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Chronic musculoskeletal (MSK) pain is a prominent health concern, resulting in pain-related disability, loss of functioning, and high health care costs. Physiotherapy rehabilitation is a gold-standard treatment for improving functioning in youth with chronic MSK pain. However, increasing physical activity can feel unattainable for many adolescents because of pain-related fear and movement avoidance. Virtual reality (VR) offers an immersive experience that can interrupt the fear-avoidance cycle and improve engagement in physiotherapy. Despite promising initial findings, data are limited and often lack the rigor required to establish VR as an evidence-based treatment for MSK pain.
This trial evaluates physiorehabilitation with VR in adolescents with MSK pain. This protocol outlines the rationale, design, and implementation of a randomized controlled trial enhanced with a single-case experimental design.
This study is a 2-group randomized controlled trial assessing the use of physiorehabilitation with VR in adolescents with MSK pain. The authors will collaborate with physical therapists to integrate VR into their standard clinical care. For participants enrolled in standard physiotherapy, there will be no VR integrated into their physical therapy program. Primary outcomes include physical function and engagement in VR. Secondary outcomes include pain-related fear and treatment adherence. Moreover, we will obtain clinician perspectives regarding the feasibility of integrating the intervention into the flow of clinical practice.
The pilot study implementing physiorehabilitation with VR demonstrated that high engagement and use of physiorehabilitation with VR were associated with improvements in pain, fear, avoidance, and function. Coupled with qualitative feedback from patients, families, and clinicians, the pilot study results provide support for this trial to evaluate physiorehabilitation with VR for youth with chronic MSK pain. Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024.
Significant breakthroughs for treating MSK pain require mechanistically informed innovative approaches. Physiorehabilitation with VR provides exposure to progressive challenges, real-time feedback, and reinforcement for movement and can include activities that are difficult to achieve in the real world. It has the added benefit of sustaining patient motivation and adherence while enabling clinicians to use objective benchmarks to influence progression. These findings will inform the decision of whether to proceed with a hybrid effectiveness-dissemination trial of physiorehabilitation with VR, serving as the basis for potential large-scale implementation of physiorehabilitation with VR.
ClinicalTrials.gov NCT04636177; https://clinicaltrials.gov/ct2/show/NCT04636177
DERR1-10.2196/40705
Chronic musculoskeletal (MSK) pain in adolescence is a significant public health concern with median prevalence rates of 11% to 38% and 3% to 5% in adolescents experiencing significant pain-related disability [
Virtual reality (VR) has the potential to facilitate breaking the cycle of fear of movement and avoidance during PT. VR enables the user to interact with a computer-generated environment that harnesses visual, audio, and tactile sensory inputs to provide an immersive experience to facilitate reaching therapeutic goals. Within the context of PT, access to a multisensory 3D experience can support patients in overcoming obstacles [
Although most commonly applied in the context of acute pain relief [
These findings are consistent with the extant literature, where VR has been suggested as an alternative to opioids with the therapeutic mechanisms centered on distraction [
Current VR studies lack the rigor and measurements over time that are critical for establishing VR as an evidence-based treatment for chronic pain rehabilitation. Moreover, the successful implementation of VR in practice requires further assessment. Initial findings suggest that clinicians find that VR supports individually tailored treatment, increases engagement in treatment, and improves the provider-client relationship, but clinicians also report persistent technology-related issues, adverse patient experiences of dizziness or headache with VR, and barriers associated with initial onboarding of the VR technology—namely, initial cost, lack of intuitive technology, need for training and technological support, and lack of staff to support implementation [
This study is a randomized controlled feasibility trial enhanced with a single-case experimental design (SCED) to compare physiorehabilitation with VR with standard PT implemented within routine clinical care. We will evaluate the functional outcomes of physiorehabilitation with VR and standard PT and characterize the feasibility of a future hybrid effectiveness-dissemination trial of PT rehabilitation treatment with VR in routine PT practice. The primary effectiveness outcome is physical function for the adolescent, and the secondary outcomes are pain-related fear and fear of movement. For feasibility, the primary outcomes are treatment acceptability, engagement, and implementation in routine clinical care, and secondary outcomes are adverse events with VR and treatment feedback from patients and clinicians.
