This paper is in the following e-collection/theme issue:

Back Pain (116) Exergames, Active Games and Gamification of Physical Activity (182) Digital Pain Assessment and Management (170) Innovations in Exercise Rehabilitation (216) Emerging Technologies for Rehabilitation (270) Virtual Reality Interventions in Mental Health (125)

Published on in Vol 10 (2023)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/43985, first published .
Effects of Virtual Reality Exercises on Chronic Low Back Pain: Quasi-Experimental Study

Effects of Virtual Reality Exercises on Chronic Low Back Pain: Quasi-Experimental Study

Effects of Virtual Reality Exercises on Chronic Low Back Pain: Quasi-Experimental Study

Authors of this article:

M Waqar Afzal1 Author Orcid Image ;   Ashfaq Ahmad1 Author Orcid Image ;   Hafiz Muhammad Bilal Hanif1 Author Orcid Image ;   Nauman Chaudhary2 Author Orcid Image ;   Syed Amir Gilani3 Author Orcid Image
Article Authors Cited by (1) Tweetations (4) Metrics

    Original Paper

    1Department of Physical Therapy, University of Lahore, Lahore, Pakistan

    2Department of Public Health, Institute of Social & Cultural Studies, University of the Punjab, Lahore, Pakistan

    3Faculty of Allied Health Sciences, University of Lahore, Lahore, Pakistan

    *all authors contributed equally

    Corresponding Author:

    M Waqar Afzal, MPhil

    Department of Physical Therapy

    University of Lahore

    1-Km Defence Road

    near Bhuptian Chowk

    Lahore, 54000

    Pakistan

    Phone: 92 42 111 865 865 ext 6115

    Email: waqarafzal621@gmail.com


    Background: Low back pain is a common health problem globally. Based on the duration of pain, it is classified as acute, subacute, or chronic low back pain. Different treatment strategies are available to reduce chronic low back pain. Virtual reality (VR) is a novel approach in back pain rehabilitation.

    Objective: This study aimed to compare the effects of VR games on chronic low back pain.

    Methods: This quasi-experimental study was conducted among 40 patients with chronic low back pain. The data were collected using a nonprobability, convenient sampling technique. Patients visiting the Department of Physiotherapy, Government Services Hospital, Lahore, Pakistan, were recruited and equally divided into 4 groups. Group A received the Reflex Ridge game; group B received the Body Ball game; group C combined the 2 games without back-strengthening exercises; and group D combined the 2 games with back-strengthening exercises. The participants received 8 treatment sessions, with 3 sessions/wk. The outcomes were pre- and posttest measurements of pain intensity, low back disability, and lumbar range of motion. The repeated measurement ANOVA was used for inter- and intragroup comparison, with significance at P≤.05.

    Results: The study comprised a sample of 40 patients with low back pain; 12 (40%) were female and 28 (60%) were male, with a mean age of 37.85 (SD 12.15) years. The pre- and posttest mean pain scores were 7.60 (SD 1.84) and 4.20 (SD 1.62) in group A, 6.60 (SD 1.776) and 5.90 (SD 1.73) in group B, 6.90 (SD 1.73) and 5.40 (SD 1.07) in group C, and 7.10 (SD 1.53) and 3.60 (SD 0.97) in group D, respectively. The mean pain score differences of group D (combining the Reflex Ridge and Body Ball games with back-strengthening exercises) compared to groups A, B, and C were –.60 (P=.76), –2.30 (P<.001), and –1.80 (P=.03), respectively. Regarding the range of motion, the forward lumbar flexion mean differences of group D compared to groups A, B, and C were 3.80 (P=.21), 4.80 (P=.07), and 7.40 (P<.001), respectively. Similarly, the right lateral lumbar flexion mean differences of group D compared to groups A, B, and C were 2.80 (P=.04), 5.20 (P<.001), and 4.80 (P<.001), respectively. The left lateral lumbar flexion mean differences of group D compared to groups A, B, and C were 2.80 (P<.001), 4.80 (P=.02), and 2.20 (P<.001). respectively, showing significant pre- and posttreatment effects.

    Conclusions: VR exercises had statistically significant effects on improving pain, low back disability, and range of motion in all groups, but the combination of Reflex Ridge and Body Ball games with back-strengthening exercises had dominant effects compared to the other groups.

