Virtual reality gameplay classification illustrates the multidimensionality of visuospatial neglect.

Brain injuries can significantly impact mental processes and lead to hidden disabilities not easily detectable. Traditional methods for assessing these impacts are imprecise, leading to unreliable prevalence estimates and treatments with uncertain effectiveness. Immersive virtual reality has shown promise for assessment, but its use as a standalone tool is rare. Our research focused on developing and validating a standalone immersive virtual reality classification system for unilateral spatial neglect, a condition common following brain injury characterized by inattention to one side of space. Our study involved 51 brain injury inpatients and 30 controls, all engaging with 'The Attention Atlas', an immersive virtual reality game for testing visual search skills. Our classification system aimed to identify patients with neglect, 'minor atypicality' (indicative of inattention not consistent enough to be labelled as neglect) or non-neglect. This categorization was based on a simple mathematical definition, utilizing gameplay to describe spatial orientation (to the left or right side) and attentional challenge (indicative of search inefficiency). These metrics were benchmarked against a normative model to detect atypical visual search, which refers to gameplay beyond the usual bounds. The combination of neglected side, orientation and challenge factors was used to categorize neglect. We discovered a strong correlation between atypical visual search patterns and neglect risk factors, such as middle cerebral artery stroke, parietal injuries and existing neglect diagnoses (Poisson regression incidence rate ratio = 7.18, 95% confidence interval = 4.41-11.90). In our study, immersive virtual reality-identified neglect in one-fourth of the patients (n = 13, 25.5%), minor atypicality in 17.6% (n = 9) and non-neglect in the majority, 56.9% (n = 29). This contrasts with standard assessments, which detected neglect in 17.6% (n = 9) of cases and had no intermediate category. Our analysis determined six categories of neglect, the most common being left hemispace neglect with above-median orientation and challenge scores. Traditional assessments were not significantly more accurate (accuracy = 84.3%, P = 0.06) than a blanket assumption of non-neglect. Traditional assessments were also relatively insensitive in detecting immersive virtual reality-identified neglect (53.8%), particularly in less severe cases and those involving right-side inattention. Our findings underline the effectiveness of immersive virtual reality in revealing various dimensions of neglect, surpassing traditional methods in sensitivity and detail and operating independently from them. To integrate immersive virtual reality into real-world clinical settings, collaboration with healthcare professionals, patients and other stakeholders is crucial to ensure practical applicability and accessibility.

A comparison of visual and direct assessments of lumbar spine posture.

BACKGROUND: Posture is assessed clinically and used to guide treatment of low back pain. Collectively, the relevance of posture and clinical postural assessments have come under scrutiny. This study aimed to determine (a) the intra-rater and inter-rater reliability of visual assessments of lumbar lordosis, and (b) the agreement between visual and direct postural assessments. METHODS: Ten physiotherapists visually assessed the lumbar lordosis from 3D scans of 50 asymptomatic participants, and 15 duplicates, using a grading scale of deviations (range: 0 = normal to 3 = severe). Lumbar lordosis angle was directly assessed using the Vitus Smart 3D whole body scanner. Cohen's Kappa was used to determine the intra-rater and inter-rater reliability of visual assessments, with polyserial correlation (ps) used to determine the agreement between visual and direct assessments. RESULTS: Overall, 93% and 83% of all intra-rater and inter-rater differences in visual assessments were within a single grade point, respectively. The intra-rater and inter-rater reliability of visual assessments was moderate (κ (95%CI): 0.56 (0.45, 0.67)) and slight (κ (95%CI): 0.13 (0.08, 0.19)), respectively. The agreement between visual and direct assessments was moderate (ps = -0.41, p = 0.04). CONCLUSION: Visual assessments of lumbar posture demonstrated moderate repeatability and agreement with quantitative assessments. While agreement between assessors was slight, 83% of the visual ratings were within a single grade point, suggesting greater coherence among clinicians than our statistics suggested. As with any clinical assessments involving uncertainty, postural assessment should not solely guide treatment.

Pain Education and Virtual Reality Improves Pain, Pain-related Fear of Movement, and Trunk Kinematics in Individuals With Persistent Low Back Pain.

