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

AIJBody Imageâ

I with Virtual Reality.

In NEUROTECHNIX 2017 - Extended Abstracts (NEUROTECHNIX 2017), pages 10-11

(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.

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