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OVERCOMING CHRONIC PAIN WITH DIGITAL THERAPIES

FEB. 11, 2021 | N°1581 | WWW.KINEACTU.COM

CONTINUING EDUCATION 19

After a very successful first edition in January 2020,
the Paris Santé Femmes congress took place this year in a virtual way.
The programme was rich and varied. Among the sessions proposed by
the College of Physiotherapy, we retained this intervention on an innovative treatment of chronic pain
on an innovative treatment of chronic pain (not only in women, by the way) thanks to
women, by the way) thanks to virtual reality. Here is a report.

GETTING THROUGH
CHRONIC PAIN
WITH DIGITAL THERAPIES

Faced with a pain that poisons the life of the patient, the physiotherapist is sometimes helpless. After a breast cancer, for example, 20 to 40% of patients (according to sources) have persistent chronic pain. In addition, there are many risk factors, which is why medicine is sometimes unable to treat them when conventional techniques do not work.
Another example is pelvic pain. 40% of women will experience at least one episode during their lifetime. However, only half of these pains are of gynaecological origin. For the other half, complementary examinations are generally normal. It is thus a complex pathology to evaluate and to take care of.
"It's in your head!" This is what we often say to women who suffer from endometriosis or vulvodynia... There is no need to look for predisposing bio-psycho-social factors in the patient. It is rather a sign of the practitioner's inadequacy in dealing with this pain.
In this context, digital tools can be relevant. Stéphane Fabri presented this innovative method of care.

The limits of the mechanical man/machine approach
It is sometimes necessary to question one's conception of pain. Pain is not always visible on imaging. Each pain does not always have a visible lesion. But this does not mean that it is psychological. We need to look at the central neurology and how information is processed.
Pain is central, produced by the brain.
That's neurology, not psychology. It is defined as an unpleasant sensory and emotional experience associated with an actual or potential tissue lesion.
It has 4 components: sensory-discriminative, affective (or emotional), cognitive and behavioural.
Nociception is peripheral (Fig. 1). A sensory process is the origin of nociceptive nerve signals. It functions as an alarm system against potential danger. There are pain blocking systems along the way, which are more powerful than any drug: the descending neuroinhibitory system (DNIS) and gate control at the spinal cord. But sometimes they fail: this is the pain disease.
Important: Studies (including Whiteside et al., 2004) have shown that muscle fatigue increases hyperalgesia. It disrupts the pain blocking systems. Pain is therefore linked to the state of fatigue and fatigability of the subject.
It is necessary to know how pain works in order to fight it well.
Then, the physiotherapist must find the key.

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The patient's beliefs... and those of the practitioner
When we talk about chronic pain, we can't ignore beliefs. Those of the patient as well as those of the physiotherapist. Communication and education of the patient are major elements of the care and can have a reassuring effect... or on the contrary deleterious! For example, a physiotherapist who talks a lot to explain everything, strong of his knowledge, risks to realize a toxic and anxiogenic demonstration. He should rather propose solutions to the patient to give her a perspective of healing.
Very quickly, from the first session, you have to tell the patient that you believe her, that she really has pain and that she is not crazy. Stéphane Fabri alluded to various very well-made educational films that can be used as support if necessary. Then you have to explain to her that it's not necessarily very serious, that it's her pain inhibition system that is failing and that the goal of the treatment will be to restore it.

The structuring of pain
We know today that the multiplication of imaging examinations favours the installation of chronic pain. Many things happen in the brain, including the secretion of chemicals (such as cholecystokinin) that amplify nociception. Fortunately, the brain also has the power to reverse this by secreting endorphin-like molecules.
The key is in the brain. So reintegration must be done through a central approach, using the visual referential (Candida 2008, Moseley 2006). This applies to all chronic female pain that is poorly explained and in need of diagnosis and appropriate management.