OBJECTIVES: To evaluate the effect of combining pain education and virtual reality (VR) exposure therapy using a cognitive-behavioral therapy-informed approach (virtual reality-based cognitive behavioral therapy [VR-CBT]) on pain intensity, fear of movement, and trunk movement in individuals with persistent low back pain. MATERIALS AND METHODS: Thirty-seven participants were recruited in a single cohort repeated measures study, attending 3 sessions 1 week apart. The VR-CBT intervention included standardized pain education (session 1) and virtual reality-based exposure therapy (VRET; session 2) incorporating gameplay with mixed reality video capture and reflective feedback of performance. Outcome measures (pain intensity, pain-related fear of movement (Tampa Scale of Kinesiophobia), and trunk kinematics during functional movements (maximum amplitude and peak velocity) were collected at baseline (session 1) and 1 week after education (session 2) and VRET (session 3). One-way repeated measures analysis of variances evaluated change in outcomes from baseline to completion. Post hoc contrasts evaluated effect sizes for the education and VR components of VR-CBT. RESULTS: Thirty-four participants completed all sessions. Significant ( P < 0.001) reductions were observed in mean (SD) pain (baseline 5.9 [1.5]; completion 4.3 [2.1]) and fear of movement (baseline 42.6 [6.4]; completion 34.3 [7.4]). Large effect sizes (Cohen d ) were observed for education (pain intensity: 0.85; fear of movement: 1.28), whereas the addition of VRET demonstrated very small insignificant effect sizes (pain intensity: 0.10; fear of movement: 0.18). Peak trunk velocity, but not amplitude, increased significantly ( P < 0.05) across trunk movement tasks. CONCLUSION: A VR-CBT intervention improved pain, pain-related fear of movement, and trunk kinematics. Further research should explore increased VR-CBT dosage and mechanisms underlying improvement.

Immersive virtual reality gameplay detects visuospatial atypicality, including unilateral spatial neglect, following brain injury: a pilot study.

BACKGROUND: In neurorehabilitation, problems with visuospatial attention, including unilateral spatial neglect, are prevalent and routinely assessed by pen-and-paper tests, which are limited in accuracy and sensitivity. Immersive virtual reality (VR), which motivates a much wider (more intuitive) spatial behaviour, promises new futures for identifying visuospatial atypicality in multiple measures, which reflects cognitive and motor diversity across individuals with brain injuries. METHODS: In this pilot study, we had 9 clinician controls (mean age 43 years; 4 males) and 13 neurorehabilitation inpatients (mean age 59 years; 9 males) recruited a mean of 41 days post-injury play a VR visual search game. Primary injuries included 7 stroke, 4 traumatic brain injury, 2 other acquired brain injury. Three patients were identified as having left sided neglect prior to taking part in the VR. Response accuracy, reaction time, and headset and controller raycast orientation quantified gameplay. Normative modelling identified the typical gameplay bounds, and visuospatial atypicality was defined as gameplay beyond these bounds. RESULTS: The study found VR to be feasible, with only minor instances of motion sickness, positive user experiences, and satisfactory system usability. Crucially, the analytical method, which emphasized identifying 'visuospatial atypicality,' proved effective. Visuospatial atypicality was more commonly observed in patients compared to controls and was prevalent in both groups of patients-those with and without neglect. CONCLUSION: Our research indicates that normative modelling of VR gameplay is a promising tool for identifying visuospatial atypicality after acute brain injury. This approach holds potential for a detailed examination of neglect.

Teaching Patients About Pain: The Emergence of Pain Science Education, its Learning Frameworks and Delivery Strategies.

Since it emerged in the early 2000's, intensive education about 'how pain works', widely known as pain neuroscience education or explaining pain, has evolved into a new educational approach, with new content and new strategies. The substantial differences from the original have led the PETAL collaboration to call the current iteration 'Pain Science Education'. This review presents a brief historical context for Pain Science Education, the clinical trials, consumer perspective, and real-world clinical data that have pushed the field to update both content and method. We describe the key role of educational psychology in driving this change, the central role of constructivism, and the constructivist learning frameworks around which Pain Science Education is now planned and delivered. We integrate terminology and concepts from the learning frameworks currently being used across the PETAL collaboration in both research and practice-the Interactive, Constructive, Active, Passive framework, transformative learning theory, and dynamic model of conceptual change. We then discuss strategies that are being used to enhance learning within clinical encounters, which focus on the skill, will, and thrill of learning. Finally, we provide practical examples of these strategies so as to assist the reader to drive their own patient pain education offerings towards more effective learning. PERSPECTIVE: Rapid progress in several fields and research groups has led to the emergence 'Pain Science Education'. This PETAL review describes challenges that have spurred the field forward, the learning frameworks and educational strategies that are addressing those challenges, and some easy wins to implement and mistakes to avoid.

