Chronic Pain: Restoring the Central Nervous System “Body Image”
with Virtual Reality
Federica Alemanno, Elise Houdayer, Daniele Emedoli, Matteo Locatelli and Sandro Iannaccone
Department of Specialistic Rehabilitation of Neurological, Cognitive and Motor Disorders, IRCCS San Raffaele Hospital
and Vita-Salute University, Milan, Italy
1 OBJECTIVES
Chronic pain, such as low-back pain and facial pain,
is a highly disabling condition affecting
approximately 20% of the European adult population
and severely degrading people’s quality of life
(Baykara et al, 2013; Weiss et al, 2017). In both
conditions, not every patient respond to
pharmacological treatment, leading to the situation of
chronic pain. Since pain refers to a multimodal
experience, the chronicity of pain can have a dramatic
impact on various aspects of people’s life such as
vitality, social functioning, general health and
consequently role limitations due to physical or
mental health (Leadley et al, 2014). Moreover, it has
been demonstrated that chronic pain can lead to a
somatic disperception, meaning a substantial
mismatch between the sensation of the affected body
part and its actual physical state (Flor et al, 1997;
Moseley et al, 2008; Forderreuther et al, 2004; Lewis
et al, 2007). Since the clinical rating of pain relies on
the subjective reports of patients, a distorted body
image could lead to an incorrect pain rating, which
could in turn lead to an incorrect pain treatment and
to the risk of drug abuse. There is thus the need for
the development of alternative non-pharmacological
treatments of chronic pain to improve patients’
quality of life, reduce pain and avoid the risk of drug
abuse.
Virtual reality (VR) constitutes an enriched
environment with augmented multiple sensory
feedbacks (auditory, visual, tactile) engaging several
cortical and subcortical neuronal circuits that
potentiate patient’s learning and recovery, including
the mirror neuron system. Mirror neurons are
involved in the mechanisms of perception/action
coupling and are fundamental in the processes of
understanding actions of other people and learning
new skills (Rizzolatti et al, 2008). VR would thus
constitute a good candidate to help patients to
augment their own movements and body position
perception (Harvie et al, 2017) in order to regain a
correct body image. The objectives of our study were
thus to use VR-based training in chronic low-back
pain and facial pain to improve patient’s quality of
life, to reduce pain sensations, and to improve
patients’ mood and functional abilities.
2 METHODS
Patients with chronic low-back pain (n=5) and facial
pain (n=5) were included. Treatment consisted in a 6
week-neurorehabilitative training (2 sessions a week;
total number of sessions = 12) using virtual reality
(VRRS-EVO, Khymeia group, Noventa Padovana,
Italy). During training, patients were taught to
execute correct movements with the painful body
parts (back or face) to regain a correct body image,
based on the augmented multisensory feedback
(auditory, visual) provided by the VRRS (Figure 1).
Figure 1: Virtual reality setting for facial pain
rehabilitation.
Before and after treatment, patients underwent the
following detailed investigations: neurological exam;
neuro-psychological evaluation testing cognitive
functions (memory, attention, executive functions),
personality traits (Minnesota Multiphasic Personality
Inventory Test), quality of life (QoL, SF-36
questionnaire) and mood (Beck Depression
Inventory); pain ratings (Numeric Rating Scale
(NRS), McGill Pain Questionnaire, Brief Pain
Inventory (Short Form)); and sensorimotor functional
abilities (Roland and Morris Disability Questionnaire
Alemanno F., Houdayer E., Emedoli D., Locatelli M. and Iannaccone S.
Chronic Pain: Restoring the Central Nervous System â
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AIJBody Imageâ
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In NEUROTECHNIX 2017 - Extended Abstracts (NEUROTECHNIX 2017), pages 10-11
Copyright
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2017 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
(RMDQ), Penn Facial Pain Scale (PFPS)). After
treatment, patients were also asked to indicate their
subjective impression of change with respect to
baseline condition using a 7-point scale (Global
Impression of Change, GIC).
3 RESULTS
Our preliminary results showed improvements of
QoL in the domains of role limitations due to physical
health and emotional issues, social functioning and
pain (Figure 2). Moreover, every patient reported a
reduction in pain rating scores (mean numerical rating
scale (NRS) score before treatment: 5,7 ± 2,3; after
treatment: 3,4 ± 2,4; p<0.05). Data showed a
significant increase in mood levels (BDI, see Figure
3) and functional scales (RMDQ pre: 10.3 ± 2.1; post:
9 ± 1.7; PFPS pre: 86 ± 32.5; post: 63.5 ± 31.5;
p<0.05). These functional improvements correlated
with the perceived reduction of pain sensation
(RMDQ: R= 0.67; PFPS: R=0.74; BDI: R=0.75;
p<0.05). Our data also showed a reduction of
analgesic drugs intake. All these results were
supported by the subjective impression of general
improvement reported by every patient after
treatment (GIC scale).
Figure 2: Mean QoL scores before (blue) and after (orange)
treatment in all patients.
Figure 3: Mean scores (+ standard deviations) of Beck
Depression Inventory before (left) and after (right)
treatment in all patients.
4 DISCUSSION
This non-pharmacological approach of chronic pain
was able to improve patients’ QoL, to reduce painful
sensations, to improve mood and to improve patient’s
functional abilities. It is noteworthy that this
treatment was also able to reduce drug intake.
Although these data need to be confirmed with a
controlled-study involving a higher number of
patients, our preliminary data showed that this virtual
reality-based treatment aimed at restoring a correct
body image had beneficial effects on the multi-
dimensional aspects of pain.
REFERENCES
Baykara, R.A., Bozgeyik, Z., Akgul, O., Ozgocmen, S.
(2013) Low back pain in patients with rheumatoid
arthritis: clinical characteristics and impact of low back
pain on functional ability and health related quality of
life. J Back Musculoskelet Rehabil. 26(4).p.367-374.
Flor, H., Braun, C., Elbert, T., Birbaumer, N. (1997)
Extensive reorganization of primary somatosensory
cortex in chronic back pain patients. Neurosci Lett,
224(1).p.5-8.
Förderreuther, S., Sailer, U., Straube, A. (2004) Impaired
self-perception of the hand in complex regional pain
syndrome (CRPS). Pain, 110(3).p.756-761.
Harvie, D.S., Smith, R.T., Hunter, E.V., Davis, M.G.,
Sterling, M, Moseley, GL. (2017) Using visuo-kinetic
virtual reality to induce illusory spinal movement: the
MoOVi Illusion. PeerJ, 22;5:e3023.
Leadley, R.M., Armstrong, N., Reid, K.J., Allen, A., Misso,
K.V., Kleijnen, J. (2014) Healthy aging in relation to
chronic pain and quality of life in Europe. Pain Pract,
14(6).p.547-558.
Lewis, J.S., Kersten, P., McCabe, C.S., McPherson, K.M.,
Blake, D.R. (2007) Body perception disturbance: a
contribution to pain in complex regional pain syndrome
(CRPS). Pain, 133(1-3).p.111-119.
Moseley, G.L. (2008) I can't find it! Distorted body image
and tactile dysfunction in patients with chronic back
pain. Pain, 140(1).p.239-243.
Rizzolatti, G, Fabbri-Destro, M. (2008) The mirror system
and its role in social cognition. Curr Opin Neurobiol,
18(2).p.179-184.
Weiss, A.L., Ehrhardt, K.P., Tolba, R. (2017) Atypical
Facial Pain: a Comprehensive, Evidence-Based
Review. Curr Pain Headache Rep. 21(2).p.8.