This study was approved by Advarra, an external Institutional Review Board (IRB) for multisite studies, as well as by the IRB at Stanford University (eProtocol 63582). Procedures will follow the ethical standards of the IRB and the Helsinki Declaration of 1975 as revised in 2000. Informed consent and assent will be obtained from all participants. This study is registered at ClinicalTrials.gov (NCT04636177).
Adolescent participants will be recruited from one of the collaborating outpatient rehabilitation sites: an outpatient PT center within an academic medical center (eg, Stanford Children’s Health) or a private outpatient PT center (eg, California Rehabilitation and Sports Therapy and Agile Physical Therapy). Adolescents are eligible to participate if they (1) have localized or diffuse MSK pain [
Adolescents who meet the eligibility criteria and their caregivers are informed of the study by their clinicians when they present to one of the clinical recruitment sites for their initial PT evaluation. In addition, a study flyer is posted on a bulletin board of all active clinical studies in the patient waiting room at each recruitment site. Clinicians and the flyer direct interested adolescents and caregivers to fill out an eligibility web-based screening form, which allows the research team to contact the family directly. If the eligibility criteria are met, a research coordinator contacts the family for additional screening and to complete the assent and consent process.
This is a 2-group RCT enhanced with SCED using multiple measures. In single-case experiments, a participant is observed repeatedly at different levels of at least one independent variable, for example, assessing engagement with PT exercises throughout pretreatment baseline and across treatment. To accomplish this, adolescents will complete daily diaries during a pretreatment phase (estimated to range from 7 to 14 days in duration) and daily diaries from day 0, when VR headsets are distributed, to end of treatment (day 0+N) and for 7 days at the 3-month follow-up. Upon arrival at the first treatment session after the baseline assessment, adolescents are informed if they are assigned to physiorehabilitation with VR or standard PT. The treatment phase consists of an estimated 6 to 8 PT sessions of 1 hour, with the number and frequency of treatment sessions determined at the discretion of the clinician. In total, the study is expected to be completed over the course of 32 months. A total of 24 months are dedicated to study enrollment, randomization, and completion of the intervention. An additional 8 months are dedicated to completing 3-month follow-up assessments and data analysis (
Study flow depicting eligibility, consent, baseline, discharge, and 3-month follow time points. DD: daily diary; PT: physiotherapy; VR: virtual reality.
RCTs provide robust estimates of the between-subject treatment response (the average difference between the 2 groups) but do not provide sufficient data on how a specific individual responds to a given treatment because of heterogeneity in treatment effects. That is, an individual patient in an RCT could show no improvement, have an adverse reaction to treatment, or benefit from the active comparator even if the active comparator is shown to be statistically inferior. Although subgroup analyses are now encouraged to better elucidate differences in treatment responses between individuals, they require large cohorts of patients for sufficiently powered analyses. For specialized patient groups such as youth experiencing chronic pain, obtaining sufficiently large cohorts for mediation and moderation analyses within the confines of RCTs is often not feasible. SCED allows for the collection of statistically rigorous data at the level of the individual patient. Moreover, such data can be used in meta-analyses of individual effect sizes and multilevel modeling to provide group-level results from small and distinctive cohorts.
Randomization schemes are developed and maintained by the study statistician, DB. Once enrolled, participants are randomized to either physiorehabilitation with VR or standard PT and 2×3 stratified on fear or disability—high fear or high disability (empirically validated clinical cutoff scores of 26-40 on the Fear of Pain Questionnaire-Short Form [FOPQ-SF] [
All participants engage in a full course of PT for MSK pain that is delivered by a trained and licensed physiotherapist. PT sessions are individually tailored based on the Guide to Physical Therapist Practice 3.0, consisting of (1) therapeutic exercise (strengthening and endurance exercises), (2) neuromuscular re-education (balance and proprioception exercises), (3) therapeutic activities (functional performance and activities of daily living), and (4) use of modalities (heat or cold packs). All adolescents receive a home exercise program (HEP) as part of the standard PT treatment. The full course of PT includes approximately 6 to 8 PT sessions delivered over 6 to 12 weeks. An adequate dose of treatment is considered to be 75% completion of the prescribed sessions. The number of treatment sessions varies based on patient presentation and individualized treatment goals as determined by the clinician and research team. Patients can continue any treatments they are currently involved in. If they choose to initiate a new treatment after PT treatment begins, they are asked to notify the research team immediately as it may affect their involvement in the study.
