Virtual reality, augmented reality and mirror therapy for musculoskeletal pain

Purpose

Musculoskeletal conditions are prevalent, often chronic, disorders that impact both physical and mental wellbeing. Exercise therapy is a common physiotherapy treatment, yet adherence to home exercise programmes is low, due in part to pain during exercise. Virtual reality therapy has been shown to be effective at treating acute pain conditions (e.g. burns and dental pain) by disrupting the pain matrix pathways, reducing perception of pain. However, such therapies have not been reviewed in the context of MSK pain. The primary objective of this systematic review was to determine the efficacy of virtual reality (VR) and augmented reality (AR) in the treatment of pain from MSK conditions. The secondary objective was to investigate the impact of VR and AR on disability levels from MSK conditions.

Approach

Database searches were performed on PubMed, Science Direct, PEDro, CINAHL/AHMED, Cochrane Library, ProQuest and the National Institute for Health Clinical Trials database, from inception to March 2018. RCT's where virtual reality, augmented reality or mirror therapy were used to treat pain from MSK conditions and compared against placebo, alternative treatment or no treatment were included. Both authors independently assessed suitable trials against inclusion criteria, assessed methodological quality (PEDro scale) and evaluated the strength of the evidence. A meta-analysis was also conducted on nine studies, to calculate the size of the treatment effect on VAS scale measured pain levels.

Outcomes

Ten trials (410 participants) were included. Strong evidence was found that supports the use of mirror therapy and VR to treat pain from MSK conditions. Moderate evidence exists for the use of mirror therapy to treat phantom limb pain. Evidence from lower quality trials indicates that VR and exercise alone are equally as effective; conflict exists about the impact of VR on disability. The meta-analysis shows an overall medium effect size of 0.50 for VR and mirror therapy interventions on MSK pain (SE 0.08, 95% CI -0.67 to -0.33), which was significant (z=-5.88, p< 0.05).  

Whilst the evidence suggests that VR and MT are effective as reducing pain from MSK conditions, there is insufficient evidence to support the use of these interventions as stand alone treatments. Further high quality research is needed that includes measures of the cognitive components of virtual reality, augmented reality and mirror therapies to better understand the underlying mechanisms of these interventions, identify the characteristics of patients for whom this treatment is likely to be successful and to begin to create a standardised treatment protocol to allow better comparability across studies.

Implications

Limited but high quality evidence that supports the use of mirror therapy to treat PLP, indicating that clinicians dealing with PLP should consider mirror therapy as a treatment option. Whilst the results from this review do not provide an imperative to use virtual reality as a stand-alone treatment of MSK conditions, the evidence does indicate that VR can be a valuable tool to augment pain in conjunction with other treatment options. However, cost is a significant barrier to the use of VR in clinical practice.

Fund acknowledgements

Research undertaken as part of MSc (pre-reg) physiotherapy degree, funded by NHS

Additional notes

This work was presented at Physiotherapy UK 2019