Efficacy of Virtual Reality on Neck Pain and Function in Patients with Non-Specific Neck Dysfunction: A Randomized Control Trial

Kadrya H Battecha^1,2, Hebah A Takrouni³, Rawan M Alzahrani³, Razan M Alzahrani³, Fatimah A Alzahrani³ and Hanaa S Mohamed^4*
*Correspondence: Hanaa S Mohamed, PhD, Lecturer, Department of Physical Therapy for Basic Science, Faculty of Physical Therapy, Modern University for Technology and Information, Egypt, Email:

Keywords

Neck pain. Non-specific neck pain. Virtual reality. Traditional treatment

Introduction

Neck pain has negative impact on subject’s life; it sometimes causes stress and anxiety over the already existed stress. As well as decreasing work hours, working quality, concentration during work, and daily activities¹.

Moreover, 13.2% of the medical student participated in previous study claimed that neck pain affected their quality of life, in the form of frequent absences from college and difficulties in carry out their daily activities. More than half of the participants claimed that they experienced depressive symptoms and may have experienced low self-esteem which reflected negatively on their performance².

Non-specific neck pain (NSNP) is one of the most significant health problems; occupy the fourth most common cause of musculoskeletal disorders around the world³. It is estimated that about 70% of people experience neck pain throughout the life, with a 15% to 50% incidence annually. According to statistics 11.8% of people in East Asia report having neck pain, West Asia at 10.14%, Australia at 10.13%, Latin America s 10.12%, Central Asia at 9.8%, Central Europe at 9.9%, Eastern Europe as 9.9%, the Caribbean at 9.7%, and Southeast Asia as 7.6%⁴.

NSNP is a pain appears in the anatomical region of the neck that does not radiate to the upper limbs. It can also described as pain in the posterior region of the neck from the superior nuchal line to the spine of the scapula and the side region down to the superior border of the clavicle and the suprasternal notch⁵. It is connected with job-related and musculoskeletal factors including extended work hours, lack of physical activity, high workload and demands, poorly designed computer workstation, and desk-bound work position⁶.

There are several traditional interventions to treat NSNP, including manual therapy like myofascial release which is applying a low-load, prolonged stretch manually to the myofascial complex to restore it to its ideal length, lessen discomfort, and enhance function⁷, therapeutic exercises as stretching, strengthening, stabilization, and endurance training⁸. Also, Thermotherapy has been used to control persistent pain in muscles and joints. It was reported as a supplementary treatment. Since applying thermotherapy causes the temperature of the skin to rise and improve circulation to the muscle and reduces muscle spasm, it could be linked to a rise in muscle flexibility. According to these findings, using thermotherapy followed by exercise during the intervention may strengthen the stability of neck muscles⁹.

Recently, virtual reality (VR) has been used as a new intervention in the treatment of many cases. It is a term of using computing system to create an artificial environment that gives individuals the impression that they can move around and interact with its objects. Three fundamental elements form the basis of VR treatment: simulation, interaction and immersion¹⁰.

Patients with neck pain may benefit from using VR as a low-cost therapeutic measure for NSNP, because of its adaptability and the fact that it requires the player to constantly pay full attention to the game. Since human attention is restricted, playing diminishes a participant's cognitive capacity to understand pain, leading to a decreased perception of it¹¹.

VR has been shown its effectiveness not only in reducing pain, but also for increasing the range of motion and reducing kinesiophobia that play an important role in treating neck pain¹². At opposite of regular conventional interventions, VR has much more motivation and social interactions which are very important practical benefits of it¹³. But unfortunately, the underlying mechanism of VR is still unclear and needs further studies to support its effects¹⁴. Therefore, the current study was conducted to investigate the effect of VR on neck pain and function of patients with non-specific neck pain.