All participants receive a VR headset to use for the duration of treatment. The research team provides participants with an Oculus Quest 2 (Oculus) VR headset and orients the adolescents to its functionality.
For standard PT participants, the VR headset is preloaded with distraction-based games for recreational use at home until treatment is completed (
Standard physiotherapy rehabilitation virtual reality (VR) game content.
Game | Description | Distraction type |
Color Spacea | Color in pieces of beautiful art and environments in virtual reality. | Creative design |
Cubisma | Challenge the mind by solving deceptively simple puzzles and assembling increasingly complex shapes out of colorful blocks. | Puzzle game |
Vacation Simulatora | Find optimal relaxation and efficient memory making while being at home. | Simulation |
NatureTrek VRa | Explore tropical beaches, underwater oceans, and >20 different animals. Command the weather, take control of the night, or shape your own world. | Exploration |
Star Charta | Explore the Solar System, view constellations, and watch meteor showers. Stand on the moon; explore Mars with the Curiosity rover; and hold planets, moons, and stars. | Exploration |
Wandera | Teleport to almost anywhere in the world, from the London Bridge to the Great Pyramids of Egypt. | Exploration |
aDenotes game accessible through a public app store.
Physiorehabilitation with VR participants bring their VR headset to each PT appointment, and a portion of the session can be delivered in VR. Participating clinicians are told that the goal for VR use in a session is at least 8 minutes, but they are also given clinical decision-making power to use VR more or less as they determine clinically feasible. Physiorehabilitation with VR engages participants in a series of immersive games customized and chosen to allow for a progressive increase in standing endurance and support individual PT goals (
Physiorehabilitation with virtual reality (VR) game content.
Game | Description | Rehabilitation engagement |
Alien Defense Foot Cannona | Squashing descending aliens before time runs out | Leg and hip strengthening with light cardiovascular exercise |
Fruity Feeta | Stomping and kicking falling fruits and vegetables before time runs out | Leg and hip strengthening with light cardiovascular exercise |
Alien Defense Slingshota | Destroying aliens using the arms as a slingshot | Arm and shoulder strengthening |
Bait!b | Fishing and passing time in front of water | Arm and shoulder strengthening |
Fruit Ninjab | Slicing fruit that is thrown the player’s way | Arm and shoulder strengthening |
Beat Saberb | Slicing blocks and dodging obstacles to the beat of the music | Arm, shoulder, leg, glute, and hip strengthening with cardiovascular exercise |
BOX VRb | Punching and dodging obstacles to the beat of the music | Arm, shoulder, leg, glute, and hip strengthening with cardiovascular exercise |
Dance Centralb | Dance battling computerized opponents in various locations to popular songs | Cardiovascular exercise and full-body strengthening through dancing |
OhShapeb | Holding fun poses and dodging obstacles to the beat of the music | Arm, shoulder, leg, glute, and hip strengthening with light cardiovascular exercise and static holds |
Pro Puttb | Playing VR golf | Arm swings and hip rotations |
Racket Fury: Table Tennisb | Playing VR table tennis | Arm, shoulder, leg, glute, and hip strengthening with light cardiovascular exercise |
Racket NXb | Hitting a ball against a 360 dome with a racket | Arm, shoulder, leg, glute, and hip strengthening with cardiovascular exercise |
Space Burgers 2a | Racing through exciting, food-filled galaxies with optional stationary bicycle | Cardiovascular exercise through stationary biking or running arm motion |
Synth Ridersb | Following the targets as they lead the player through dance moves to popular songs | Cardiovascular exercise and full-body strengthening through dancing |
Tilt Brushb | Drawing and painting in a 3D space | Arm and shoulder strengthening |
aDenotes games accessible through Invincikids.
bDenotes games accessible through a public app store.
