Exploring the effectiveness of immersive Virtual Reality interventions in the management of musculoskeletal pain: a state-of-the-art review

Figures & data

Table 1. Data extraction table.

Study	Condition	Study design	Objective	No. of participants	Intervention group	Control group	Outcome measures	Results	Adverse events
Sarig Bahat et al. [24]	Neck Pain	RCT	To investigate the effects of kinematic training with and without VR in patients with neck pain.	32	N = 16 Participants completed Kinematic training using VR (4–6 sessions)	N = 16 Participants completed Kinematic training without VR (4–6 sessions)	Neck disability index (NDI) Neck range of motion (ROM)	Both groups significantly improved in NDI immediately post intervention, (control (p < 0.05) VR (p < 0.01) but this improvement was only kept by the VR group at 3-month follow up (p < 0.01) Both groups showed significant improvements in flexion and rotation at both time points (p < 0.05). Only the VR group improved in extension at 3-month follow up (p < 0.05).	Y 4 participants experienced motion sickness
Sarig Bahat et al. [25]	Neck Pain	RCT	To evaluate the effect of home-based kinematic training with and without VR	92	N = 48 Participants completed Kinematic training using VR for 4 weeks	N = 44 Participants completed Kinematic training using laser for 4 weeks	Neck disability index (NDI) Kinematics (Movement Velocity)	Both groups showed significant improvements in NDI (p < 0.05) but there were no significant differences between the groups. Both groups showed significant improvements in mean velocity in all directions post intervention and at 3 month follow up (p < 0.05), except for the KT who did not show significant improvements in left rotation mean velocity at 3 month follow up (p < 0.05) The VRKT group showed significantly greater improvements in flexion and left rotation velocity compared to the control group (p < 0.05)	Y 5 participants experienced motion sickness or headache
Harvie et al. [23]	Neck Pain	Experimental Design	To examine whether altering visual proprioceptive feedback through VR in people with neck pain alters pain onset during movement.	24	N = 24 Participants rotated their necks under three different conditions: Accurate visual feedback Understated visual feedback Overstated visual feedback	NA	Pain free cervical range of motion Pain intensity (NRS 0–10)	There was a large overall effect of visual proprioceptive feedback using VR k on pain free range of motion F(2,94) = 18.9, p < 0.001 No difference in pain was found between conditions (p = 0.6)	N
Harvie et al. [26]	Neck Pain	Case Series	To examine whether neck exercises performed in VR with visual feedback of amplified movement would reduce pain.	8	N = 8 Participants used VR at home to perform neck exercises with and without visual proprioceptive illusion	NA	Movement evoked pain threshold Pain intensity (NRS 0–10)	No significant between phase differences were found for Movement evoked pain threshold or pain intensity (p > 0.05)	Y 2 participants experienced motion sickness
Tejera et al. [27]	Neck Pain	RCT	To compare the effects of VR versus exercise on pain, function, and psychological variable in patients with chronic nonspecific neck pain.	44	N = 22. Participants played immersive VR games that involved neck movements of varying levels of challenge.	N = 22. Participants completed three sets of 10 repetitions of neck exercises	Pain - VAS Range of Movement Neck Disability Index	Both groups demonstrated significant improvement in Pain intensity at all time points (p < 0.01) but there was no significant difference between then groups. The VR group showed significant improvement in rotation at 1-month (p < 0.05) and lateral flexion at 3-months (p < 0.05) compared to the control group. Both groups showed significant improvements in NDI scores at all time points (p < 0.01) but there was no significant difference between the groups.	N
Igna et al. [28]	Low Back Pain	Clinical Trial	To compare the effect of CBT with mindfulness versus CBT with VR versus standard physiotherapy for patients with low back pain.	68	Intervention group 1: (n = 25) Mindfulness-based CBT − 6 sessions Intervention group 2: (n = 35) VR-enhanced CBT − 6 sessions classical CBT and 5 mins of SnowWorld game	Treatment as usual (n = 25) - standard physiotherapy and pharmacotherapy	Pain Intensity - VAS McGill Pain Questionnaire	The MBCBT group showed significant improvement in VAS scores compared to the usual treatment group (MD = 1.35, SE − 0.52, p = 0.04). The CBT group showed a near significant improvement in McGill Pain Questionnaire scores compared to the usual treatment group (MD = 6.49, SE = 2.88, p = 0.08).	N