    Trial Registration: Iranian Registry of Clinical Trial IRCT20200330046895N1; https://en.irct.ir/trial/46916

    JMIR Rehabil Assist Technol 2023;10:e43985

    doi:10.2196/43985

    Keywords

    low back pain, lumbar range of motion; pain; Oswestry disability index; virtual reality; exercise; back pain; lumbar; range of motion; virtual reality; VR; rehabilitation; gaming; serious game 


    Low back pain (LBP) is a prevalent health concern that becomes more common as people age [1]. Based on the duration of pain, it is further classified into 3 categories: acute, subacute, or chronic LBP [2]. LBP affects people of all ages, from children to older adults, and can afflict people in high-, middle-, and low-income countries. People with physically demanding jobs, those with physical and mental illnesses, smokers, and people with obesity are more likely to have LBP [3]. From the third decade of life to 60 years of age, the frequency of chronic LBP rises linearly, with women being more affected [4]. Furthermore, the fear of pain is more strongly linked to impairment in people with chronic LBP than in people with acute LBP [5]. Patients avoid spinal flexion because of the fear of pain, especially lumbar flexion [6]. This kinesiophobia can be managed using virtual reality (VR) maneuvers including the neuromodulation of body perception, distraction, and graded exposure therapy. These 3 mechanisms are considered the theoretical basis of VR therapeutic effects [7].

    To treat persistent LBP, various treatments, including nonpharmacological interventions, can be used. VR is a type of rehabilitation technology that allows users to engage in a computer-generated environment [8]. Recently, the development of portable and affordable motion tracking systems has broadened the use of VR in the management and rehabilitation of patients with musculoskeletal pain [9]. VR has 3 elements: interaction, immersion (sometimes nonimmersive), and imagination [10]. Through a head-mounted display that follows the movement of the participant’s body, VR gives the sensation of being entirely encircled by a virtual world [11]. VR games have already been integrated into rehabilitation programs for patients with chronic pain [12]. Distraction is one of the suggested mechanisms that explains the effects of VR on pain [13]. In orthopedic rehabilitation, clinical trials have previously assessed VR effectiveness in individuals with different musculoskeletal disorders, including ankle sprain, anterior cruciate ligament injury, and frozen shoulder [14]. It also makes it possible to increase movement in patients with kinesiophobia due to chronic pain [15]. Among different treatment regimens, the use of isokinetic and VR exercises is considered to be effective [16]. The idea is to catch the attention of the user in such a way that the patient’s mind focuses on the game while performing game tasks that are actually exercises for pain and rehabilitation [17]. With this approach, we are able to translate clinical guidelines into the VR environment to facilitate future implementation in the care pathway [18]. Virtual exercises are based on body movements including catching, squatting, bending, jumping, and a combination of these movements during the rehabilitation process [19]. The lack of adequate physical activity or sedentary lifestyle is one of the major problems [20]. The use of virtual embodiment to influence body perception is beginning to receive more attention, and it might have clinical implications for disorders such as chronic pain that include altered body image [21].

    Various studies have reported the positive impact of VR games, but there is a need to explore the comparison and combination of different routine VR games. Different VR games can help manage chronic LBP. This study aimed to assess the effects of 2 games, the Reflex Ridge and Body Ball VR games, in patients with chronic LBP. We hypothesized that the VR games used would constitute an acceptable exercise program for patients with chronic LBP.


    Design

    This was a quasi-experimental study conducted in Lahore, Pakistan. Initially, a randomized controlled trial had been intended; however, due to the COVID-19 pandemic and the uncertainties caused by it, the study design was changed to a quasi-experimental study. The institutional review board of the University of Lahore approved the amendments made to the research project.

    Ethical Considerations

    The ethical approval of the study was obtained from The University of Lahore (IRB-UOL-FAHS/696-IV/2020).

    Participants and Settings

    A total of 70 patients with LBP were screened for the study, and 40 participants (10 in each group) were recruited from the Department of Physiotherapy, Government Services Hospital, Lahore, Pakistan. The participants were recruited using the nonprobability, convenient sampling technique.

    Sample Size

    The sample size was calculated as follows:

    where z1 – α/2 was the level of significance, µ1 was the expected mean of the visual analogue scale (4.0) in group A [22], µ2 was expected mean of the visual analogue scale (5.0) in group B [22], the expected SD was 0.75 in group A and 2.0 in group B, the power of study was 80%, and the expected sample size was 40 (n=10 for each group).

    Patient Characteristics

    Basic information regarding age, BMI, marital status, occupation, and symptoms with a complete history was obtained before enrollment.

    Interventions and Procedures

    Pretest assessment was made after informed consent from all participants. In all, 40 patients with chronic LBP were equally divided into 4 groups following the inclusion and exclusion criteria (Textbox 1).

    Textbox 1. Study selection criteria of patients with low back pain.

