Playing your pain away: designing a virtual reality physical therapy for children with upper limb motor impairment.

Children with upper limb motor impairment often undergo repetitive therapeutic physiotherapy sessions to minimize functional disabilities of the affected area. Even though therapeutic processes can improve functional outcomes and minimize persistent disabilities, patients often neglect to participate fully in physical therapies due to the associated procedural pain. Over recent decades, there has been a growing interest in designing non-pharmacological interventions which aim to minimize pain during physical therapies and improve functional outcomes. Via two interrelated studies, we explored the use of virtual reality (VR) as a tool to provide therapeutic physiotherapy for child patients in an out-patient hospital department. We found that VR is an effective solution for children with upper limb motor impairment undergoing painful therapeutic process within a hospital environment. VR can improve functional disabilities, alleviate perceived pain, reduce the perceived difficulty of rehabilitation exercises, increase exercise duration and produce positive emotions towards the therapy. Trial registration number and date of registration Protocol ID NCT03998995. Release Date: June 25, 2019.

Designing effective virtual reality environments for pain management in burn-injured patients.

Burn patients engage in repetitive painful therapeutic treatments, such as wound debridement, dressing changes, and other medical processes high in procedural pain. Pharmacological analgesics have been used for managing pain, but with ineffective results and negative side effects. Studies on pain management for burn patients suggested that Virtual Reality can treat procedural pain. This paper describes the process of designing, testing, and deploying a Virtual Reality system into a hospital setting. Firstly, a workshop was conducted to identify the most suitable types of Virtual Reality contents for the needs of burn-injured patients. Then, an experimental study, with 15 healthy adults, explored the analgesic impact of the Virtual Reality contents. The pain was induced through a cold pressor. Finally, we deployed the Virtual Reality system into the hospital to examine its efficiency on burn-injured inpatients. This study presents factors for the effective design and deployment of Virtual Reality for burn-injured patients residing in a hospital. Those factors refer to the use of cartoonish features and a choice of content based on each patient's interests to increase the positive emotions and the use of interactive features, portable equipment to reduce pain and increase the feasibility of the technology in clinical settings. Finally, our results indicated that the extension of the VR use after the therapeutic session could support more effective pain treatment. Trial registration number Protocol ID: AA8434.

Home-based immersive virtual reality physical rehabilitation in paediatric patients for upper limb motor impairment: a feasibility study.

Upper limb motor impairment (ULMI) rehabilitation is a long-term, demanding and challenging process to recover motor functionality. Children and adolescents may be limited in daily life activities due to reduced functions such as decreased joint movement or muscle weakness. Home-based therapy with Immersive Virtual Reality can offer greater accessibility, delivery and early rehabilitation to significantly optimise functional outcomes and quality of life. This feasibility study aimed to explore the perceptions and impacts of an immersive and interactive VR scenario suitable for ULMI rehabilitation for children at home. It was analysed using mixed methods (quantitative and qualitative) and from a multidirectional perspective (patients, clinicians and family members). Amongst the main results, it was found that IVR for ULMI home rehabilitation (1) is easy to learn and acceptable; (2) improves motor function; (3) reduces the difficulty in the reproduction of therapeutic movements; (4) is motivating and enjoyable and (5) improves quality of life. This study is the first study on the use of IVR applied to home rehabilitation of ULMI in children. These results suggested that similar outcomes may be possible with self-directed IVR home rehabilitation compared to face to face conventional rehabilitation, which can be costly to both the patient and the healthcare system, decreasing the length of stay at the hospital and treatment duration. It has also presented an innovative solution to the Covid-19 emergency where children could not receive their clinic therapy. Further research is recommended to understand better the mechanisms involved in physiotherapeutic recovery and how IVR rehabilitation helps to improve conventional treatments. Trial Registration Protocol ID NCT05272436. Release Date: 9th March 2022.

Immersive virtual reality in children with upper limb injuries: Findings from a feasibility study.

PURPOSE: Children who sustain Upper Limb Injuries (ULIs), including fractures and burns, may undergo intensive rehabilitation. The discomfort of therapy can reduce their compliance, limit their range of motion (ROM) and lead to chronic pain. Virtual Reality (VR) interventions have been found to reduce anticipated and procedural pain.This feasibility study aimed to explore perceptions and impacts of a custom-made, fully immersive Head-Mounted Display VR (HMD-VR) experience within a United Kingdom (UK) National Health Service (NHS) outpatient rehabilitation service for children with ULIs. METHODS: Ten children aged 9-16 in one UK Children's hospital trialled HMD-VR during one rehabilitation session. They, their parents (n = 10), and hospital physiotherapy staff (n = 2) were interviewed about their perceptions of pain, difficulty, enjoyability, therapeutic impacts, benefits, and limitations. Children rated the sessions on enjoyability, difficulty, and pain compared to usual rehabilitation exercises. Physiotherapists were asked to provide range of motion readings. RESULTS: Inductive thematic analysis of interview data generated three themes, 'Escape through Engagement'; 'Enhanced Movement'; and 'Adaptability and Practicality'. Children rated the session as more enjoyable, less difficult and painful than their usual rehabilitation exercises. Findings suggested that HMD-VR was an engaging, enjoyable experience that distracted children from the pain and boredom of therapy. Also, it seemed to enhance the movement they achieved. Participants perceived it was useful for rehabilitation and adaptable to individual needs and other patient groups. Suggestions were made to increase adaptability and build in practical safeguards. CONCLUSION: Findings from this small-scale feasibility study suggested HMD-VR was perceived as usable, acceptable, and effective with potential for further development. Future work could include larger scale trials.