Adolescents and caregivers complete baseline, discharge, and 3-month follow-up assessments. The adolescent completes daily diaries, and the caregiver completes weekly health cost diaries from the date of consent until the end of treatment at discharge. An additional 7 daily diaries by the adolescent and 1 additional health cost diary by the caregiver are completed at the start of the 3-month follow-up. All adolescent and caregiver surveys are completed on the web through the secure web-based app REDCap (Research Electronic Data Capture; Vanderbilt University), and the diaries are completed through the mobile phone–based app LifeData (LifeData, LLC) [
Outcomes (primary, secondary, additional, single-case experimental design, exploratory, and implementation) and covariates.
Category, subcategory, and measure | Respondent | Time point administereda | |||||
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0 | 1 | 2 | 3 | ||
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Lower Extremity Functional Scale | Adolescent | ✓ |
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✓ | ✓ |
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Upper Extremity Functional Index | Adolescent | ✓ |
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✓ | ✓ |
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||||||
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Fear of Pain Questionnaire-Short Form | Adolescent | ✓ |
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✓ | ✓ |
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Photographs of Daily Activities for Youth | Adolescent | ✓ |
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✓ | ✓ |
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|
Tampa Scale for Kinesiophobia-17 | Adolescent | ✓ |
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✓ | ✓ |
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|||||||
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||||||
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Treatment satisfaction questionnaire | Adolescent |
|
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✓ | ✓ |
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Virtual Reality acceptability questionnaire | Adolescentb |
|
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✓ |
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Virtual Reality acceptability questionnaire | Clinicianb |
|
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✓ |
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Pittsburgh Rehabilitation Participation Scale | Clinician |
|
✓ |
|
|
|
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ManageXR Usage data | Researcher |
|
✓ |
|
|
|
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||||||
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Treatment Expectancy and Credibility: Youth | Adolescent | ✓ |
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Semistructured interview | All |
|
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✓ |
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Home exercise program | Clinician |
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✓ |
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VRc adverse events survey | Clinician |
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✓ |
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ManageXR usage data | Researcher |
|
✓ |
|
|
|
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Percentage of dropouts | Researcher |
|
✓ |
|
|
|
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Tracked adherence to treatment and surveys | Researcher |
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✓ |
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Functional Disability Inventory | Adolescent | ✓ |
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✓ | ✓ |
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PROMISd Pediatric Mobility scale | Adolescent | ✓ |
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✓ | ✓ |
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PROMIS Pain Interference | Adolescent | ✓ |
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✓ | ✓ |
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Pain Catastrophizing Scale: Youth | Adolescent | ✓ |
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✓ | ✓ |
|
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Pain Intensity Numeric Rating Scale | Adolescent | ✓ |
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✓ | ✓ |
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Pain Self-Efficacy Scale: Youth | Adolescent | ✓ |
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✓ | ✓ |
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Patient Global Impression of Change | Adolescent |
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✓ | ✓ |
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Presence Measure: Youth | Adolescent |
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✓ |
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Daily diary | Adolescent | ✓ | ✓ |
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✓ |
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Modified Borg Dyspnea Scale | Clinician |
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✓ |
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Physical assessment | Adolescent | ✓ |
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✓ |
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ActiGraph tracked physical activity levels | Researcher | ✓ |
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✓ |
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Health cost diary | Caregiver | ✓ | ✓ | ✓ | ✓ |
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Demographic survey | Caregiver | ✓ |
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Medical history survey | Caregiver | ✓ |
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a0=baseline, 1=discharge, 2=assessed throughout treatment, either daily (adolescents), weekly (caregivers) or after each physiotherapy session (clinicians), and 3=3-month follow-up.
bOnly completed by those in physiorehabilitation with virtual reality (VR) arm.
cVR: virtual reality.
dMeasures that are assessed throughout treatment, either daily or after each physiotherapy session.
eHEP: home exercise program.
dPROMIS: Patient-Reported Outcomes Measurement Information System.
