Virtual Reality as a Therapy Adjunct for Fear of Movement in Veterans With Chronic Pain: Single-Arm Feasibility Study

Christopher A Fowler, Lisa M Ballistrea, Kerry E Mazzone, Aaron M Martin, Howard Kaplan, Kevin E Kip, Katherine Ralston, Jennifer L Murphy, Sandra L Winkler, Christopher A Fowler, Lisa M Ballistrea, Kerry E Mazzone, Aaron M Martin, Howard Kaplan, Kevin E Kip, Katherine Ralston, Jennifer L Murphy, Sandra L Winkler

Abstract

Background: Virtual reality (VR) has demonstrated efficacy for distraction from pain-related thoughts and exposure to feared movements. Little empirical VR research has focused on chronic pain management.

Objective: The purpose of this study was to examine the feasibility of VR as an adjunctive intervention for Veterans with chronic pain. We designed a hierarchy ranging from low-intensity pain distraction to high-intensity movement-based exposure for this purpose. VR apps were mapped onto the hierarchy.

Methods: Sixteen Veterans receiving inpatient chronic pain rehabilitation participated in daily VR sessions over a 3-week period. Trajectories across the distraction-to-exposure hierarchy and Veteran-reported intensity ratings were described and evaluated over time. Minimum clinically important differences (MCIDs), pre-post effect sizes, and 95% confidence intervals were examined for fear of movement using the Fear of Daily Activities Questionnaire (FDAQ) and Pain Outcomes Questionnaire-VA (POQ-VA; fear scale). This approach was applied to secondary outcomes: POQ-VA (pain intensity, interference, negative affect), Pain Catastrophizing Scale, and Patient-Specific Functioning Scale (PSFS). Session attendance, completion, and VR experiences were described.

Results: Ten of 14 Veterans (71%) who participated in three or more VR sessions completed the distraction-to-exposure hierarchy. Only three trajectories emerged more than once. Due to high completion rates, Veterans that completed the hierarchy could self-select nonhierarchy apps. Veterans rated all hierarchy levels (low, medium, high) near medium intensity. Self-selected activities were rated as high intensity. For kinesiophobia, six Veterans (38%) exceeded the MCID on the FDAQ and a small effect size improvement was observed (Cohen d=-0.35). The confidence interval (95% CI -0.71 to 0.01) indicated the possibility of a null effect. The POQ-VA fear scale yielded no effect (Cohen d=0.06, 95% CI -0.43 to 0.54). For secondary outcomes, Veterans exceeding MCID were calculated with complete data: pain intensity (1/15, 7%), pain catastrophizing (5/14, 36%), and patient-specific functioning (10/15, 67%). Effect sizes were large for patient-specific functioning (Cohen d=1.14, 95% CI 0.50-1.78), medium for mobility interference (Cohen d=-0.56, 95% CI -0.96 to -0.16), and small for pain intensity (Cohen d=-0.40, 95% CI -0.69 to -0.12) and catastrophizing (Cohen d=-0.41, 95% CI -0.79 to -0.02). No effects were observed for interference in daily activities (Cohen d=0.10, 95% CI -0.27 to 0.47) and negative affect (Cohen d=0.07, 95% CI -0.26 to 0.40). Veterans attended 85.2% (98/108) of VR sessions and completed 95% (93/96) of sessions attended. Twenty-minute sessions were rated as too short. No significant adverse events were reported.

Conclusions: Findings support the feasibility of VR as an adjunct for Veterans with chronic pain. However, the hierarchy will require modification, as evidenced by homogeneous intensity ratings. Veteran-selected activities presented the highest intensity ratings, largest outcome effect size (PSFS), and MCID. This highlights the important role of utilizing Veteran stakeholders in hierarchy modification, design of VR interventions, and outcome selection.

Keywords: Veterans; chronic pain; distraction therapy; exposure therapy; fear of movement; kinesiophobia; pain management; rehabilitation; virtual reality.

Conflict of interest statement

Conflicts of Interest: JLM serves as the Chief Behavioral Health Officer of Karuna Labs. This is a recent appointment. JLM was not in this position during the conceptualization of this study, data collection, or drafting of this manuscript.

©Christopher A Fowler, Lisa M Ballistrea, Kerry E Mazzone, Aaron M Martin, Howard Kaplan, Kevin E Kip, Katherine Ralston, Jennifer L Murphy, Sandra L Winkler. Originally published in JMIR Formative Research (http://formative.jmir.org), 30.10.2019.

Figures

Figure 1
Figure 1
Samsung Oculus Gear VR with supplemental hand controller (left) and Oculus Rift (right).
Figure 2
Figure 2
Median Veteran progression across the distraction-to-exposure hierarchy. App movement intensity: 1=low, 2=medium, 3=high, 4=self-selected. VR: virtual reality.
Figure 3
Figure 3
Veteran-reported intensities for virtual reality (VR) apps across sessions. Self-reported app intensity: 1=low, 2=medium, 3=high.
Figure 4
Figure 4
Veteran-reported intensities for virtual reality (VR) apps across movement intensity levels.
Figure 5
Figure 5
Veteran-rated immersion across virtual reality (VR) sessions. Immersion rating scale: 1=using technology, 2=using technology and immersed in the virtual world, 3= completely immersed in the virtual world.
Figure 6
Figure 6
Veteran-rated virtual reality (VR) session length. Session length: 1=too short, 2=just right, 3=too long.

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