Immersive Virtual Reality for Pain Relief in Upper Limb Complex Regional Pain Syndrome: A Pilot Study.

Objective: This pilot study explored the effects of therapeutic immersive virtual reality (VR) on pain in upper limb complex regional pain syndrome (CRPS). While acute pain relief with VR has been studied in multiple populations, there is little data on the use of this modality in treating chronic pain, especially CRPS. Participants: Volunteer participants were recruited from outpatient rehabilitation services. Inclusion criteria required the diagnosis of CRPS in at least one upper limb and the ability to communicate in English to receive instructions from study personnel. A total of eight participants were recruited, with six fully completing the study. Interventions: An immersive virtual three-dimensional interactive kitchen environment was designed that allowed visualization of and object manipulation with virtual hands. Participants performed tasks representative of daily activities, as well as guided visualization exercises for a total of 10 sessions. Main Outcome Measure: Preand post-session pain scale measurements (Short Form McGill Pain Questionnaire, Visual Analog Scale, and Wong-Baker FACES) and subjective feedback were collected with each session. Results: Four of the six participants that completed the study reported subjective improvement of their pain and daily function. However, objective pain scales had limited correlation to reported subjective relief. Conclusions: Immersive virtual reality might provide subjective analgesia and functional improvement in select patients with upper limb complex regional pain syndrome, but objective data is lacking.

Reducing Pain During Wound Dressings in Burn Care Using Virtual Reality: A Study of Perceived Impact and Usability With Patients and Nurses.

Burns patients often suffer severe pain during interventions such as dressing changes, even with analgesia. Virtual Reality (VR) can be used to distract patients and reduce pain. However, more evidence is needed from the patients and staff using the technology about its use in clinical practice and the impact of different VR strategies. This small-scale qualitative study explored patient and staff perceptions of the impact and usability of active and passive VR during painful dressing changes. Five patients took part in three observed dressing changes-one with an active VR scenario developed for the study, one with passive VR, and one with no VR-following which they were interviewed about their experiences. Three nurses who performed the dressing changes participated in a focus group. Thematic analysis of the resulting data generated four themes: "Caution replaced by contentment," "Distraction and implications for pain and wound care," "Anxiety, control and enjoyment," and "Preparation and communication concerns." Results suggested that user-informed active VR was acceptable to burn patients, helped manage their perceived pain, and was both usable and desirable within the clinical environment. Further testing with larger samples is now required.

A Mixed-Methods Investigation Into the Acceptability, Usability, and Perceived Effectiveness of Active and Passive Virtual Reality Scenarios in Managing Pain Under Experimental Conditions.

Burn patients often suffer excruciating pain during clinical procedures, even with analgesia. Virtual Reality (VR) as an adjunct to pharmacological therapy has proved promising in the management of burn pain. More evidence is needed regarding specific forms of VR. This mixed-method study examined the impact of active and passive VR scenarios in experimental conditions, gathering data relating to user experience, acceptability, and effectiveness in managing pain. Four scenarios were developed or selected following a consultative workshop with burn survivors and clinicians. Each was trialed using a cold pressor test with 15 University students. Data were gathered regarding pain threshold and tolerance at baseline and during each exposure. Short interviews were conducted afterwards. The two active scenarios were ranked highest and significantly extended participants' pain threshold and tolerance times compared to passive and baseline conditions. Passive scenarios offered little distraction and relief from pain. Active scenarios were perceived to be engaging, challenging, distracting, and immersive. They reduced subjective awareness of pain, though suggestions were made for further improvements. Results suggested that active VR was acceptable and enjoyable as a means of helping to control experimental pain. Following suggested improvements, scenarios should now be tested in the clinical environment.

Immersive Virtual Reality Therapy with Myoelectric Control for Treatment-resistant Phantom Limb Pain: Case Report.

Objective: Phantom limb pain is a condition frequently experienced after amputation. One treatment for phantom limb pain is traditional mirror therapy, yet some patients do not respond to this intervention, and immersive virtual reality mirror therapy offers some potential advantages. We report the case of a patient with severe phantom limb pain following an upper limb amputation and successful treatment with therapy in a custom virtual reality environment. Methods: An interactive 3-D kitchen environment was developed based on the principles of mirror therapy to allow for control of virtual hands while wearing a motion-tracked, head-mounted virtual reality display. The patient used myoelectric control of a virtual hand as well as motion-tracking control in this setting for five therapy sessions. Pain scale measurements and subjective feedback was elicited at each session. Results: Analysis of the measured pain scales showed statistically significant decreases per session [Visual Analog Scale, Short Form McGill Pain Questionnaire, and Wong-Baker FACES pain scores decreased by 55 percent (p=0.0143), 60 percent (p=0.023), and 90 percent (p=0.0024), respectively]. Significant subjective pain relief persisting between sessions was also reported, as well as marked immersion within the virtual environments. On followup at six weeks, the patient noted continued decrease in phantom limb pain symptoms. Conclusions: Currently available immersive virtual reality technology with myolectric and motion tracking control may represent a possible therapy option for treatment-resistant phantom limb pain.