Once eligibility is confirmed, the baseline assessment is completed in 2 parts. First, adolescents and caregivers complete consent and baseline self-report questionnaires. Adolescents and caregivers are oriented to the mobile diaries, which adolescents complete daily and caregivers complete weekly while enrolled in treatment. Following the baseline study visit, adolescents and caregivers undergo a pretreatment data collection period for the number of days between consent and their subsequent PT appointment. During this time, adolescents complete daily diaries, and caregivers complete weekly health cost diaries. The second part of the baseline assessment takes place at the adolescent’s next PT session, during which a research coordinator completes a baseline physical assessment via ViFive (ViFive, Inc) [
The discharge assessment occurs after all PT treatment sessions are completed. The discharge assessment consists of a physical assessment at the final session as well as self-report questionnaires. The diaries conclude, and the adolescents return the ActiGraph watch as well as the VR headset. Following completion of the study, adolescents and caregivers in the physiorehabilitation with VR group complete Zoom (Zoom Video Communications)-based or in-person semistructured interviews to provide feedback regarding their treatment experience. Finally, clinicians complete an acceptability measure assessing their experiences integrating VR into patient sessions for each participant in the physiorehabilitation with VR arm and, subsequent to discharge of their final trial patient, will complete Zoom-based semistructured interviews to further assess PT perceptions of feasibility in integrating VR.
The follow-up assessment occurs at 3 months after discharge, at which time adolescents complete a set of self-reported questionnaires as well as 7 additional daily diaries. Caregivers complete 1 additional health cost diary. Adolescents receive the battery of self-report questionnaires via REDCap and respond to the daily diaries via LifeData. Caregivers receive their single health cost diary via REDCap.
Following each PT session, the adolescent’s clinician completes a brief series of questions regarding the adolescent’s engagement in PT and exercise exertion as well as any adverse events that occurred during the session. Clinicians document and describe the HEP they prescribed to the adolescent to be completed between sessions.
The primary effectiveness outcome is physical function (adolescent), measured using the Lower Extremity Functional Scale (LEFS) and Upper Extremity Functional Index (UEFI). The secondary effectiveness outcome is pain-related fear and avoidance, measured using the FOPQ-SF, the Photographs of Daily Activities for Youth (PHODA-Youth), and the Tampa Scale for Kinesiophobia-17 (TSK-17).
The LEFS is a 20-item self-report survey that asks participants to report on their ability to perform everyday tasks using their lower extremities [
The UEFI is a 20-item self-report survey that asks participants to report on their ability to perform everyday tasks using their upper extremities [
The FOPQ-SF consists of 10 items, with each item rated on a 5-point Likert scale (0=“strongly disagree” to 4=“strongly agree”) [
The PHODA-Youth is a 50-item measure assessing worry associated with activities of daily living (13 items), sports or exercise activities (15 items), school or social activities (13 items), and upper extremity activities (9 items) [
The TSK-17 is a 17-item self-report measure assessing fear of movement that has been implemented in a variety of pain conditions [
The primary feasibility outcomes are treatment satisfaction, acceptability, and engagement. The secondary feasibility outcomes are treatment expectations, treatment feedback, treatment fidelity, treatment adherence and retention, and adverse events.
Treatment satisfaction is assessed using an adapted version of the Pain Service Satisfaction Test. The Pain Service Satisfaction Test is a 22-item measure that asks patients about their experiences in pain treatment, for instance, perceptions of the effectiveness of the intervention, the treatment team, and the impact on their own outcomes [
To evaluate the acceptability of the treatment intervention, the VR acceptability questionnaire is an 11-item measure completed by patients and clinicians at discharge. For patients, it asks about their enjoyment of VR, satisfaction with the VR treatment, perceived reduction of pain, and barriers experienced during the physiorehabilitation with VR intervention. For clinicians, it assesses their perceived difficulty associated with VR use, assessment of the games, ability of VR to facilitate engagement, overall satisfaction levels, and willingness to implement VR in the future for those in the physiorehabilitation with VR arm.
