Virtual reality training for management of chronic neck pain: a systematic review with meta-analysis

Figures & data

Figure 1. The study search and selection process.

A photograph showing the diagram of study selection and elimination process. Description: A photograph showing the diagram of study selection and elimination process. After screening PubMed, Scopus and PEDro databases as well as other sources, 144 records were screened. Of these, 26 were sought for retrieval, 24 were assessed for eligibility, and finally, 11 were included in the review. Of these 11, 9 were included in the meta-analysis.

Table 1. Intervention descriptions of included studies.

Study	General intervention description	VRT tasks	Duration of intervention (weeks)	One training duration	Weekly frequency	Supervised (yes/no)
Rezaei et al. [28]	Non-immersive VRT which included unidirectional (flexion/extension or rotation only) and two-directional neck movements using video game Cervigame^® version 1.01, where the rabbit moves at constant speed in one direction, and its movement in the opposite direction is controlled by the patient’s head movement.	The main visual component of the game was a rabbit attempting to reach carrots. The virtual carrots appeared continuously along the line of the movement pattern being trained. Patient needed to make head movements (flexion/extension/rotation or two-directional neck movements) so that rabbit could reach the carrots on the screen.	4	21 min	2 sessions/week	Yes
Bahat et al. [27]	Immersive VRT programme which contained three modules (RoM/velocity/accuracy) interspersed with kinematic training. Participants had to control virtual pilot flying the aeroplane by head motion.	During the RoM module, the participants had to align the head of the virtual pilot with yellow virtual targets by moving the head in the direction of the targets. During the velocity module, the participant first had to activate the game by positioning the pilot’s head in the centre of a red virtual ring. When participant achieved correct mid-position, a yellow target appeared in a random direction, and the participant was required to move the head in that direction within 7 s before the target disappeared. During accuracy module, a moving target was presented on a vertical or horizontal line, at a constant velocity of 10 °/s. The participant was required to maintain the pilot’s head position on the moving target as closely as possible by tracing the vertical/horizontal line.	5	EG: 30 min (15–20 min using VR + 10–15 min kinematic training) CG: 30 min	4–6 sessions in 5 weeks	Yes, but also encouraged to perform unsupervised kinematic training 3x/week for 30 min
Beltran-Alacreu et al. [37]	VR condition: Non-immersive VR training included neck flexion,extension, lateral inclincations but no rotations. ‘Active Airlines’ game was used, where participants controlled virtual aeroplane using head motions.	Flexion-extension movements moved the virtual plane down or up and lateral inclinations moved the plane to the sides. The participants had to reach targets by moving virtual plane with head movements.	12 weeks (4 weeks VR + 4 weeks washout period + 4 weeks conventional exercises).	VR: 210 sec; Conventional exercises: 30–45 min	2 sessions/week	Yes
Tejera et al. [39]	Immersive VRT which included neck movements in all directions. Two VR applications were used: ‘Fulldive VR’ (where participants had to change the images in the viewfinder by tilting their head) and ‘VR Ocean Aquarium 3D’ (where observing different marine animals was possible by making neck movements).	During the ‘Fulldive VR’ only tilting movements of the neck were necessary, while during ‘VR Ocean Aquarium 3D’ flexion, extension and rotation movements had to be performed.	4	Not specified	2 sessions/week	Yes
Nusser et al. [40]	EG1 (VR group): Immersive VRT which included neck specific sensorimotor training (e.g. finding neutral position of the head, following a virtual subject by moving head), combined with general and neck specific exercise therapy. EG2 (sensorimotor group): General and neck specific exercise therapy, combined with general sensorimotor training, that included coordination and balance exercises, small game forms (e.g. throwing and catching), partner games.	A globe was shown, moving in a virtual space on predetermined trajectories, on the monitor. The patient was asked to follow the globe by moving the head the orbital pathways of the globe. The patient had to try to track the virtual globe as closely as possible with a white circle, whose position in the virtual scene corresponded to their head position. Head Repositioning test and Head to Target Test: The subject started in an upright seated position, with their head in a neutral position, which the subject was asked to memorise. The globe then led the subject’s head to a specific position in 1 of the 8 directions and disappeared. After that, the subject was asked to first find the neutral position again without visual guidance, and then the specific end position. Dynamic exercise: In this exercise, globes travelled along specific trajectory, one after another, and the subject had to follow them in the virtual scene by moving their head precisely.	3	EG1: 20 min of VR training EG2: 30 min of sensorimotor training	EG1: 6 sessions in 3 weeks; EG2: 4 sessions in 3 weeks	Yes
Bahat et al. [29]	EG1: Immersive VR home training program which contained three modules (RoM/velocity/accuracy) directed towards increasing RoM, increasing motion velocity and increasing motion accuracy. Participants had to control virtual pilot flying the aeroplane by head motion. EG2: Kinematic home training with head-mounted laser beam aimed at a 70 by 70 poster. Tasks in laser group were similar to VR exercises (following the line with laser, moving quickly from one circle to another, etc.).	VRT was the same as in Bahat et al. [27] study (described above).	4	5 min, 4x /day	4 sessions/week	No (home training)
Bahat et al. [38]	Immersive VR home training including exercises to train fast and accurate head control using three VR modules: RoM/velocity/accuracy. During the VR the subject’s head was visualised as an animated image of a pilot flying a small aeroplane. They also continued physical therapy, if receiving any.	Not described in detail.	4	5 min	4 sessions/week	No (home training)
Cetin et al. [41]	Immersive VR consisted of ‘Ocean Rift’ and ‘Gala 360’ applications, which provide views from countries and cities or watching see animals. Patients were encouraged to move their necks during VRT.	The patients were seated and were asked to look in all directions during the VR application. They were encouraged to move their necks by expressions such as ‘follow that dolphin, the sea turtles you chose will come soon, there may be a starfish below. Now you are in front of the Eiffel Tower, you can look around’.	6	EG: 40 min (20 min motor control exercises + 20 min VR) CG: 40 min (motor control exercises)	3 sessions/week	Yes