Material and Methods

Design of the study

The present study was a prospective, pre-test post-test, randomised controlled trial with parallel groups. The current study was accepted by the university of Umm Al-Qura, biomedical research ethics committee (No: HAPO-02-K-012-2022-11- 1316).The study was performed at Faculty of Applied Medical Sciences, physical therapy department (Umm Al-Qura University/,Makkah, Saudi Arabia) from November 2022 to May 2023. The participants were informed about the study's purpose, advantages, the right to withdraw at any stage, and the confidentiality of the gathered data. Before participating, a formal consent form was signed.

Participants

Thirty female (physical therapists) student enrolled in the study based on the following criteria: The participants' ages ranged from 18 to 25 with a mean of 21.5 ± 0.845 years, body mass index (BMI) between 18-25 kg/m2 with a mean of 20.6 ± 2.66., complaining from non- specific mechanical neck pain. The following were used as exclusion criteria: participants with neck pain resulting from serious pathology (tumor, rheumatoid arthritis, ankylosing spondylitis, fracture, dislocation, myelopathy, radiculopathy). Also any dermatological conditions, hemorrhagic blood diseases, epilepsy, long term use of corticosteroids or receiving any treatment for their pain currently, or have any previous cervical surgery.

They were assigned randomly into two groups: control group (n=15) who lasting received traditional treatment only (stretching and isometric exercises for neck muscles) and study group (n=15) who received VR therapy for all neck movements (flexion, extension, side bending and rotation) combined with traditional treatment.

Sample size

The sample size calculation was done before starting the study to avoid type II error, the sample size was estimated using G*POWER statistical software (version 3.0.10). Therefore, a total of thirty participants were chosen for the sample.

Randomization

Thirty females with non-specific neck pain and BMI between 18-25 kg/m2 were randomly allocated to virtual reality group (study group) and traditional treatment group (control group) with computer-generated block randomization program at http://www.randomization.com/. To minimize bias and variation between the two groups, participants were randomly assigned to blocks with sizes of 4, 6, and 8 using a 1:1 allocation ratio. The randomization was carried out by the first author, who was not involved in the recruitment process, data collection, or treatment. To ensure disguised allocation, randomization codes were sequentially numbered and remain confidential in sealed, opaque envelopes.

Intervention

The last author opened envelopes after baseline measurements and continued treatment in accordance with group allocation. Control group received traditional treatment (stretching exercises and isometric strengthening) for three sessions per week ¹⁵. Stretching protocol was applied for 3 minutes then strengthening exercises for 7 minutes. Passive stretching was applied in all directions (flexion, extension, side bending to both sides and rotation to both sides). Each direction was performed for 3 repetition, each one was maintained for 10 seconds. Patients were allowed to take rest before starting another direction. Strengthening exercises were initiated after the end of stretching repetitions. Isometric strengthening was performed for all directions; each direction was repeated 10 times for 2 sets. Isometric strengthening is sustained muscle contraction with an increase in tension that is accompanied by fixed length of the recruited muscle tissue or change in angle of the joint by giving maximum resistance for the head ¹⁶. Movement maintained for 10 sec and repeated ten times¹⁷.

Participants in the study group received both virtual reality training program and traditional exercises. The participant was immersed in an ocean environment collaborated with sound of Scuba Diving. VR systems immerse individuals in a data-created environment with 3D representation and perception and often spatial interaction in real time. Three VR devices (BOBOVR Z-6 model) attached to smartphones (SAMSUNG galaxy A30s) were used. The free mobile software "VR Ocean aquarium operated by HY Games Version 1.0.25" which included rotation, flexion, side bending, and extension movements. The participant moved forward and performed neck movements to view various marine species while immersed in a virtual environment that represented an ocean. The animals the participant was seeing were given names and also he can hear the sound of the sea. The application provided auditory and sensual inputs¹⁸.

In the first session, The VR group was directed to carry out the same previous exercises in addition to VR intervention for two series, 10 repetitions of each movement (Flexion, Extension, Rotation, side bending) with 30 s rest between them (3 sessions per week). For each exercise, the participant's number of movements was counted, documented, and supervised by the physiotherapist to ensure that the recommended dosage was not exceeded.

