A virtual reality intervention for fear of movement for Veterans with chronic pain: protocol for a feasibility study

Abstract

BackgroundA key concern for people with chronic pain is experiencing increased pain and/or re-injury. Consequently, individuals with chronic pain can develop a maladaptive fear of movement that leads to adverse functional consequences. A primary goal of chronic pain rehabilitation is re-engagement in feared movements through exposure. This is often challenging since safe movement can be uncomfortable. Virtual environments provide a promising opportunity to safely and gradually expose Veterans to movements that are avoided in the real world. The current study will utilize multiple virtual reality (VR) applications (APPs) of varying the intensity levels ranging from passive distraction from pain to active exposure to feared movement. The primary aims of this pilot are to examine VR as an adjunctive nonpharmacological intervention to assist with the adoption and implementation of skills to decrease fear of movement and increase overall functioning among Veterans with chronic pain. Second, to build a hierarchy of VR APPs to assist in gradual exposure to feared movements.MethodsThis study will be conducted in the Chronic Pain Rehabilitation Program (CPRP) at the James A. Haley Veterans Hospital, a unique inpatient program within the VA system. Participants will include up to 20 Veterans who receive a VR intervention as part of their physical therapy. A rating form containing qualitative and quantitative experiences will be administered following each VR session to assess feasibility and to provide descriptive information for the proposed hierarchy. Effect sizes will be calculated from intake and discharge measures for the primary outcome fear of movement and secondary pain and functional outcomes.DiscussionThis study will inform the feasibility of a randomized controlled trial examining the clinical utility of using VR to reduce fear of movement and increase function among Veterans with chronic pain. VR has the advantage of being easily implemented both within VA healthcare settings as well as in Veterans’ own residences, where engagement in ongoing self-management approaches is often most challenging. Presumably, VR that is matched to patient needs, progresses in intensity, immerses Veterans in the applications, and is perceived positively by Veterans, will result in positive functional outcomes.

Effects of Virtual Reality versus Exercise on Pain, Functional, Somatosensory and Psychosocial Outcomes in Patients with Non-specific Chronic Neck Pain: A Randomized Clinical Trial

“…The psychosocial variables also showed significant changes for both groups, especially in the VR group. For the fear-avoidance beliefs, in 2019 Fowler et al [13] indicated that the use of VR on elderly people with a fear of movement showed positive results when the treatment matched the patient's level of functioning. There was a progression in intensity so that the patients presented a positive perception which presented better benefits.…”

“…Regarding kinesiophobia, we found that it was the only variable to have significantly improved compared to the exercise group, especially at 3 months follow-up, and was considered as an effective tool for reducing fear of movement. Other studies have found that VR reduces kinesiophobia in patients with chronic spinal pain which was associated with an increase in function [13,67,72]. In 2020, Martínez et al concluded on a narrative review that the participants' physical condition and cognitive and emotional characteristics should be considered before implementing interventions that employ movement representation techniques.…”

“…In addition, psychological factors, such as fear of movement, anxiety or depression, are also associated with chronic neck pain [12,13]. These psychological factors trigger a functionality decrease, which is explained by the "fear-avoidance model", associated with increased hypervigilance, leading to a vicious cycle of psychological and physical factors that lower the threshold at which painful experiences are triggered [14][15][16].…”

Occupational Therapy's Role in Pain Management using Virtual Reality

“…Because of this, these individuals will tend to avoid movement and even physical activities altogether (Alazba, Al-Khalifa & AlSobayel, 2018). By addressing this fear of movement, VR has the OT's ROLE IN PAIN MANAGEMENT USING VIRTUAL REALITY ability to alter one's pain perception, thereby allowing them to not only move, but thrive in a less painful environment (Fowler, Ballistrea, Mazzone, Martin, Kaplan, Kip, Murphy, & Winkler, 2019). Garcia-Palacios et al (2015) explored the potential use of VR as a behavioral intervention for managing pain and addressing the fear of movement.…”

“…By distracting pain and facilitating purposeful movement, VR can significantly reduce one's risk for greater functional disability, improve their ability to perform desired activities, and more importantly, improve their coping ability so that they can better manage their pain experience (Fowler et al, 2019;Alazba, Al-Khalifa & AlSobayel, 2018). However, like opioids, OT's ROLE IN PAIN MANAGEMENT USING VIRTUAL REALITY 8 the use of virtual reality alone cannot effectively improve an individual's pain management.…”