VR: virtual reality; EG: experimental group; CG: control group; VRT: virtual reality training; RoM: range of motion.

Table 2. Characteristics of included studies.

Author (year)	Participants				Baseline values	Control group	Follow-up assessment time (if any)	Post-intervention values	Results/ Conclusions
	Sample size	Age (years) mean ± SD	Duration of neck pain (months) mean ± SD	Inclusion criteria
Rezaei et al. [28]	n = 42 EG: 21 CG:21	EG: 36.19 ± 9.80 CG: 31.23 ± 9.49	EG: 22.42 ± 15.52 CG: 22.04 ± 16.79	A history of non-traumatic NP for > 3 months; age between 20 and 55 years,	VAS (100): 47.11 ± 10.24 (EG); 38.95 ± 10.07 (CG)	Conventional proprioceptive training, consisted of: eye-follow, gaze stability, eye-head coordination and position sense and movement sense training.	5 weeks	VAS (100): 10.75 ± 8.43 (EG); 19.63 ± 9.15 (CG)	There were significant improvements in all variables in both groups immediately after and 5 weeks after the intervention. Greater improvements were observed in the VAS and NDI scores in VRT group.
					NDI (50): 13.00 ± 1.30 (EG); 12.28 ± 1.38 (CG)			NDI (50): 4.57 ± 2.39 (EG); 8.14 ± 3.13 (CG)
Bahat et al. [27]	n = 32 EG: 16 CG: 16	EG: 40.36 ± 14.18 CG: 41.13 ± 12.59	EG: 98.06 ± 96.81 CG: 87.31 ± 111.99	Age 18 years or more; prolonged NP for >3 months; NDI score greater than 10%.	NDI (%): 20.38 ± 7.6 (EG); 20.19 ± 6.5 (CG)	Kinematic training (KT) with laser pointer: active neck movements to increase RoM, quick head movements, head stability exercises, accurate neck movement training.	3 months	NDI (%): 20.38 ± 7.6 (EG); 20.19 ± 6.5 (CG)	KTVR may have some advantages in the short term for pain intensity, neck disability, RoM, and fast neck motion control and longer term for global perceived effect 3 months post intervention. Nevertheless, direct comparison between the groups suggested that the KTVR was not superior to the KT training.
					VAS (100): 35.72 ± 17.7 (EG); 35.17 ± 16.7 (CG)			VAS (100): 22.1 ± 24.1 (EG); 27.72 ± 21.9 (CG)
					TSK (0–68): 32.75 ± 6.8 (EG); 30.38 ± 5.8 (CG)			TSK (0–68): 30.13 ± 5.7 (EG); 28.64 ± 9.9 (CG)
					RoM-flexion: 38.69 ± 14.6 (EG); 43.94 ± 14.3 (CG)			RoM-flexion: 57.31 ± 11.3 (EG); 49.87 ± 17.2 (CG)
					RoM-extension: 48.72 ± 15.1 (EG); 51.09 ± 13.2 (CG)			RoM-extension: 57.45 ± 14.1 (EG); 54.19 ± 12.8 (CG)
					RoM-right rotation: 62.32 ± 13.1 (EG); 57.06 ± 16.6 (CG)			RoM-right rotation: 71.84 ± 14.0 (EG); 77.21 ± 10.6 (CG)
					RoM-left rotation: 58.58 ± 15.3 (EG); 57.94 ± 15.3 (CG)			RoM-left rotation: 77.74 ± 16.0 (EG); 72.58 ± 13.6 (CG)
Beltran-Alacreu et al. [37]	n = 14 (Cross-over study)	81.85 ± 6.82	>3 months	Over 65 years of age: NP for > 12 weeks, scored more than 5 points on NDI; have no cognitive impairment below 20 points, as assessed by the MMSE scale.	NDI: 15.77 ± 8.19	Control condition: Conventional exercises included: stairs, pedalling, pulleys, obstacle walking, cervical joint mobility exercises in all ranges without resistance.	4 weeks	VAS (10): 3.77 ± 1.92 (EG); 3.46 ± 2.22 (CG)	Both conventional exercises and the use of the serious game had the same effect in reducing neck pain. Playing the serious game first followed by conventional exercise reduced pain more than conventional exercise first followed by playing the serius game.