Virtual reality, a digital painkiller
The idea is to trick the brain with virtual reality. This process was developed by
Dr Hoffman, who treated burn victims. His goal was to avoid them taking too many opioids to fight against pain. Virtual reality acts as a digital painkiller. We extract the patient from her physicality (at first).
The literature is encouraging. Many articles show that virtual reality has a real beneficial impact on chronic pain, that it is effective quickly and that the benefits last over time. It would even be more effective than hypnosis (Gupta et al. 2018).
It reduces chronic pain after breast cancer (Austin et al. 2019, Garett et al. 2020). Moderate intensity exergamma reduces pain sensitivity (Carey C. 2017, Matteo 2017).
They are effective on pain and function after breast cancer (Furtado de Oliveira et al. 2020).
Their effectiveness is related to the patient's enjoyment during the session (Howard M.C. 2017).
Combining passive and active virtual reality In this field, there are both passive and active techniques. Both are important. The principle of the treatment is to gradually expose the patient to constraints. First a very immersive environment, without making any gestures, then take the patient to areas with functional constraints close to the difficulties she experiences in her daily life, work and/or sport.
At the beginning, she is made to do gestures that do not cause pain, then she is gradually led to the gestures that she fears. The virtual reality acts as a distraction and little by little, the patient is able to perform them without pain.
There comes a time when the patient must be confronted with her image, because chronic pain is often linked to a distorted body image, especially in chronically painful patients. Therefore, improving this image leads to an improvement in the symptoms of chronic pain.
In the continuity of immersive virtual reality (with a mask), we can make a transition with exergames, which are video games with modeling and reconstruction of the body image thanks to an avatar. Moreover, in his office, Stéphane Fabri has a room dedicated to virtual reality: it is important that the avatar is the same size as the patient, so that she can identify herself more easily.
The game retains the same principle of hypnosis, thus integrating the patient in a virtual model, but without mask and not immersive (or with a moderate immersion). The advantage of body modeling through the avatar is that it allows a global mirror therapy aimed at rebuilding the body image, by performing movements proposed by the game. These exercises require concentration, but they remain playful.
After the exergames, the patient will be able to do more traditional physical exercises (mobility, muscular reinforcement, work on an eliptical, physical activity in the gym or outdoors). This is important because it is known that physical activity generally has an analgesic effect, thanks to central inhibitory mechanisms (production of natural opioids - cf Lima et al. 2017). But be careful: the effort must be adapted to the patient. If it is excessive, it can produce the opposite effect.

Conclusion
Physiotherapists should be interested in virtual reality because it offers interesting levers to tackle pain. In some cases, it is really relevant. The central approach of painful pathologies is a very promising track.
We need to move away from the vision we sometimes have of the "man-machine" and the "pain structure".
There are sometimes injured structures that are not painful, and healthy structures that are nevertheless painful, despite the treatment. We must accept the idea that the brain is capable of producing pain on its own, and that this is not psychological.
SOPHIE CONRARD

Speech proposed by Stéphane Fabri, MKDE and osteopath (34). No links of interest with the pharmaceutical industry or medical device manufacturers.

QUESTIONS TO STÉPHANE FABRI
How did you get started?
I started with consumer VR (virtual reality), a mobile phone, a Samsung Gear mask and VR 360 movies on YouTube. It's passive VR. It's interesting to get the hang of it but it's limited. To go further, I looked at what was available on the market and I was seduced by the Virtualis device. It was developed by Franck Assaban, a physiotherapist who is involved in digital health. He started with the concept of rehabilitation and built a tool adapted to it. It is perfectly in line with what I need in my practice because its use is part of a global approach, which respects the cognitive and functional fidelity of movement. With the VR modules he has developed, we go even further, with the possibility for the patient to do double-task exercises in a totally immersive environment.

How does it work?
Many things are managed by the brain: motor pattern, joint stability, body perceptions, pain. When the traditional peripheral mechanistic approach fails, we have to go to the heart of the problem: in the brain. At the motor and perceptual level, the gateways are somesthesia (body perception), the vestibular system and the eye. They work together at the level of body perception necessary for joint stability and the production of gesture. There is a hierarchy and the eye takes precedence over the others. VR uses this characteristic to put the patient in an illusionary environment that will change his internal models. It is a form of digital hypnosis that produces a dissociation from reality to produce therapeutic functional changes in the brain.

Why is it so interesting?
The exercises we prescribe have limits, both in terms of performance and perception. We know today that the element that limits an individual's performance is not his physical capacity, it is his perception of the effort required. When people say "it's in the head", they are right but it has nothing to do with the psychological character: it's neuroscience. VR "goes into the head of patients" to modify this perception of effort by making the environment different and pleasant. A chronic pain sufferer is often in a context of kinesiophobia. Any effort in this context will be perceived as an aggression and will be counterproductive because it generates pain, even if the exercise is not the cause. VR puts the patient in a modified and reassuring environment in order to play on his beliefs and remove his obstacles. The exercises can then take place in better conditions.
Today, physical therapists who use this type of tool are still few. This is why I am thinking about a training course on VR and new technologies. So that we no longer say to patients in therapeutic failure "it's in your head!" but "it's in your brain, and we have adapted and efficient tools to remedy it".
Extract from an interview published in Ka n°1573 in October 2020.

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