To assess patient engagement in the physiorehabilitation with VR intervention, clinicians complete a postsession survey following every session, which includes the Pittsburgh Rehabilitation Participation Scale [
Oculus analytics dashboard via ManageXR software (Mighty Immersion, Inc) capturing virtual reality engagement.
Treatment expectations are measured using the child Treatment Expectancy and Credibility measure (TEC-C) [
Patient and clinician feedback regarding the VR intervention is collected via semistructured interviews. The goal of the interviews is to better understand the experience of using VR, strengths of the VR intervention, and barriers or considerations for future use.
Treatment fidelity is assessed by examining VR use analytics displayed on the ManageXR dashboard (
Adherence and retention are assessed by examining patient adherence to daily diaries, the percentage of patients who drop out before treatment completion, and the percentage of sessions completed on schedule.
The clinician tracks adverse events related to VR use. Specifically, in the postsession survey, clinicians can indicate any adverse events of dizziness, nausea, or disorientation that occurred. As part of clinician orientation to the VR, important safety precautions are discussed to reduce the potential for accidents to occur.
Additional outcomes of interest include changes in functional disability, mobility, pain interference in life, pain catastrophizing, pain intensity, self-efficacy while in pain, global impression of change, and perceived immersion in the VR technology.
Functional disability is assessed using the FDI, a 15-item self-report measure of perceived difficulty in performing activities in the school, home, physical, and social contexts
Mobility is assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility measure, a subset of the PROMIS physical health function self-report outcomes [
The PROMIS Pain Interference instrument assesses patient perception of the impact of pain on their ability to engage across several life domains—namely, social, emotional, and recreational activities [
The Pain Catastrophizing Scale-Children assesses negative cognitions associated with pain [
Patients provide their pain rating when they complete their daily diary (
I enjoyed my PT exercises
How much
While doing your PT exercises, how
While doing your PT exercises, how
While doing your PT exercises, how
I forgot everything around me during my PT exercises.
How much
Today, because of my pain, I have ________ difficulty doing my usual work, chores, or school activities.
Today, because of my pain, I have ________ difficulty doing my usual hobbies, recreational or sporting activities.
Today, because of my pain, I have ________ difficulty going up or down 10 stairs (about 1 flight of stairs).
Today, because of my pain, I have ________ difficulty lifting an object, like a bag of groceries, above my head.
On a scale of 0 (no pain) to 10 (worst possible pain), tell us
Please make note of anything exciting or stressful that happened today.
What time did you get into bed last night?
What time did you get out of bed this morning?
How well did you sleep last night?
Did you have a physical therapy appointment today?
How much time did you spend on your home exercise program today?
Did you use VR today?
The Pain Self-Efficacy Scale-Children is a 7-item self-report questionnaire that measures patient beliefs about their ability to complete daily activities despite being in pain [
The self-report measure Patients’ Global Impression of Change reflects a patient’s belief about the efficacy of treatment [
The child presence measure assesses the patients’ perceived involvement or immersion, realism, and transportation while using the VR headset [
The participant daily diary consists of 20 items assessing engagement or fun, self-efficacy, immersion or distraction, function, pain, notable events, and sleep (
The Modified Borg Dyspnea Scale is completed by the patient after each appointment [
To assess changes in physical ability and function, the 6-minute Walk Test [
ViFive (ViFive, Inc) app screen showing 2 assessments delivered and captured by ViFive.
To examine daily physical activity, the participants wear an ActiGraph watch for the duration of their study participation (baseline phase and across treatment). The ActiLife software (ActiGraph, LLC) will be used to extract data and calculate the mean and peak daily activity. Physical activity (mean and peak) is modeled at 2 time points, and the rate of change in physical activity from baseline to discharge will also be examined.