					VAS (10): 4.92 ± 1.88			NDI not reported.
Tejera et al. [39]	n = 44 EG: 22 CG: 22	EG: 32.72 ± 11.63 CG: 26.68 ± 9.21	Not mentioned	Non-specific CNP; age 18 to 65 years.	VAS: 4.97 ± 1.88 (EG); 4.27 ± 1.3 (CG)	Neck exercises: neck flexion/extension/lateral flexion/rotations (without resistance).	1 and 3 months	VAS: 2.67 ± 1.91 (EG); 3.11 ± 1.47 (CG)	Kinesiophobia was the only outcome that showed differences between VR and exercise at 3 months follow-up. Pain intensity, CPM, TS, RoM, neck disability, pain catastrophizing, fear-avoidance beliefs, PPT and anxiety did not show differences between both interventions. Most variables showed intra-group differences in VR.
					NDI: 13.72 ± 6.68 (EG); 14.09 ± 9.32 (CG)			NDI: 6.9 ± 6.28 (EG); 7.45 ± 5.36 (CG)
					TSK-11: 22.90 ± 7.11 (EG); 21.40 ± 6.63 (CG)			TSK-11: 18.90 ± 10.73 (EG); 18.36 ± 7.48 (CG)
Nusser et al. [40]	n = 51 EG1: 17 EG2: 16 CG: 18	EG1: 51.2 ± 8.8 EG2: 53.1 ± 5.7 CG: 49.8 ± 8.1	> 3 months	18 years or more; CNP for >3 months; no pain medication or muscle relaxants use for 24 h before the tests.	NRS (10) (during rest): 4.2 ± 2.6 (CG); 4.9 ± 2.1 (EG)	General and neck  specific exercise therapy: strengthening, mobilisation, relaxation, medical training therapy, functional gymnastics, aqua therapy, physical therapy.	/	NRS (10) (during rest): 3.2 ± 3.0 (CG); 2.2 ± 2.0 (EG)	Compared with the control group, the VR group showed significant advantages in relief of headaches, and active cervical RoM in flexion and extension. Compared with the sensorimotor group, the VR group showed significant improvements in cervical extension.
					NRS (10) (during motion): 5.3 ± 2.2 (CG); 5.3 ± 2.6 (EG)			NRS (10) (during motion): 3.5 ± 2.2 (CG); 3.7 ± 2.0 (EG)
					RoM-flexion: 45.8 ± 12.9 (CG); 40.9 ± 14.6 (EG)			RoM-flexion: 42.9 ± 12.6 (CG); 48.5 ± 13.3 (EG)
					RoM-extension: 43.1 ± 13.3 (CG); 35.4 ± 12.8 (EG)			RoM-extension: 39.8 ± 14.7 (CG); 44.6 ± 12.9 (EG)
					RoM-left rotation: 59.3 ± 10.1 (CG); 57.4 ± 12.7 (EG)			RoM-left rotation: 59.9 ± 9.3 (CG); 65.2 ± 16.9 (EG)
					RoM-right rotation: 61.8 ± 15.3 (CG); 55.6 ± 10.4 (EG)			RoM-right rotation: 64.0 ± 15.2 (CG); 59.5 ± 14.0 (EG)
					NDI (0–50): 18.2 ± 6.7 (CG), 18.7 ± 5.2 (EG)			NDI (0–50): 13.7 ± 7.0 (CG), 13.7 ± 7.9 (EG2); 11.4 ± 7.5 (EG)
Bahat et al. [29]	n = 90 EG1: 30 EG2: 30 CG: 30	EG1: 48.0 ± 5.4 EG2: 47.6 ± 6.7 CG: 47.9 ± 6.9	>3 months	Adults aged 18 years or more with NP for more than 3 months; NDI score greater than 12%, and VAS during the recent week greater than 20 mm.	NDI (%): 32.88 ± 12.5 (EG);24.72 ± 10.7 (CG)	Waiting.	3 months	NDI (%): 23.75 ± 15.7 (EG); 26.88 ± 14.0 (CG)	The results support home kinematic training using VR or laser for improving disability, neck pain and kinematics in the short and intermediate term with an advantage to the VR group. The advantages for using the VR compared to the laser were not enough to recommend its use in its current state.