    Inclusion criteria

    • All genders
    • Aged 25-50 years
    • Low back pain that lasted more than 12 weeks
    • Nonradiating pain

    Exclusion criteria

    • Recurrent low back pain
    • Neurological symptoms
    • Any previous history of fracture in the spine or lower limb, cardiac or endocrine disease, or neurological disorders such as Parkinson disease and stroke

    Group A was given the Reflex Ridge game, and group B was given the Body Ball game. Group C combined the Reflex Ridge game with the Body Ball game without back-strengthening exercises; the rest of treatment protocol was same. Group D combined the Reflex Ridge game with the Body Ball game along with back-strengthening exercises, including bridging, prone leg raises, trunk extension while keeping the arms on the back, and trunk rotation exercises [23]. After the VR exercises, all groups were given moist heat therapy with transcutaneous electrical nerve stimulation for 10 minutes, with a frequency of 10 repetitions. The participants received 8 treatment sessions, with 3 sessions/wk.

    VR was provided through the Kinect Xbox 360 device (v.2 model; Microsoft) [24]. This sensitive device for motion sensing incorporates time-of-flight and red-green-blue cameras for the detection of body skeletal movements and real-time gesture evaluation. This is attached to an LCD monitor. In the Reflex Ridge game, participants performed different movements (lumbar side bending, lumbar movement with shoulder elevation, sitting, and jumping) to avoid hitting the obstacle. In the Body Ball game, arm and leg movements were used to hit the ball.

    Outcomes

    The outcome measures were pain intensity, low back disability, and lumbar range of motion (ROM), measured through a numerical pain rating scale, the Oswestry disability index (ODI), and pre- and posttest evaluations.

    Pain Intensity

    Pain intensity was measured using the numerical pain rating scale. Patients were asked to select a circle that best describes the current level of pain, from 0 (no pain) to 10 (severe pain) [25].

    Low Back Disability

    Low back disability was measured using the ODI. It is considered valid and suitable for the assessment of disability among patients with LBP [26]. It consists of 10 sections including pain, personal care, sitting, lifting, walking, sleeping, standing, traveling, social life, and sexual life, each having scores from 0-5 with a total score of 50. It is a broader level assessment of disability compared to pain intensity alone [27].

    Lumbar ROM

    Lumbar ROM was recorded using a gravity-based inclinometer in the standing position. The inclinometer was placed at the T12-L1 level of the spinal column, marked, and zeroed. Flexion and extension were measured at the T12-L1 level with a command to bend forward and backward, respectively. The right and left lumbar lateral flexion ROMs were measured by keeping the inclinometer parallel to the axis of the spinal column, and patients were asked to bend on their respective sides with fingertips pointed down toward the respective side of the thigh [28]. The inclinometer has a good reliability for measuring spinal (r=0.97), flexion (r=0.98), and extension (r=0.75) ROMs [29].

    Data Analysis

    All data were encoded and entered anonymously and remained confidential. IBM SPSS (version 24.0) was used for statistical analysis. The means and SDs of quantitative data were measured. However, frequencies and percentages were used to present categorical data. Normality tests were applied for data distribution using skewness, kurtosis, and the Shapiro-Wilks test. The distribution of data was normal as the P value was >.05. For pre- and posttest evaluations, parametric repeated measurement ANOVA was used to analyze intragroup comparisons and measure mean intergroup differences for pain intensity, low back disability, and lumbar ROM. The tests were conducted at a significance level of P≤.05.


    Patient Characteristics

    The study comprised 40 patients with LBP; 12 (40%) were female and 28 (60%) were male, with a mean age of 37.85 (SD 12.15) years. All the participants were married. Most had a BMI in the normal (n=13, 32%) and overweight (n=18, 45%) categories (Table 1).

    Table 1. Patient characteristics.
    Demographics and categoryValue (n=40), n (%)
    Sex

    		Male28 (60)

    		Female12 (40)
    BMI

    		Underweight6 (15)

    		Normal13 (32)

    		Overweight18 (45)

    		Obese3 (8)
    Occupation

    		Teacher14 (35)

    		Shopkeeper16 (40)

    		Computer worker8 (20)

    		Banker2 (5)

    Outcomes

    Pain Intensity

    The pre- and posttest mean pain scores were 7.60 (SD 1.84) and 4.20 (SD 1.62) in group A, 6.60 (SD 1.776) and 5.90 (SD 1.73) in group B, 6.90 (SD 1.73) and 5.40 (SD 1.07) in group C, and 7.10 (SD 1.53) and 3.60 (SD 0.97) in group D, respectively (Table 2). The mean pain score differences of group D compared to groups A, B, and C were –.60 (P=.76), –2.30 (P<.001), and –1.80 (P=.03), respectively (Table 3). There was a significant improvement in pain rating in all groups (all P<.05), but pre- and posttest differences showed a significant improvement in group D for pain (P<.001).