Diaries on health care service use; personal costs; and support provided by family, friends, and professional carers are completed by parents once at baseline, on a weekly basis from pretreatment baseline to end of treatment, and once at the 3-month follow-up. Parents report on youths’ health care service use—general and specialist medical practitioners, physiotherapists, alternative health care practitioners, medications, hospital admissions, and out-of-pocket costs—and other impacts on youth and parental activity—athletic extracurricular activities and parental days off work and sick leave.
Variables related to chronic pain, including pain onset, duration, and intensity of pain symptoms as well as course and medications, are collected.
Demographic variables—namely, age, gender, sex, school grade, and ethnicity—are assessed via adolescent and parent reports at baseline.
The study biostatisticians conduct all analyses. Covariates (age, pain variables, gender, and diagnosis) are examined for the primary, secondary, additional, and exploratory outcomes.
Linear mixed effects models will be used to compare physiorehabilitation with VR with standard PT across all non-SCED outcomes. We will model our outcomes at 3 time points using a mixed effects linear model with fixed effects for treatment assignment, period, interaction between treatment and period, and baseline covariates, and a random effect for individual. The random effect will allow us to account for the correlation in the outcome within an individual over time.
To examine biomechanical data, physical assessment metrics will be extracted. We will model physical assessment metrics of walk distance, single leg balance duration, and hand taps using mixed 2 (time)×2 (group) ANOVAs. If physical assessment metrics differ by pain site (upper, trunk, lower, or diffuse), this will be included as a covariate. To examine actigraphy data, the ActiLife software will be used to extract data and calculate the mean and peak daily activity. Published data reduction methods will be used [
Mean satisfaction and acceptability scores will be examined for both patients and clinicians. To assess patient engagement, the mean adolescent daily diary completion, percentage of patient dropouts before treatment completion, and percentage of sessions with benchmark VR met will also be examined. To assess patient and clinician feedback regarding the feasibility and acceptability of the VR treatment, thematic analysis will be conducted of semistructured interviews to identify barriers, catalysts, and perceptions of integrating VR into clinical care. To evaluate engagement in the VR treatment, the mean clinician ratings on the Pittsburgh Rehabilitation Participation Scale will be examined. Acceptability of the VR treatment will be assessed using patient-reported treatment expectancy mean scores. Finally, adherence to the suggested benchmark VR engagement will be assessed by examining the mean time engaged in VR across participations (standard PT and physiorehabilitation with VR) as well as across VR game type (eg, Fruity Feet vs Vacation Simulator).
The data obtained from the randomized SCED used in this study have a hierarchical 2-level structure with observations (level 1) nested within patients (level 2). This nested structure induces dependency within the data—observations vary not only because of random sampling within a patient but also between different patients. For data analysis, we will use a
The largest feasible sample size will be recruited to obtain as precise estimates as possible of improvement in adolescent function while also ensuring adequate power for the treatment difference in improvement in our primary outcome, physical function. In our primary power calculation, we assumed that we would observe a (medium) effect size of 0.70 for the effect of treatment on outcome (LEFS or UEFI), which corresponds to an absolute difference between physiorehabilitation with VR and standard PT at discharge of 11.9 points assuming an SD of 17 from the validation cohort. This difference of 11.9 equates to 1.32 times the minimal clinically important difference (9). Under this scenario, and accounting for a 20% attrition rate based on previous experience, we will have a power of 80% with 68 participants (34 in each arm) at follow-up. Under more conservative assumptions, we will have a power of 80% with 40 participants (20 in each arm) at follow-up to detect an effect size of ≥0.90. For our secondary outcome, pain-related fear (FOPQ-SF), with 20 participants in each arm, we would have 80% power to detect a minimal clinically important difference between groups (8.6). A recent interoceptive exposure treatment for youth with chronic pain showed improvement in pain-related fear, with a medium effect (Cohen
The study is monitored by Navitas Clinical Research for the executive secretary of the National Institute of Arthritis and Musculoskeletal and Skin Diseases. A safety monitoring committee of 3 experts, approved by the National Institute of Arthritis and Musculoskeletal and Skin Diseases via Navitas Clinical Research, meets quarterly to review overall participant enrollment status, accrual, adherence, protocol deviations, and adverse events.