Outcome measure

All the measured outcomes were evaluated before and after the six-week treatment program. The outcome measures were Range of motion, pain intensity, neck disability index (NDI) and pressure pain threshold (PPT).

1. Range of motion assessment: Inclinometer was used to measure neck range of motion in all directions in participant with non -specific neck pain. It is considered as high accuracy among the measuring tools for neck range in clinical practice, inclinometer is simple to use: place it close to the joint you intend to measure; turn the dial till the scale reaches zero; take the joint through its range; read the range-of-motion (in degrees) to determine the range from the dial ¹⁹.

2. Pain assessment: Visual analog scale (VAS) was used to assess pain intensity. VAS is a validated, subjective measure for pain. VAS consists of a 10 cm line, with two end points choosing 0 (which means "no pain") and 10 (which means "pain as severe as it could possibly be"). The participants were asked to identify how much pain they were currently suffering from by marking the line. The distance in centimeters between the present pain mark and the "no pain marker" (zero) was measured using a ruler²⁰.

3. Assessment of neck disability: Neck disability index questionnaire (NDI) was used to assess neck disability. It was introduced to participants to fill it. It is a condition-specific functional status questionnaire with 10 items including pain, private hygiene, carrying objects, reading, migraines, attention, job, driving, sleeping and recreation. Every item received a score between 0 and 5, where the highest number denotes a higher level of self-reported impairment. This questionnaire has an overall range of 0 to 50. For calculating the percentage, just multiply the total by two ²¹.

4. Assessment of pressure pain threshold (PPT): In this study, The PPT on the cervical muscles was measured using a Manual Muscle Test system (MMT) which is a device used to quantify PPT as the minimum quantum of pressure that produces pain²². There're several studies examined the reliability of Manual Muscle Test in myofascial detector points assessment and reported that they have high reliability²³,²⁴.

Statistical analysis

Descriptive analysis in the form of means and standard deviation for comparison of data of both groups was used in this study. Dependent and independent T-test was used to measure the mean values of pre and post for all variables in all subjects within the group and between both groups of treatment, respectively. Level of significance was set as 0.05. All statistical calculations were done using computer program SPSS release 22 for Microsoft Windows.

Results

30 subjects participated in this study. The subjects were randomly assigned into two groups. The mean for control group and study group in age was 21.26 ± 0.79 years, body mass index was 20.92 ± 2.1 kg/m and 21.23 ± 0.83 years and BMI was 21.33 ± 2.04 Kg/m, respectively. As shown in Table 1 there was no significant difference in all demographic data mean values of all measured variables in both groups.

As shown in Table 2 Independent T-test was performed to examine the VAS, NDI, cervical ROM and PPT mean values between both treatment groups. The results showed that there was no significant difference in all measured variables of pre and post treatment mean values between both studied groups except a significant difference was found between both groups at the post treatment values of Right and Left sides in PPT.

According to Table 3, dependent T-test was performed to examine the VAS, NDI, cervical ROMs and PPT between pre and post mean values for all variables within both groups. The results showed a significant difference between pre and post mean values in all measured variables except the extension ROM of both groups, flexion and Right side bending ROM of control group only. (Tables 1-3)

.

Discussion

This study was conducted to compare the effect of traditional treatment and virtual reality on non-specific neck pain. The results showed a significant difference between pre and post mean values in most of measured variables in each group while there was no significant difference between post treatment mean values of both groups in all variables except the post Right and Left PPT.

This results agreed with a study that was done on 30 patients who had Nonspecific chronic neck pain, they were randomly split into two equal groups.Group A-control group received traditional treatment (chin tuck exercise for posture correction); for four weeks, three sets of ten repetitions, each lasting five seconds, were performed for three minutes every day. Group-B-study group obtained the same as group A in addition to VR training (15 min each session three times each week) for 4 weeks. The pain intensity “VAS” and neck disability “NDI” were measured pre and post treatment. The findings revealed that there was a significant decrease of neck pain and disability in both groups especially group B²⁵.

