.2196/53129
KEYWORDS
Introduction
Chronic pain is defined as persistent or recurrent pain lasting longer than 3 months [
]. Chronic pain is an increasingly prevalent health condition worldwide, as three of the primary contributors to years lost to disability in recent decades are chronic pain conditions (back pain, musculoskeletal disorders, and neck pain) [ , ]. Estimated pooled prevalence rates for chronic pain in adults vary across studies from 20.5% in the United States [ ] to 28.3% in Germany [ ], 34% in the United Kingdom [ ], and 48.1% in Chile [ ]. High prevalence of chronic pain is not only found in industrial nations but also in low- and middle-income countries, where the prevalence ranges from 13% to 49.4% [ ]. Chronic pain affects not only adults but also has a significant prevalence in children, adolescents, and young adults, ranging from 8% to 23% [ - ]. Common consequences of chronic pain include physical disability, psychological distress, and reduced quality of life [ , ]. Furthermore, chronic pain affects relationships and self-esteem and is associated with higher rates of divorce and suicide [ , ]. From a societal perspective, chronic pain places an enormous financial burden on health care systems. In Australia, the financial costs associated with chronic pain were estimated to be ~US $57.1 billion in 2018 [ ]. In the United States, the Institute of Medicine estimated that the annual cost of chronic pain, including medical costs and lost productivity, was US $560 billion to US $635 billion in 2010 [ ]. In Germany, chronic pain was estimated to cost at least US $63.7 billion annually [ ]. At the same time, the care situation for people with chronic pain is characterized by a shortage of health care specialists, resulting in an inadequate supply of treatments [ ], particularly of psychotherapy [ ]. In contrast, the guidelines for chronic pain explicitly recommend interdisciplinary multimodal pain management, including cognitive and psychological interventions [ ].Virtual reality (VR) is a relatively new nonpharmacological modality to help people suffering from chronic pain, which can also help to improve the care situation [
]. VR treatment for people with chronic pain includes VR games, mindfulness-based interventions, practical exercises, and visual illusions [ ]. A meta-analysis showed large effects of VR interventions on pain (standardized mean difference [SMD] 1.6, 95% CI 0.83-2.36) and body functioning (SMD 1.4, 95% CI 0.13-2.67) in people with chronic pain [ ]. Although the mechanisms underlying the observed benefits of VR for chronic pain are not yet fully understood, distraction of the patient and embodiment have been discussed as possible explanations for changes in outcomes [ ]. Distraction is based on the limited capacity of people to simultaneously attend to different stimuli [ ]. It is assumed that attention that would normally be focused on pain is redirected to the VR experience, thereby reducing or eliminating the perception of pain [ ]. Embodiment describes the experience of the virtual body in virtual space and can lead to a change in the perception of the physical body and the body matrix, which can have a positive effect on pain perception and physical activity in people with chronic pain [ ]. Other mechanisms, including the gamification of exposure to feared movements through the VR [ ] and accelerated time perception in VR [ ], have also been proposed to have an influence on chronic pain.VR can therefore be seen as a promising therapeutic option for people with chronic pain. However, there has been no large-scale implementation of this technology in the health care of people with chronic pain. Previous research has shown that organizational structures and the VR technology itself are barriers to the implementation of VR interventions in various health care settings [
- ]. Regarding the use of VR in physiotherapy, due to technical limitations, lack of protocols for VR interventions, and patient-related factors, VR itself seems to be the main barrier [ ]. Conversely, staff and health care professionals may act as facilitators, as they reduce the anxiety of new technologies and can change patients’ attitudes toward VR. Health care professionals are also generally interested in using VR in rehabilitation [ - ]. However, people with chronic pain are a group with unique characteristics and diverse impairments, as they may experience pain-related fears and fear of movement, and often have maladaptive coping strategies, mental disorders such as depression or anxiety [ ], or cognitive impairments [ ]. Since these factors may influence the implementation of VR interventions, it is essential to identify barriers and facilitators for this population in using VR to derive a targeted implementation strategy.A systematic implementation strategy is necessary to enable large-scale successful implementation and use of VR interventions for people with chronic pain. This requires a comprehensive review of all known barriers and facilitators. The Theoretical Domains Framework (TDF) offers an approach to systematically examine barriers and facilitators toward the development of an implementation strategy [
]. The TDF is an implementation framework for behavioral change that incorporates 128 theoretical concepts derived from 33 different behavior change theories and organizes them into 14 domains into which the barriers and facilitators can be classified [ ]. The findings gained in this way can be used to support implementation efforts. For example, this approach was used to support the implementation of stratified care for people with nonspecific low back pain in Canada [ ], and was also used to inform the development and implementation of digital tools in a bariatric surgery service [ ].Therefore, the aim of this scoping review was to systematically identify and categorize barriers and facilitators to the implementation of VR interventions for people with chronic pain. The identified barriers and facilitators will provide a basis for recommendations for the successful integration of VR interventions into clinical practice, future development of VR interventions, and future implementation studies in the field of chronic pain management.