					VAS (100): 47.79 ± 20.9 (EG); 45.78 ± 21.5 (CG)			VAS (100): 31.1 ± 23.6 (EG); 45.78 ± 21.5 (CG)
					TSK (68): 35.22 ± 7.4 (EG); 32.64 ± 7.2 (CG)			TSK (68): 33.26 ± 7.8 (EG); 33.96 ± 6.2 (CG)
					RoM-flexion: 60.54 ± 10.1 (EG); 62.98 ± 7.3 (CG)			RoM-flexion: 61.38 ± 7.1 (EG); 64.52 ± 6.0 (CG)
					RoM-extension: 63.17 ± 11.9 (EG) 65.42 ± 11.2 (CG)			RoM-extension: 64.67 ± 11.0 (EG); 67.11 ± 7.9 (CG)
					RoM-right rotation: 73.77 ± 16.2 (EG); 78.87 ± 12.2 (CG)			RoM-right rotation: 75.28 ± 13.3 (EG); 75.64 ± 12.2 (CG)
					RoM-left rotation: 76.86 ± 14.5 (EG); 78.93 ± 16.0 (CG)			RoM-left rotation: 77.43 ± 11.9 (EG); 77.14 ± 11.4 (CG)
Bahat et al. [38]	n = 45 EG: 22 CG: 23	EG: 30 ± 5.8 CG: 28 ± 5.1	Median (Q1, Q3) EG: 36 (5.0, 84.0) CG: 12 (6.0, 48.0)	Fighter and helicopter pilots from the Israeli Air Force with acute, subacute, or chronic neck pain; with or without referral to the upper limbs; average NP intensity (during the past week) of at least 20% [on a VAS/100 mm].	VAS (100): 36.4 ± 22.8 (EG); 49.5 ± 21.1 (CG)	Physical therapy if  receiving any.	6 months	VAS (100): 25.7 ± 24.0 (EG); 26.9 ± 22.3 (CG)	Findings showed a positive effect on kinematic performance in the training group as compared to the controls, and a positive relationship between exercising time and improvement in neck associated disability. However, results showed no change in self-reported measures such as pain intensity and disability.
					Median (Q1, Q3): NDI (%): 15 (12–22) (EG); 16 (10–20) (CG)			Median (Q1, Q3): NDI (%): 10 (6–26) (EG); 16 (8–20) (CG)
					Median (Q1, Q3) RoM-flexion: 65.2 (65.1, 65.6) (EG); 65.2 (63.6, 65.9) (CG)
					RoM-extension: 73.5 (70.9, 76.3) (EG); 73.3 (72.6, 75.2) (CG)
					RoM-right rotation: 81.5 (80.2, 83.1) (EG); 80.9 (80.1, 81.8) (CG)
					RoM-left rotation: 80.1 (78.1, 81.7) (EG); 80.7 (80.2, 81.3) (CG)
Cetin et al. [41]	n = 34 EG: 17 CG: 17	EG: 40.0 ± 11.88 CG: 41.94 ± 10.76	>6 months	Age between 18 and 65 years with a minimum of 6 months of NP; a baseline NDI score of at least 20% (10 points); and the neck region as the primary pain area.	RoM-flexion: 49.05 ± 7.89 (EG); 44.64 ± 9.92 (CG)	Motor control (MC)  exercises: strenghtening of the deep cervical flexors/extensors and axioscapular muscles, stretching exercises, postural correction exercises.	/	(Reported as % change) RoM-flexion: 10.64 ± 7.44 (EG); 8.47 ± 7.21 (CG)	The results indicated that VR in addition to MC exercises was more effective than MC exercises alone in improving PPTs (C1/2 and C5/6), JPSE, and functional limitation. However, neither intervention was superior in improving RoM, pain, muscle performance, symptoms, psychosocial status, or quality of life.
					RoM-extension: 62.47 ± 11.88 (EG); 61.23 ± 9.44 (CG)			RoM-extension: 10.05 ± 9.25 (EG); 7.7 ± 7.05 (CG)
					RoM-right rotation: 56.76 ± 9.83 (EG); 51.47 ± 8.43 (CG)			RoM-right rotation: 6.05 ± 13.6 (EG); 8.52 ± 6.06 (CG)
					RoM-left rotation: 55.0 ± 9.18 (EG); 49.11 ± 8.33 (CG)			RoM-left rotation: 7.35 ± 9.0 (EG); 9.41 ± 9.98 (CG)
					VAS (10): 5.77 ± 1.39 (EG); 5.98 ± 1.93 (CG)			VAS (10): −3.69 ± 1.85 (EG); −2.44 ± 2.14 (CG)

