The current limited evidence suggests that interactive virtual reality may reduce pain associated with ankylosing spondylitis, mastectomy, neuropathy, phantom limb or complex regional pain syndrome. Evidence from the studies in chronic neck pain, subacromial impingement syndrome and chronic low back pain is inconsistent. However, these conclusions should be interpreted with caution, as several methodological weaknesses mean that relevant studies may have been missed, and reviewer error and bias may be present. Further randomised controlled trials are needed to fully appraise the effectiveness of virtual reality in pain management.
Overall summary High risk of bias in the review
Studies were restricted based on publication format (only published full-texts were included). No information was provided on the number of reviewers involved in the data extraction or quality assessment.
|A. Did the interpretation of findings address all of the concerns identified in Domains 1 to 4?||Probably no|
|B. Was the relevance of identified studies to the review's research question appropriately considered?||Probably yes|
|C. Did the reviewers avoid emphasizing results on the basis of their statistical significance?||Probably yes|
|Risk of bias in the review||High|
|Number of studies||13|
|Number of participants||469|
|Last search date||16 July 2018|
|Objective||To evaluate the effect of immersive and non-immersive interactive virtual reality on pain perception in patients with a clinical pain condition.|
|Population||Participants with a clinical pain condition.|
|Interventions||Interactive virtual reality (VR) (either immersive or non-immersive). Virtual reality was considered to be interactive when a motion tracking system was used in order to allow the participant to use their own body movements to control those of a virtual object or avatar in real-time.
Studies that utilised VR as a non-interactive distraction, to induce relaxation, or hypnosis were excluded.
|Comparator||Not prespecified, but ultimately included inactive controls (e.g. placebo or no treatment) or active controls (e.g. a different variant of the same intervention, or a different kind of therapy).|
|Study design||Randomised controlled trials, quasi-randomised trials, and uncontrolled trials (including crossover and parallel-group design).
Case studies, reviews, theses and abstracts were excluded.
Overall, 13 out of 14 comparisons reported that pain was reduced following VR interventions compared to active controls or no intervention controls.
In terms of specific pain presentations, two randomised controlled trials (RCTs) reported on neck pain: one study reported an improvement in pain intensity for VR compared to an active control in patients with chronic neck pain both immediately following the intervention (standardised mean difference [SMD] -0.47, 95% confidence interval [CI] -0.69 to -0.25; 1 study, n=32 patients) and at follow-up (SMD -0.26, 95% CI -0.50 to -0.02; 1 study, n=32 patients); and one study reported no difference in pain intensity for VR intervention compared to an active control group in patients with chronic neck pain (1 study, n=32 patients). One RCT reported that VR interventions (exergames, such as table tennis or bowling) reduced pain compared to no intervention in patients with ankylosing spondylitis (SMD -0.67, 95% CI -1.02 to -0.32; 1 study, n=60 patients). One RCT reported no difference in pain intensity at rest, during movement and at night for VR interventions (Wii exergames) compared to kinematic exercises in patients with subacromial impingement syndrome (1 study, n=30 patients). One RCT reported no difference in pain scores for VR interventions (exergame of dodgeball) compared to no intervention in patients with chronic low back pain (1 study, n=52 patients). One non-randomised controlled study reported a reduction in pain for VR intervention (Wii exergames) compared to no intervention in breast cancer survivors following mastectomy (1 study, n=77 patients). Five out of five pre-test post-test studies (with no control arm) reported a reduction in pain intensity in limbs affected with neuropathic pain, phantom limb pain or complex regional pain syndrome compared to baseline following VR intervention (range: 32 to 39.1%).
In terms of side effects, motion sickness and headaches were reported by several studies.
The research objective was clearly stated. Eligibility criteria were well described and appeared appropriate to address the present review question. No restrictions were applied to eligibility criteria based on study characteristics. Studies were restricted based on publication format (only published full-texts were included).
|1.1 Did the review adhere to pre-defined objectives and eligibility criteria?||Probably yes|
|1.2 Were the eligibility criteria appropriate for the review question?||Probably yes|
|1.3 Were eligibility criteria unambiguous?||Probably yes|
|1.4 Were all restrictions in eligibility criteria based on study characteristics appropriate (e.g. date, sample size, study quality, outcomes measured)?||Probably yes|
|1.5 Were any restrictions in eligibility criteria based on sources of information appropriate (e.g. publication status or format, language, availability of data)?||Probably no|
|Concerns regarding specification of study eligibility criteria||High|
MEDLINE (Ovid), PsycINFO, CINAHL, Cochrane Library and Web of Science were searched for relevant studies. The reference lists of included studies and previously published systematic reviews were handsearched for additional relevant studies. The search strategy was not available in the supplementary material so it is not possible to comment on its efficacy or whether any restrictions were appropriate. Two reviewers were involved in the study selection and disagreements were resolved by consulting a third reviewer.