Methods
Study Design and Registration
A scoping review was conducted to comprehensively search and synthesize the published literature on barriers and facilitators reported by patients and health care professionals in implementing VR interventions for the treatment of people with chronic pain. The methodological background for this scoping review is based on the five steps outlined by Arksey and O’Malley [
] and the methodological guidance for conducting scoping reviews published by the Joanna Briggs Institute [ ]. Reporting follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines; the PRISMA-ScR checklist can be found in [ ]. The scoping review was registered with the Open Science Framework [ ].Search Strategy, Eligibility Criteria, and Selection of Evidence Sources
A database-specific literature search was conducted in the electronic databases MEDLINE (through PubMed), Cochrane Central Register of Controlled Trials, CINAHL, PEDro, LILACS, and Web of Science on November 1, 2022. A search strategy was developed using the keywords “chronic pain,” “virtual reality,” and “implementation.” The detailed search string for each database can be found in
. Additionally, one reviewer (AE) screened the reference lists of the included studies.The search results were combined and uploaded to CADIMA, a web application that assists in conducting and documenting the evidence synthesis process [
], which we used for the selection process. After removing duplicates, two authors (AE and ML) independently screened the titles and abstracts of identified publications.The initial inclusion criteria for publications were: (1) use of quantitative, qualitative, or mixed method study designs; (2) involves people with any type of chronic pain; (3) the treatment was a VR intervention; (4) published in the English or German language; and (5) reported implementation outcomes. The exclusion criterion was studies involving children (aged<18 years).
Two reviewers (AE and ML) tested the inclusion and exclusion criteria by screening the titles and abstracts of a random sample of 25 publications to ensure consistent use. If agreement was below 75%, the criteria were adjusted [
]. After title and abstract screening, the reviewers (AE and ML) discussed refining the criteria for full-text screening. As a result, the criterion to include only studies that specifically reported barriers or facilitators as reported by patients or health care professionals as implementation outcomes was added. Barriers were defined as any factors that inhibit or negatively influence patients’ use of a VR intervention. Facilitators were defined as all factors that enhance or positively influence patients’ use of a VR intervention. Barriers and facilitators had to be self-reported by patients or health care professionals. The two reviewers (AE and ML) independently screened the full texts. Disagreements throughout the review process were resolved by discussion between the two reviewers.Data Charting Process
One reviewer (AE) extracted the data into a custom data template created for the purpose of this scoping review (see
). A second reviewer (ML) reviewed all extracted data and commented on discrepancies, which were resolved through discussion. We extracted study characteristics (title, authors, year of publication, design, population, and sample size), intervention characteristics (setting, type of intervention), and barriers and facilitators (separately for patients and health care professionals). From qualitative studies, all barriers and facilitators reported by patients or health care professionals were extracted. For quantitative studies, barriers and facilitators were extracted if ≥50% of participants agreed that this factor had an influence on the implementation of VR interventions [ ].Collating, Summarizing, and Reporting
The resulting data were transferred into MAXQDA Plus 2022 (VERBI software, 2021) to code and categorize the barriers and facilitators separately for patients and health care professionals according to the domains of the TDF (see
). After coding of the barriers and facilitators by two reviewers (AE and ML), inconsistencies were resolved through discussion. Extracted barriers and facilitators could be categorized in more than one domain.After evaluation of the number of barriers and facilitators assigned to each domain of the TDF, separately for patients and health care professionals, the most common barriers and facilitators were analyzed to determine underlying themes.
Results
Study Selection
The database search resulted in 2252 publications. After removal of 388 duplicates, 1864 titles and abstracts were screened. Of those, 86 publications met the inclusion and exclusion criteria and were subject to screening of the full text. Among these 86 publications, 72 were excluded because they did not meet the inclusion criteria, were duplicates, did not provide primary data, or were not accessible. Duplicates occurred again in the screening of full texts because the initial removal of duplicates before the screening of titles and abstracts was based solely on the DOI. However, some publications were not recognized by CADIMA in this step due to missing DOIs. Finally, 14 studies were included in the qualitative analysis. The entire selection process is shown in the PRISMA-ScR flowchart in
.![](https://xr.jmir.org/api/download?filename=0901f35f788697e4ac1b3f762816b90b.png&alt_name=53129-918411-1-PB.png)
Description of Included Studies
Of the 14 studies, there were 8 mixed methods studies [
- ], four qualitative studies [ - ], and two quantitative studies [ , ]. All studies reported barriers and facilitators from the patient perspective, whereas one study also reported barriers and facilitators from the health care professional perspective [ ]. The included studies were published between 2013 and 2022, with 9 studies published in 2020 or later [ - , - , , ]. The sample size of the studies ranged from 7 [ ] to 84 [ ] participants, with the mean age ranging from 35.86 [ ] to 81.85 [ ] years. The studies included various VR interventions such as a 5-minute nature relaxation video [ ], physically active tasks [ ], and specifically developed interventions with guided exercises for focused attention and open awareness [ ]. For more information on the characteristics, study settings, and VR interventions of the included studies, please refer to [ - ].Overview of Identified Barriers and Facilitators
A total of 65 barriers and facilitators were identified. Among these, there were 30 (46%) barriers and 33 (51%) facilitators from the patient perspective and 2 (3%) facilitators reported from the health care professional perspective. All identified barriers and facilitators are summarized for each TDF domain in
.Barriers From the Patient Perspective
The 30 barriers identified from the patient perspective were categorized into six different TDF domains (
). The other eight TDF domains did not address the barriers identified from the patient perspective.