    Table 2. Intragroup comparison for pain and disability index.
    Group and evaluationPain ratingODIa


    		Mean (SD)Mean SEP valuebMean (SD)Mean SEP valueb
    Group A.001

    		<.001

    		Pretest7.60 (1.84).58
    		25.10 (3.035).959

    		Posttest4.20 (1.62).51
    		13.10 (1.85).586
    Group B.02

    		<.001

    		Pretest6.60 (1.776).56
    		25.30 (2.791).88

    		Posttest5.90 (1.73).54
    		17.30 (3.35)1.05
    Group C.01

    		<.001

    		Pretest6.90 (1.73).54
    		24.30 (2.75).87

    		Posttest5.40 (1.07).33
    		13.20 (4.661)1.47
    Group D<.001

    		<.001

    		Pretest7.10 (1.53).48
    		24.20 (2.098).66

    		Posttest3.60 (.97).30
    		3.30 (1.49).47

    aODI: Oswestry disability index.

    bP values are significant at ≤.05.

    Table 3. Intergroup comparison for pain and disability index.
    Group and compared groupPain ratingODIa


    		Mean differenceP valueMean differenceP value
    Group A
    Group B–1.70.04–4.20.002
    Group C–1.20.23–.10>.99
    Group D.60.769.80.001
    Group B
    Group A1.70.044.20.02
    Group C.50.854.10.02
    Group D2.30.0014.00.001
    Group C
    Group A1.20.23.100.68
    Group B–.50.85–4.10.02
    Group D1.80.039.90<.001
    Group D
    Group A–.60.76–9.80<.001
    Group B–2.30<.001–14.00<.001
    Group C–1.80.03–9.90<.001

    aODI: Oswestry disability index.

    Low Back Disability

    After 8 sessions, the pre- and posttest ODI were 25.10 (SD 3.035) and 13.10 (SD 1.85) in group A, 25.30 (SD 2.791) and 17.30 (SD 3.35) in group B, 24.30 (SD 2.75) and 13.20 (SD 4.661) in group C, and 24.20 (SD 2.098) and 3.30 (SD 1.49) in group D, respectively (Table 2). In the intergroup analysis, group D showed dominant effects on the disability index compared to groups A, B, and C, with mean differences of –9.80, –14.00, and –9.90 (all P<.001), respectively (Table 3).

    Lumbar ROM

    The pre- and posttest mean scores for lumbar flexion were 36.10 (SD 4.91) and 42.50 (SD 5.78) in group A, 37.20 (SD 3.43) and 38.90 (SD 2.64) in group B, 36.10 (SD 4.91) and 41.50 (SD 5.42) in group C, and 37.20 (SD 3.42) and 46.30 (SD 1.95) in group D, respectively. The pre- and posttest mean scores for right lateral lumbar flexion were 12.90 (SD 1.19) and 16.70 (SD 1.05) in group A, 13.60 (SD 1.95) and 14.30 (SD 2.35) in group B, 12.90 (SD 1.197) and 15.60 (SD 0.966) in group C, and 13.50 (SD 1.96) and 19.5 (SD 3.57) in group D, respectively. The pre- and posttest mean scores for left lateral lumbar flexion were 12.90 (SD 1.19) and 16.0 (SD 1.76) in group A, 13.60 (SD 1.96) and 14.00 (SD 1.24) in group B, 14.60 (SD 2.41) and 16.60 (SD 2.17) in group C, and 14.60 (SD 1.35) and 18.80 (SD 1.32) in group D, respectively. The pre- and posttest mean scores for lumbar extension were 8.6 (SD 1.71) and 11.60 (SD 1.84) in group A, 7.90 (SD 1.10), and 8.70 (SD 0.94) in group B, 8.20 (SD 1.686) and 10.70 (SD 1.636) in group C, and 7.90 (SD 1.37) and 13.50 (SD 0.85) in group D, respectively (Table 4).

    The mean differences in forward lumbar flexion ROM for group D compared to groups A, B, and C were 3.80 (P=.21), 4.80 (P=.07), 7.40 (P<.001), respectively. The mean differences in right lateral lumbar flexion ROM for group D compared to groups A, B, and C were 2.80 (P=.04), 3.90 (P<.001), and 5.20 (P<.001), respectively. The mean differences in left lateral lumbar flexion ROM for group D compared to groups A, B, and C were 2.80 (P<.001), 2.20 (P=.02), and 4.80 (P<.001), respectively. The mean differences in lumbar extension ROM for group D compared to groups A, B, and C were 1.90 (P=.02), 2.80 (P<.001), and 4.80 (P<.001), respectively (Table 5).