Also, another study found a significant difference in pain threshold and neck ROM after 4 weeks of intervention. Forty- four patients with Non-specific chronic neck pain participated and assigned into two equal groups, a VR treatment group and neck exercises group. The intervention consisted of two treatment sessions per week, for four weeks. After treatment there was a significant difference in pain threshold and neck ROM in both treatment groups¹¹.

A significant improvement in pain intensity that was measured by VAS for pre- and post-treatment mean values had been found. Many studies are compatible with this finding, one of these studies investigated the effect of VR technology on spinal pain versus exercises. It found that patients with chronic pain had statistically significant improvement as pain intensity significantly decreased and neck function quality increased, but these changes were found within treatment values of both groups. While, between post treatment mean values of both groups there was non-significant difference²⁶.

On the contrary, the current study's findings differed from previous study that assessed Virtual Reality Assisted Non-Pharmacological Treatments in Chronic neck pain management and showed a non-significant decrease in VAS scores for virtual reality therapy with other interventions, like exercise and laser therapy¹⁴. Also, a systematic review and meta-analysis study evaluated the effect of Virtual reality on neck pain and it showed a non-significant difference in pain intensity after applying VR, and there was a non-statistical difference in pain intensity at follow-up between the VR group and the control group²⁷.

The current study showed that there was a great improvement of post mean values of NDI in both groups and this finding was compatible with previous study that investigated the effect of virtual reality and traditional exercises treatment on cervical pain and neck function in forward head posture and they found that there was a statistically significant improvement in the NDI score after four weeks of treatment in both virtual reality and control groups²⁵.

Moreover, the results of current study showed that there was a non -significant difference in post mean values of ROM at both VR group and control group. This is compatible with the study that investigated the Impact of Virtual Reality on Pain, Function, Somatosensory, and Psychosocial Results in Patients with Non-specific Chronic Neck Pain in Comparison to Exercise¹¹, they found that there were not any significant differences in ROM post intervention mean values between both groups.

In contrast, another study that investigated the effect of virtual reality- based neck-specific sensory- Motor development for individuals with persistent cervical pain²⁸, and they divided the participants into 3 groups: VR group, sensorimotor group (SM), and control group (CG) found that neck ROM had been improved and there was a significant difference between the VR and both control and SM groups with favor to VR group. This may be due to the nature of VR intervention and time of single session.

Regarding to pain pressure threshold, the current study showed a significant improvement in pain pressure threshold measured with MMT, and this is consistent with a study that examined how exercise and virtual reality affected patients with non-specific chronic neck pain in terms of pain and function. They found statistically significant differences in the VR group between baseline and 1 month and 3 months measures¹¹.

Limitations

The study's limitations were acknowledged by the authors. This assessment was limited by the patient's lessened ability to finish treatment procedures, as patients were experiencing headaches, tired or impaired vision. It was the psycho-physiological elements that patients experienced at the time of testing and training, which were supposed to be consistent across the study.

Conclusion

From the obtained results, it could be concluded that patients with non-specific neck dysfunction who received VR and traditional treatment program can be improved, by decreasing their pain intensity and NDI, and increasing their pain threshold and neck ROM. Both modalities of treatment were successful in improvement and there was non-significant difference between them. So, they can be combined or applied alternatively to treat patients with non-specific neck dysfunction.

Recommendations

It is recommended to do the same study should carry out on a larger sample, utilize VR on patient with posture abnormalities will be helpful, such as, people with forward head posture, or to compare the effects of VR with another therapeutic modalities such as, TENS on cervical pain.

Contributions statement: The authors confirm contribution to the paper as follows: study conception and design: K.B., H.T. and H.M.; Data collection: R.A. and F.A.; Randomization: K.B.; Analysis and interpretation of results: K.B., H.M.; Performing the practical part of the study: R.A.; draft manuscript preparation: H.T. and F.A.; All authors reviewed the results and approved the final version of the manuscript.

Competing interests: There was no conflict of interest stated by the authors.

Funding: The authors received no funding for their research, authorship or publication.

Data access: Original data are available upon request

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