VR: virtual reality; EG: experimental group; CG: control group; n: numerus; VRT: virtual reality training; VAS: visual analogue scale; NDI: neck disability index, RoM: range of motion; KT: kinematic training; TSK: TAMPA scale of kinesiophobia; KTVR: kinematic plus virtual reality training; MMSE: mini-mental state examination; CPM: conditioned pain modulation; PPT: pain pressure threshold; NRS: numerical rating scale; JPSE: joint position sense error; IRP: Interdisciplinary Rehabilitation Programme; MC: motor control, NP: neck pain; CNP: chronic neck pain; TS: temporal summation.

Table 3. Assessment of study quality with Assessment of study quality with Pedro Scale.

	TOTAL SCORE	Eligibility criteria	Random allocation	Concealed allocation	Baseline comparability	Blind subjects	Blind therapists	Blind assessors	Adequate follow-up	Intention-to-treat analysis	Between-group comparisons	Point estimates and variability
Razaei et al. [28]	6	1	1	0	1	0	0	1	1	0	1	1
Bahat et al. [27]	7	1	1	1	1	0	0	1	1	0	1	1
Beltran-Alacreu et al. [37]	3	1	1	0	0	0	0	1	0	0	0	1
Tejera et al. [39]	6	1	1	0	1	0	0	0	1	1	1	1
Nusser et al. [40]	6	1	1	0	1	0	0	0	1	1	1	1
Bahat et al. [29]	7	0	1	1	1	0	0	1	0	1	1	1
Bahat et al. [38]	8	1	1	1	1	0	0	1	1	1	1	1
Cetin et al. [41]	4	1	1	0	1	0	0	0	0	0	1	1

Figure 2. The meta-analysis for neck pain (VAS).

The figure shows a forest plot, combining studies that assessed the effects of virtual reality training on neck pain. Description: The figure shows a forest plot that contains 8 studies that assessed the effects of virtual reality training on neck pain. The overall effects favour virtual reality training over control interventions, but not statistically significantly. The studies are very heterogenous, some showing large effect and some pointing in the opposite direction.

Figure 3. The meta-analysis for neck disability index (NDI).

The figure shows a forest plot, combining studies that assessed the effects of virtual reality training on neck disability index. Description: The figure shows a forest plot that contains 6 studies that assessed the effects of virtual reality training on neck disability index. The overall effects favour virtual reality training over control interventions, but not statistically significantly. The studies are very heterogenous, with one study showing especially large effect.

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