Limited use of virtual reality in primary care physiotherapy for patients with chronic pain

Slatman et al. BMC Musculoskeletal Disorders https://doi.org/10.1186/s12891-024-07285-5 (2024) 25:168 BMC Musculoskeletal Disorders Open Access RESEARCH Limited use of virtual reality in primary care physiotherapy for patients with chronic pain Syl Slatman1,2*, J. Bart Staal1,3, Harry van Goor4, Raymond Ostelo5,6, Remko Soer7,8 and Jesper Knoop1,5 Abstract Background Chronic pain is a disabling condition which is prevalent in about 20% of the adult population. Physiotherapy is the most common non-pharmacological treatment option for chronic pain, but often demonstrates unsatisfactory outcomes. Virtual Reality (VR) may offer the opportunity to complement physiotherapy treatment. As VR has only recently been introduced in physiotherapy care, it is unknown to what extent VR is used and how it is valued by physiotherapists. The aim of this study was to analyse physiotherapists’ current usage of, experiences with and physiotherapist characteristics associated with applying therapeutic VR for chronic pain rehabilitation in Dutch primary care physiotherapy. Methods This online survey applied two rounds of recruitment: a random sampling round (873 physiotherapists invited, of which 245 (28%) were included) and a purposive sampling round (20 physiotherapists using VR included). Survey results were reported descriptively and physiotherapist characteristics associated with VR use were examined using multivariable logistic regression analysis. Results In total, 265 physiotherapists participated in this survey study. Approximately 7% of physiotherapists reported using therapeutic VR for patients with chronic pain. On average, physiotherapists rated their overall experience with therapeutic VR at 7.0 and “whether they would recommend it” at 7.2, both on a 0–10 scale. Most physiotherapists (71%) who use therapeutic VR started using it less than two years ago and use it for a small proportion of their patients with chronic pain. Physiotherapists use therapeutic VR for a variety of conditions, including generalized (55%), neck (45%) and lumbar (37%) chronic pain. Physiotherapists use therapeutic VR mostly to reduce pain (68%), improve coordination (50%) and increase physical mobility (45%). Use of therapeutic VR was associated with a larger physiotherapy practice (OR = 2.38, 95% CI [1.14–4.98]). Unfamiliarity with VR seemed to be the primary reason for not using VR. Discussion Therapeutic VR for patients with chronic pain is in its infancy in Dutch primary care physiotherapy practice as only a small minority uses VR. Physiotherapists that use therapeutic VR are modestly positive about the technology, with large heterogeneity between treatment goals, methods of administering VR, proposed working mechanisms and chronic pain conditions to treat. Keywords Virtual reality (VR), Chronic pain, Physiotherapy, Survey *Correspondence: Syl Slatman Full list of author information is available at the end of the article © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Slatman et al. BMC Musculoskeletal Disorders (2024) 25:168 Introduction Approximately one in five adults suffer from chronic pain [1], which mostly occurs in the lower back [2]. Chronic pain is defined as pain lasting longer than three months and is often caused and sustained by a complex interplay of biological, psychological and social factors [3]. Patients with chronic pain report lower quality of life, more social problems, depression and other mental complaints [2, 4] compared to people without chronic pain. Moreover, chronic pain is associated with high direct and indirect societal costs [5]. Treatment options for patients with chronic pain are diverse and include both pharmacological and non-pharmacological possibilities, of which physiotherapy is the most common non-pharmacological treatment [1, 2]. It is recommended to administer stepped care for patients with chronic pain, meaning that treatment modalities of more basic steps (e.g. education, resume normal activities) should be applied before advanced treatment modalities (e.g. physical or psychological therapy) can be considered [6]. During their patient journey, most patients with chronic pain visit a physiotherapist to receive exercises and patient education [1, 2]. However, effects of this treatment are often small to moderate and diminish over time [7, 8], partly due to a lack of treatment adherence of patients [9]. Virtual Reality (VR) could offer a possibility to support physiotherapists in their treatment of patients with chronic pain, amongst other potential mechanisms by motivating patients to keep exercising [10]. VR is an emerging technology in healthcare [11], and is defined as an interactive, 3D computer-generated program in a multimedia environment [12]. VR can be categorized as either immersive or non-immersive, in which immersion usually evokes a greater sense of presence and feeling of being there in the virtual environment (VE). In immersive VR, the user wears equipment, like a headmounted display (HMD), through which the VE is delivered. In non-immersive VR, the VE is usually delivered through a computer or television screen and controlled using a joystick or other device [13, 14]. Besides motivating patients, proposed working mechanisms of VR for chronic pain include distraction [15], graded exposure therapy [16], relaxation [17] and neurophysiologic alterations [18]. VR has shown to be an effective therapeutic tool in several chronic pain conditions, including fibromyalgia [19, 20], complex regional pain syndrome [21] and chronic low back pain [22, 23]. Besides this, VR in primary care physiotherapy offers possibilities including patient monitoring and at-home treatment, while also offering physiotherapy practices the opportunity to present themselves as innovative [24, 25]. Given the rising healthcare costs, VR could be a useful tool in the Page 2 of 11 treatment of the growing population of patients with chronic pain, by a (...truncated)