Solcà et al. [29]	CRPS	Cross-over Double-Blind Study	To develop and test VR for use in CRPS patients.	48	N = 24 CRPS patients immersed in a virtual environment with a depiction of their affected limb flashing in synchrony and asynchrony with their heartbeat.	N = 24 Age and sex match healthy control immersed in a virtual environment with a depiction of their affected limb flashing in synchrony and asynchrony with their heartbeat.	Pain (VAS) Grip Strength	Pain ratings decreased after synchronous vs asynchronous stimulation (F(1,94.09) = 4.63, p = 0.033) Grip strength increased after synchronous stimulation compared to before stimulation (t(17) = 2.5, p = 0.023, mean 0.85 kg, 95% CI 0.072–1.63, SEM 0.37), whereas no significant change was observed after asynchronous control stimulation (t(17) = −2.09, p = 0.06, mean −1.0 kg, 95% CI −2.007 to 0.007, SEM 0.48)	N
Jeon et al. [30]	CRPS	Pilot Study	To investigate whether virtual body swapping is applicable to patients with CRPS.	10	N = 5 Participants watched a video clip using HMD and mentally rehearsed movements presented.	N = 5 Participants watched a video clip using HMD with no added mental rehearsal.	Pain Intensity (NRS 0–10) Body perception disturbance questionnaire Virtual body swapping illusion	No significant different between groups in pain intensity. F(1,7) = 0.05, p = 0.81) BPD showed significant difference between groups in favor of the treatment group. F(1,8) = 16.22, p = 0.01 Significant differences in virtual body swapping scores between the groups in favor of the treatment group. T(8) = 2.40, p = 0.04	N
Matamala-Gomez et al. [31]	CRPS & PNI	Experimental Design	To investigate how manipulating characteristics of a virtual arm modulates pain ratings in patients with CRPS type 1 and peripheral nerve injury.	19	N = 19 While using VR participants were exposed to different representations of the virtual arm	NA	Pain intensity (NRS 0–10)	All conditions where the virtual arm was manipulated (in size or transparency) led to a pain reduction of at least 50%.	N
Chau et al. [32]	CRPS	Clinical Trial	To investigate the effect of VR on pain and daily function in patients with CPRS.	8	N = 8 Participants were asked to perform tasks within immersive virtual three-dimensional kitchen and guided visualization exercises for 10 sessions.	NA	Short form McGill Pain Questionnaire Visual Analogue Scale (VAS)	Higher average scores noted in SFMPQ for those participants who completed 10 sessions. VAS scores for all participants who completed 10 sessions showed lower pain scores after each VR sessions.	Y 1 participant experienced increased sensitivity of nervous system
Gulsen et al. [33]	Fibromyalgia	RCT	To evaluate the effects of immersive VR combined with exercise in Fibromyalgia patients.	16	N = 8. 30 mins Aerobic exercise + 30 mins Pilates + 20 mins VR games immersive twice weekly for 8 weeks	N = 8. 30 mins Aerobic exercise + 30 mins Pilates twice weekly for 8 weeks	Pain (VAS) Kinesiophobia (Tampa Scale of Kinesiophobia) Fatigue (Fatigue Severity Scale) Level of Physical Activity (Physical Activity Questionnaire) Quality of Life (SF − 36)	The VR group showed significantly greater improvement compared to the to exercise alone group in pain (mean change VR group −4, Control group −2.05 p = 0.021), kinesiophobia (VR group −12, Control group −10, p = 0.034), fatigue (VR Group −2.82, Control (−1.16), level of physical activity (VR Group 1797.25, Control Group 528.5, p = 0.001) and mental component of quality of life (VR Group 148, Control Group 70.25, p = 0.016).	N
Jin et al. [34]	TKR	RCT	To evaluate the clinical practicality and benefits of VR interventions for postoperative rehabilitation in OA patients undergoing TKA	66	Routine post-operative exercise programme (ankle and knee ROM, quadriceps strengthening) psychological intervention, pain education Immersive VR rowing for 30 min, three times daily	Routine post-operative exercise programme (ankle and knee ROM, quadriceps strengthening) psychological intervention, pain education Passive knee flexion x 30 repetitions, three times daily	Western Ontario and McMaster University osteoarthritis index (WOMAC) Hospital for Special Surgery knee score (HSS) Pain Intensity (VAS) Knee Range of motion (ROM)	WOMAC: 1-month post TKA VR group 32.00, Control group 35.06 (p = 0.02); 3-month post TKA VR group 25.79, Control group 29.67 (p = 0.002); 6-month post TKA VR group 21.58, Control group 26.33 (p = 0.000) HSS: 1-month post TKA VR group 68.39, Control group 60.45 (p = 0.000), 3-month post TKA VR group 77.73, Control Group 67.94 (p = 0.000); 6-month post TKA VR group 87.55, Control Group 80.39 (p = 0.000) VAS: 7-day post TKA VR group 3.87, Control Group 4.42 (p = 0.002) ROM: 14-day post TKA VR group 93.73, Control Group 86.36 (p = 0.000)	N
Hong and Lee [35]	TKR	Case Report	To use VR in a training programme with a woman following total knee replacement	1	62-year old woman treated post-operatively with 20 min of VR training followed by range of motion exercises, isometric quadriceps exercises, thermotherapy and electrotherapy.	NA	Muscle Strength (5xSit to stand test) Knee Proprioception (flexion angle reproduction test) Walking speed	Lower limb muscle strength increased by 32% Knee proprioception improved by 45% Walking speed returned to similar level as pre-surgery	N

Figure 1. Flow diagram of search strategy.

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