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Virtual Reality, an aid to the diagnosis of painful spine

Pain is the number one cause of consultation for spinal conditions. In an ideal world, many patients would be satisfied with a single consultation if we managed to eliminate their pain from the first session. Our role as a therapist is to carry out an assessment with precise elements in order to explain to the patient the origin of his symptoms. Without this, how can we make them aware that their pain is not proportional to the lesions but a warning signal announcing an underlying disorder?

How can we justify a long-term therapeutic strategy for which the physiotherapist will be responsible in part, and the patient in part?

Otherwise our know-how will be worth no more to them than that of the experts at Google and Facebook and their many inadequate online exercise programmes.

Behind a multitude of patients and different pathologies, the practitioner must always respond to the same problem: how to make a patient who is in pain move? How to make him understand that his pain is a symptom like any other which must be evaluated and monitored during the session but that it should not be the centre of attention of the treatment? However, it will be this symptom that the patient will take as a reference to judge the effectiveness of his treatment.

The clinical approach to pain often stops at noting the moment or angle of onset, but not its evolution when faced with the repetition of a specific movement. The patient's defence mechanisms can evolve with progressive exposure to a constraint, just like a person who finds the sea too cold but who will gradually get used to the temperature to finally manage to swim. Thus, the patient should be asked to repeat a progressive exposure to the pain and to note whether, with repetition, the intensity of the pain decreases or whether the amplitude of the movement increases for the same intensity of pain.

Virtual reality (VR) is a tool of choice for this type of assessment. It allows the recording of quantitative parameters of amplitude and speed of movement so that the practitioner can concentrate exclusively on a qualitative assessment. The data recording can be accurately compared over time using graphical exports or raw data. Moreover, these evaluations can be carried out in various environments, which are conducive to the diversion of the patient's attention, thus reducing possible kinesiophobia.

In addition to this diagnostic aid, VR will add the possibility of carrying out spinal stabilisation or mobility exercises that can be segmented or integrated into functional gestures. The numerous universes and exercises available contribute to varying the rehabilitation sessions and above all to adapting the exercises in real time to the patient's abilities. In this way, the practitioner helps to reduce the lassitude that some patients feel when repeating exercises over time. Once again, thanks to this tool which monitors the parameters of the sessions, the practitioner will have objective elements relating to the evolution of the treatment, allowing him to adapt to the needs of the patient. The practitioner is freed from part of the re-evaluation of the patient's aptitudes, as this is done automatically in real time in the software used.

Virtual reality makes it possible to offer the patient various tasks and situations. The practitioner offers the patient the possibility of resuming certain activities within a virtual world that he would not consider in his real world. These activities allow the integration of the spine in its role as a stabiliser and control of the movement of the limbs, making the functional link between the upper and lower limbs. Virtual reality rehabilitation thus gives another dimension to sessions carried out in a sometimes restricted space, echoing a now well-known expression: "good treatment is movement".

Sources :

[1] HAS. Management of the patient with common low back pain. High Authority for Health. 2019.

[2] Virtual immersive gaming to optimize recovery (VIGOR) in low back pain: A phase II randomized controlled trial. Christopher R. France and James S. Thomas. Contemp Clin Trials. 2018 Jun; 69: 83-91. Published online 2018 May 3. doi: 10.1016/j.cct.2018.05.001

[3] Is Virtual Reality Effective in Orthopedic Rehabilitation? A Systematic Review and Meta-Analysis. Phys Ther. 2019 Oct 28;99(10):1304-1325. doi: 10.1093/ptj/pzz093. Mohammed Gumaa 1, Aliaa Rehan Youssef 2 PMID: 31343702 DOI: 10.1093/ptj/pzz093

[4] Hoffman, H. G., Richards, T. L., Coda, B., Bills, A. R., Blough, D., Richards, A. L., and Sharar, S. R. (2004). Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI. Neuroreport, 15(8), 1245-1248.

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