|2.1 Did the search include an appropriate range of databases/electronic sources for published and unpublished reports?||Probably yes|
|2.2 Were methods additional to database searching used to identify relevant reports?||Probably yes|
|2.3 Were the terms and structure of the search strategy likely to retrieve as many eligible studies as possible?||No information|
|2.4 Were restrictions based on date, publication format, or language appropriate?||No information|
|2.5 Were efforts made to minimise error in selection of studies?||Yes|
|Concerns regarding methods used to identify and/or select studies||Unclear|
No information was provided on the number of reviewers involved in the data extraction. Sufficient study characteristics appear to have been extracted to allow interpretation of results. Relevant study results appear to have been extracted. The quality of included studies was assessed using the Cochrane Collaboration’s assessment tool for RCTs or the Quality Assessment of Before-After (Pre-Post) Studies developed by the National Heart, Lung, and Blood Institute for studies with a single group pre-test post-test design; these were considered appropriate. No information was provided on the number of reviewers involved in the risk of bias assessment.
|3.1 Were efforts made to minimise error in data collection?||No information|
|3.2 Were sufficient study characteristics considered for both review authors and readers to be able to interpret the results?||Probably yes|
|3.3 Were all relevant study results collected for use in the synthesis?||Probably yes|
|3.4 Was risk of bias (or methodological quality) formally assessed using appropriate criteria?||Probably yes|
|3.5 Were efforts made to minimise error in risk of bias assessment?||No information|
|Concerns regarding methods used to collect data and appraise studies||Unclear|
The synthesis appeared to include all relevant studies. All departures from predefined analyses were explained. A meta-analysis could not be performed due to differences in study designs and types of comparators. A narrative synthesis was performed instead, this was considered appropriate. The quality of individual studies was considered in the synthesis.
|4.1 Did the synthesis include all studies that it should?||Probably yes|
|4.2 Were all pre-defined analyses reported or departures explained?||Probably yes|
|4.3 Was the synthesis appropriate given the degree of similarity in the research questions, study designs and outcomes across included studies?||Probably yes|
|4.4 Was between-study variation minimal or addressed in the synthesis?||Probably yes|
|4.5 Were the findings robust, e.g. as demonstrated through funnel plot or sensitivity analyses?||Probably yes|
|4.6 Were biases in primary studies minimal or addressed in the synthesis?||Probably yes|
|Concerns regarding synthesis and findings||Low|
PURPOSE: The aim of this systematic review was to evaluate the effect of immersive and non-immersive interactive virtual reality on pain perception in patients with a clinical pain condition.; METHODS: The following databases were searched from inception: Medline (Ovid), PsychInfo, CINAHL, Cochrane library and Web of Science. Two reviewers screened reports and extracted the data. A third reviewer acted as an arbiter. Studies were eligible if they were randomized controlled trials, quasi-randomized trials, and uncontrolled trials. Crossover and parallel-group designs were included. Risk of bias was assessed for all included studies.; RESULTS: Thirteen clinical studies were included. The majority of studies investigated a sample of participants with chronic pain. Six were controlled trials and seven uncontrolled studies. Findings from controlled research suggest that interactive virtual reality may reduce pain associated with ankylosing spondylitis and post-mastectomy, but results are inconsistent for patients with neck pain. Findings from uncontrolled studies suggest that interactive virtual reality may reduce neuropathic limb pain, and phantom limb pain, but had no effect on nonspecific chronic back pain.; CONCLUSIONS: There is a need for more rigorous randomized control trials in order to conclude on the effectiveness of the use of virtual reality for the management of pain. Implications for rehabilitation Interactive virtual reality has been increasingly used in the rehabilitation of painful conditions. Interactive virtual reality using exergames may promote distraction from painful exercises and reduce pain post-mastectomy and in patients with ankylosing spondylitis. Interactive virtual representation of limbs may reduce neuropathic and phantom limb pain.