Could Vulnerability to Motion Sickness and Chronic Pain Coexist within a Sensorimotor Phenotype? Insights from over 500 Pre-Pain Motion Sickness Reports.

BACKGROUND: The sensorimotor incongruence theory proposes that certain instances of pain result from conflicts in the brain's sensorimotor networks. Indeed, injuries may cause abnormalities in afferent and cortical signaling resulting in such conflicts. Motion sickness also occurs in instances of incongruent sensorimotor data. It is possible that a sensory processing phenotype exists that predisposes people to both conditions. AIM: The aim of this study was to investigate whether participants with chronic pain recall greater susceptibility to motion sickness before chronic pain onset. METHOD: Data were collected via an online LimeSurvey. A self-report tendency toward motion sickness was measured using the Motion Sickness Susceptibility Questionnaire. Group differences were analysed using analysis of covariance methods. RESULTS: 530 patients (low back pain, n = 198; neck pain, n = 59; whiplash-associated disorder, n = 72; fibromyalgia syndrome, n = 114; Migraine, n = 41) and 165 pain-free controls were surveyed. ANCOVA analysis, using sex and anxiety as covariates, suggested that childhood motion sickness susceptibility scores differed by group (F = 2.55 (6, 615), p = 0.019, (ηp2) = 0.024). Planned comparisons, with corrected p-values, suggested that childhood motion sickness was not statistically greater for low back pain, rheumatoid arthritis, migraine, neck pain or whiplash-associated disorder (ps > 0.05), although scores were on average 27%, 42%, 47%, 48% and 58% higher, respectively. Childhood susceptibility was statistically higher in people with FMS (p = 0.018), with scores on average 83% higher than controls. ANCOVA analysis, using sex and anxiety as covariates, suggested that adult motion sickness susceptibility scores did not differ by group (F = 1.86 (6, 613), p = 0.086), although average scores were, on average, at least 33% higher in persistent pain groups. CONCLUSIONS: According to retrospective reporting, greater susceptibility to motion sickness appears to pre-date persistent pain in some conditions. This supports the possibility that motion sickness and chronic pain may, in some cases, have overlapping mechanisms related to the handling of incongruent sensorimotor data.

"It made you feel like you've still got it": experiences of people with chronic low back pain undertaking a single session of body image training in virtual reality.

INTRODUCTION: Embodying fit avatars in virtual reality (VR) is proposed as a possible treatment for cortical body representations and pain-related self-perceptions. OBJECTIVE: To explore consumer perceptions of a novel VR intervention (VR-BiT) for chronic low back pain. METHODS: Adults (n = 17, mean age(SD) = 52(14)) with chronic low back pain who had undergone a single session of VR-BiT as part of a randomized controlled trial underwent a semi-structured interview using open-ended questions. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically. RESULTS: Data reduction identified four themes: clinically beneficial and beyond; helping and hindering use; desire for more; and individualized future. Participants experienced wide ranging effects, including improved physical self-efficacy, pain, ability to perform physical activity and psychological symptoms. The intervention was well tolerated, except for two reports of nausea, and a few participants indicating pain associated with unaccustomed movement. Most participants were motivated to use VR-BiT again, despite some having technical issues. Participants suggested that personalizing VR-BiT and regular use would be beneficial. CONCLUSIONS: There was strong consumer support for further use of VR-BiT. Future studies of VR-BiT effectiveness are warranted and should consider incorporating individual user preferences, including people with diverse pain presentations, and involving a multi-session design.

The attention atlas virtual reality platform maps three-dimensional (3D) attention in unilateral spatial neglect patients: a protocol.

