Feasibility and Safety of a Virtual Reality Dodgeball Intervention for Chronic Low Back Pain: A Randomized Clinical Trial

Abstract

Whereas the fear-avoidance model of chronic low back pain (CLBP) posits a generic avoidance of movement that is perceived as threatening, we have repeatedly shown that individuals with high fear and CLBP specifically avoid flexion of the lumbar spine. Accordingly, we developed a virtual dodgeball intervention designed to elicit graded increases in lumbar spine flexion while reducing expectations of fear and harm by engaging participants in a competitive game that is entertaining and distracting. We recruited 52 participants (48% female) with CLBP and high fear of movement and randomized them to either a game group (n = 26) or a control group (n = 26). All participants completed a pregame baseline and a follow-up assessment (4-6 days later) of lumbar spine motion and expectations of pain and harm during standardized reaches to high (easier), middle, and low (hardest to reach) targets. For 3 consecutive days, participants in the game group completed 15 minutes of virtual dodgeball between baseline and follow-up. For the standardized reaching tests, there were no significant effects of group on changes in lumbar spine flexion, expected pain, or expected harm. However, virtual dodgeball was effective at increasing lumbar flexion within and across gameplay sessions. Participants reported strong positive endorsement of the game, no increases in medication use, pain, or disability, and no adverse events. Although these findings indicate that very brief exposure to this game did not translate to significant changes outside the game environment, this was not surprising because graded exposure therapy for fear of movement among individuals with low back pain typically last 8 to 12 sessions. Because of the demonstration of safety, feasibility, and ability to encourage lumbar flexion within gameplay, these findings provide support for a clinical trial wherein the treatment dose is more consistent with traditional graded exposure approaches to CLBP.

Perspective: This study of a virtual reality dodgeball intervention provides evidence of feasibility, safety, and utility to encourage lumbar spine flexion among individuals with CLBP and high fear of movement.

Trial registration: ClinicalTrials.gov NCT02301741.

Keywords: Virtual reality; chronic back pain; fear; intervention.

Conflict of interest statement

JST, CRF, MEA, STL, and SW have read and approved the final manuscript and certify that they have no conflicts of interest or financial involvement with this manuscript. Research reported in this publication was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award Number R21AR064430. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Copyright © 2016 American Pain Society. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

The Fear-avoidance model of chronic low back pain.

Figure 2

Experimental flow chart

Figure 3

Target locations are standardized based on an individual’s hip height, trunk length, and arm length such that the high target could be reached, with the shoulder flexed to 90 degrees and the elbow extended, simply by flexing the hips 15 degrees. The middle and low targets could, in theory, be reached by flexing the hips 30 and 60 degrees respectively. It should be noted that participants were not positioned as shown; rather this illustration shows how the target locations were normalized to each individual.

Figure 4

The methods for computing location of the impact heights (IH0-IH4) of the launched virtual balls for a single game level (top). The lumbar spine flexion used to reach the high, middle, and low targets during the baseline standardized reaching tasks was used to compute the lowest impact height (IH4). The distribution of launched balls across the three levels of a single gameplay session (bottom).

Figure 5

Participant flow chart.

Figure 6

The effects of game level at each impact height on lumbar spine flexion is illustrated. While there was no effect of game level on spine flexion for Impact Height 0 (IH0), there were significant increases in spine flexion as a function of game level for Impact Heights 1 through 4 (IH1 to IH4).

Figure 7

The interaction of days of gameplay by impact height (IH) of the launched virtual balls. Horizontal lines indicate significant pairwise differences in lumbar spine flexion (p

Figure 8

Participant ratings of gameplay experience.