The physiorehabilitation with VR RCT was prospectively registered at ClinicalTrials.gov (NCT04636177). Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024.
Improving treatment outcomes for adolescents with chronic pain requires engagement in gold-standard treatment and notably progressive physical activity as guided by a physiotherapist. Given existing barriers to engaging in this treatment, innovative and engaging technologies may offer an important option for improving engagement and reducing fear and avoidance of pain, thus allowing for the optimal benefit of PT support. A critical element of engagement in PT is the HEP, which requires patients and families to be diligent in completing daily stretching as well as strength and endurance training, all of which can be difficult and uncomfortable and even more so in the context of chronic pain. Improving engagement in PT as well as adherence to at-home exercise programs are important opportunities for potentially accelerating improvements in PT.
Although we know that the use of VR equipment can be helpful in several contexts, we still do not know if it can facilitate improved functioning and reduced pain-related fear and avoidance in the context of PT in a pediatric pain population. These results will add to this growing body of literature by providing a rigorous assessment of the feasibility of physiorehabilitation with VR in outpatient PT for MSK pain and, thus, support or refute the feasibility of disseminating physiorehabilitation with VR for large-scale implementation.
The findings of this study will also illuminate the feasibility of integrating VR technology into current clinical practice across diverse clinical settings, from private to academic medical PT. Engagement and feasibility outcomes will support the understanding of the feasibility of implementing VR within the PT session as well as how VR can augment HEPs for adolescents. Qualitative interview results will further the existing literature [
The addition of the SCED will further highlight the potential of VR to operate as a tailored treatment intervention through the identification of individual experiences and outcomes associated with the use of VR in physiotherapy. Through analysis of individual daily diary data, these findings will support a greater understanding of what elements of the intervention are most impactful and how that may differ across individuals engaged in the study as well as when inclusion of the VR intervention may be most helpful during PT for MSK pain. Together, the results of this RCT, including the SCED and feasibility elements, may support a large hybrid effectiveness-dissemination RCT serving as the basis for potential large-scale implementation of physiorehabilitation with VR and ultimately expand effective, tailored treatment options for adolescents struggling with persistent MSK pain and related fear and disability.
This study has several strengths. This is the first pragmatic trial to implement VR in busy and diverse clinical settings, including academic medicine at a major children’s hospital as well as private PT clinics. This offers important information regarding the feasibility of VR in distinct real-world care settings. The embedded single-case design within the RCT study is also a strength as it allows for the evaluation of individual treatment responses (responder or nonresponder) within a small cohort of individuals.
With regard to limitations, an emphasis on integration into the flow of clinical care may result in less control in the implementation of the intervention and, thus, create variability in the VR dose. Importantly, we have metrics to assess the degree of use for each participant so that this factor can be adequately accounted for in the analysis. This study is also being implemented within primarily private clinical settings and, thus, generalizability to other settings is limited. Future research should examine the utility of VR in physical therapy settings in more diverse clinical contexts and geographical locations and in populations of diverse patients. Finally, this study relies on the researchers’ ability to engage and support implementation in the care setting, and ongoing evaluation of integration is warranted following the end of the trial as clinics may require the support of the research team to maintain engagement.
Functional Disability Inventory
Fear of Pain Questionnaire-Short Form
home exercise program
Institutional Review Board
Lower Extremity Functional Scale
musculoskeletal
Photographs of Daily Activities for Youth
Patient-Reported Outcomes Measurement Information System
physiotherapy
randomized controlled trial
single-case experimental design
child Treatment Expectancy and Credibility
17-item Tampa Scale for Kinesiophobia
Upper Extremity Functional Index
virtual reality
This investigation was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R21AR079140) awarded to LES.
The information and mentioned materials are available from the corresponding author upon reasonable request. Once data are collected and analyzed, they will be posted on ClinicalTrials.gov and will be available from the corresponding author upon reasonable request.
TJC is a recipient of philanthropic donations from Meta, Inc and Magic Leap, Inc.