BACKGROUND: Deficits in visuospatial attention, known as neglect, are common following brain injury, but underdiagnosed and poorly treated, resulting in long-term cognitive disability. In clinical settings, neglect is often assessed using simple pen-and-paper tests. While convenient, these cannot characterise the full spectrum of neglect. This protocol reports a research programme that compares traditional neglect assessments with a novel virtual reality attention assessment platform: The Attention Atlas (AA). METHODS/DESIGN: The AA was codesigned by researchers and clinicians to meet the clinical need for improved neglect assessment. The AA uses a visual search paradigm to map the attended space in three dimensions and seeks to identify the optimal parameters that best distinguish neglect from non-neglect, and the spectrum of neglect, by providing near-time feedback to clinicians on system-level behavioural performance. A series of experiments will address procedural, scientific, patient, and clinical feasibility domains. RESULTS: Analyses focuses on descriptive measures of reaction time, accuracy data for target localisation, and histogram-based raycast attentional mapping analysis; which measures the individual's orientation in space, and inter- and intra-individual variation of visuospatial attention. We will compare neglect and control data using parametric between-subjects analyses. We present example individual-level results produced in near-time during visual search. CONCLUSIONS: The development and validation of the AA is part of a new generation of translational neuroscience that exploits the latest advances in technology and brain science, including technology repurposed from the consumer gaming market. This approach to rehabilitation has the potential for highly accurate, highly engaging, personalised care.

A randomized controlled pilot study examining immediate effects of embodying a virtual reality superhero in people with chronic low back pain.

PURPOSE: In virtual reality, avatar embodiment can spur perceptions and behaviours related the avatars' characteristics. We tested whether embodying superhero-like avatars can change self-perceptions in people with chronic low back pain (CLBP). DESIGN: A non-blinded pilot randomized controlled trial. METHODS: Participants were randomly allocated to embody a superhero (VR-SH, n = 20) or a neutral, non-superhero (VR-Play, n = 10) avatar. Primary outcomes related to body image (e.g., self-perceived vulnerability) and pain intensity were assessed at baseline, during exposure, immediately after and at one-week follow-up. Fear of movement, strength and patient impression of change were also recorded. RESULTS: The VR-SH group reported gains in body image during (p < .001, Î·p2=0.71) and immediately after (p < .001, Î·p2=0.66) VR, whereas the VR-Play group reported small gains during VR (p = .021, Î·p2=0.46) but not immediately after (p = .076, ηp2=0.31). Pain, strength and fear of movement did not change and there were no sustained effects at follow-up (all ps > .05). A greater proportion of people in the VR-SH group reported at least minimal improvement at follow-up (7/20 vs. 1/10). CONCLUSION: A VR-SH session produced temporary positive effects on body image. Future research may consider whether larger and sustained effects can be obtained with multisession exposures or explore combined interventions. Implications for rehabilitationPhysical confidence and bodily trust can be significantly enhanced in people with chronic back pain using virtual reality.These positive body image effects may have implications for rehabilitation, such as in enhancing confidence with movementWhether a multisession intervention might produce more robust effects and changes in pain is yet to be determined.

Key Learning Statements for Persistent Pain Education: An Iterative Analysis of Consumer, Clinician and Researcher Perspectives and Development of Public Messaging.

Over the last decade, the content, delivery and media of pain education have been adjusted in line with scientific discovery in pain and educational sciences, and in line with consumer perspectives. This paper describes a decade-long process of exploring consumer perspectives on pain science education concepts to inform clinician-derived educational updates (undertaken by the authors). Data were collected as part of a quality audit via a series of online surveys in which consent (non-specific) was obtained from consumers for their data to be used in published research. Consumers who presented for care for a persistent pain condition and were treated with a pain science education informed approach were invited to provide anonymous feedback about their current health status and pain journey experience 6, 12 or 18 months after initial assessment. Two-hundred eighteen consumers reported improvement in health status at follow-up. Results of the surveys from 3 cohorts of consumers that reported improvement were used to generate iterative versions of 'Key Learning Statements'. Early iteration of these Key Learning Statements was used to inform the development of Target Concepts and associated community-targeted pain education resources for use in public health and health professional workforce capacity building initiatives. PERSPECTIVE: This paper reflects an explicit interest in the insights of people who have been challenged by persistent pain and then recovered, to improve pain care. Identifying pain science concepts that consumers valued learning provided valuable information to inform resources for clinical interactions and community-targeted pain education campaigns.