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Sports Medicine – The impact of Virtual Reality on treating athletes to return to sports performance

Article written by Sylvain Desquerre, Masseur-Kinésithérapeute.

Historically, the major players in virtual reality (VR) have been the military, airline industry, space agencies (ie : NASA), and video game manufacturers. The video game industry first developed virtual reality for the general public and has helped make it accessible for therapeutic purposes [1].

Rehabilitation and sports performance professionals are finding increasing relevance of VR applications. MRI showing brain activity corresponding to pain. On the left, without VR. Right, with VR.

Kinesiophobia can arise during rehabilitation of the athlete following an injury. VR proves to be a formidable weapon to counter this phenomenon.

In Seattle, a study from the University of Washington showed that virtual reality use reduced the amount of time that participants thought about pain by 44%, reduced emotional pain by 45%, and reduced sensory pain scores by 30% (Figure 1). As pain decreases in intensity and becomes less distressing, patients adopt fewer avoidance strategies [2].

The immersive aspect of VR therefore helps to combat kinesiophobia. During the early stages of rehabilitation, VR allows the athlete to carry out movements of very low amplitude and, while diverting attention from the pain, to achieve normal range of motion faster.

A review of eighteen studies on VR published in 2018 further highlighted that increased immersion in VR improves navigation task performance, assignment accuracy, and postural instability [3].

Also related to performance, a 2019 study on young karate athletes showed that integrating virtual reality into the athlete's daily practice was useful in improving recognition of the opponent's type of attack so that athletes could anticipate and improve their response time and decision-making. Where other studies only assumed an increase in motivation, Petri et al. (2019) statistically proved this increase in anticipation and decision-making. The excitement came from the ability of the fighter to try new movements and reactions in a safe environment [4].

In the later stages of rehabilitation, Gokeler et al. (2016) showed that athletes cleared for return to sport following ACL reconstruction had altered movement patterns in the surgical knee, resulting in a risk of relapse or injury to the contralateral limb. Rehabilitation with VR improved these patterns, approximating those of healthy subjects. Immersive virtual reality can improve return to sport criteria and motor learning in rehabilitation to decrease the risk of relapse in post-ACL reconstruction patients [5].

As physical therapists, we know that the psychological aspect of athletes is also extremely important. In VR it is possible to recreate an environment close to the competition, which is very useful for stress management. Visual perception, anticipation, reaction time, and decision-making are also critical factors simulated in VR. A 2019 study on basketball players' decision-making shows transferable and generalized gains through the use of VR [6].

Imagine dodging a flying object in virtual reality, which involves reading the trajectory, coordinating vision and body movement, incorporating proprioceptive and vestibular processing to maintain balance, and so on. Now transfer this to a maneuver to a defensive action in boxing or a dodge in fencing.

Of course, VR will not replace the real conditions of a sports practice, but it shows potential. Although still being explored, the future of VR in rehabilitation remains more than encouraging. It is a customizable tool, that can be used in early rehabilitation to fight against kinesiophobia, through the advanced phases of rehab and return to sport. It is possible to work on various aspects such as joint amplitude of motion, precision, weight shifting, balance, coordination, reaction time, decision-making, even stress management. It is an effective as an immersive device and not only fun, but can track patient performance and motivate our athletes. VR allows the simulation of sports-like activity in a controlled, safe environment where parameters can be modified in real time.

[1] Katz, L., Parker, J., Tyreman, H., Kopp, G., Levy, R., & Chang, E. (2006). Virtual reality in sport and wellness: Promise and reality. International Journal of Computer Science in Sport, 4(1), 4-16.
[2] Hoffman, Hunter G.; Richards, Todd L.; Coda, Barbara; Bills, Aric R.; Blough, David; Richards, Anne L.; Sharar, Sam R. (2004). Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI. NeuroReport, 15(8), 1245-1248.
[3] Rose, T., Nam, C. S., & Chen, K. B. (2018). Immersion of virtual reality for rehabilitation-Review. Applied ergonomics, 69, 153-161.
[4]Petri, K., Masik, S., Danneberg, M., Emmermacher, P. & Witte, K. Possibilities to use a virtual opponent for enhancements of reactions and perception of young karate athletes. Int. J. Comput. Sci. Sport 18, 20-33 (2019)
[5] Gokeler, Alli; Bisschop, Marsha; Myer, Gregory D.; Benjaminse, Anne; Dijkstra, Pieter U.; van Keeken, Helco G.; van Raay, Jos J. A. M.; Burgerhof, Johannes G. M.; Otten, Egbert (2016). Immersive virtual reality improves movement patterns in patients after ACL reconstruction: implications for enhanced criteria-based return-to-sport rehabilitation. Knee Surgery, Sports Traumatology, Arthroscopy, 24(7), 2280-2286. doi:10.1007/s00167-014-3374-x
[6] Pagé C, Bernier PM, Trempe M. Using video simulations and virtual reality to improve decision-making skills in basketball. J Sports Sci. 2019 Nov;37(21):2403-2410. doi: 10.1080/02640414.2019.1638193. Epub 2019 Jul 6. PMID: 31280685.

Figure 1 From: Hoffman, Hunter G.; Richards, Todd L.; Coda, Barbara; Bills, Aric R.; Blough, David; Richards, Anne L.; Sharar, Sam R. (2004). Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI. NeuroReport, 15(8), 1245-1248.

Author: Sylvain Desquerre - PT and former Captain of the French Waterpolo team

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