    Table 4. Intragroup comparison for lumbar range of motion.
    Range of motion and evaluationGroup AGroup BGroup CGroup D
    Mean (SD)Mean SEP valueMean (SD)Mean SEP valueMean (SD)Mean SEP valueMean (SD)Mean SEP value
    Lumbar forward flexion<.001.38<.001<.001
    Pretest36.10 (4.91)1.5537.20 (3.43)1.0836.10 (4.91)1.5537.20 (3.42)1.08
    Posttest42.50 (5.78)1.8338.90 (2.64)0.8341.50 (5.42)1.7146.30 (1.95)0.61
    Right lateral lumbar flexion<.001.10<.001<.001
    Pretest12.90 (1.19)0.3713.60 (1.95)0.6112.90 (1.197)0.3713.50 (1.96)0.61
    Posttest16.70 (1.05)0.3314.30 (2.35)0.7415.60 (0.966)0.319.5 (3.57)1.13
    Left lateral lumbar flexion<.001.49<.001<.001
    Pretest12.90 (1.19)0.3713.60 (1.96)0.6114.60 (2.41)0.7614.60 (1.35)0.42
    Posttest16.0 (1.76)0.2714.00 (1.24)0.3916.60 (2.17)0.6818.80 (1.32)0.41
    Lumbar extension<.001<.001<.001<.001
    Pretest8.6 (1.71)0.547.90 (1.10)0.348.20 (1.686)0.537.90 (1.37)0.43
    Posttest11.60 (1.84)1.558.70 (0.94)0.3010.70 (1.636)0.5113.50 (0.85)0.26
    Table 5. Intergroup comparison for lumbar range of motion.
    Groups and compared groupForward lumbar flexionRight lateral lumbar flexionLeft lateral lumbar flexionLumbar extension
    Mean differenceP valueMean differenceP valueMean differenceP valueMean differenceP value
    Group A
    Group B3.60.252.40.092.00.052.90<.001
    Group C1.00.951.10.69–.600.85.90.47
    Group D–3.80.21–2.80.04–2.80<.001–1.90.02
    Group B
    Group A–3.60.25–2.40.09–2.00.05–2.90<.001
    Group C–2.60.53–1.30.57–2.60<.001–2.00.01
    Group D–4.80<.001–5.20<.001–4.80<.001–4.80<.001
    Group C
    Group A–1.00.95–1.10.69.60.85–.90.47
    Group B2.60.531.30.562.60<.0012.00.01
    Group D–4.80.07–3.90<.001–2.20.02–2.80<.001
    Group D
    Group A3.80.212.80.042.80<.0011.90.02
    Group B4.80.073.90<.0012.20.022.80<.001
    Group C7.40<.0015.20<.0014.80<.0014.80<.001

    Principal Findings

    LBP is one of the major musculoskeletal health issues prevalent among the general population. This quasi-experimental study was conducted among 40 patients with chronic LBP who were treated with VR exercises along with traditional exercises. VR exercises were found to have dominant effects in improving pain, low back disability, and lumbar ROM in the different groups, but the combination of VR games, including the Reflex Ridge and Body Ball games with back-strengthening exercise, was better than other groups.

    Comparison With Prior Work

    This study was conducted among 40 patients. We hypothesized that VR exercises through the Reflex Ridge and Body Ball games could be one of the effective methods used in the clinical management of LBP and improve lumbar ROM and disability index, similar to the findings of dodge ball games in the literature [6]. Our study results favored VR exercises for improving pain, low back disability, and lumbar ROM. Park et al [30] used the Nintendo Wii exercise program for LBP and reported that exercise programs significantly improved physical function related to LBP. In health-related quality of life, the Nintendo Wii exercise program showed significant improvements in both the mental and physical health composites, but other groups showed significant improvement only in the physical health composite.

    The integration of VR with physiotherapy was found to be effective for pain, ROM, disability index, and kinesiophobia. Experimental treatment with VR reduced pain and improved physical function in patients with acute and chronic pain as well [15]. In another study, a VR dodgeball intervention provided evidence of safety and feasibility and can be used to encourage spinal flexion in individuals with chronic LBP [6]. Group D reduced pain intensity compared to other groups that were treated with the Body Ball or Reflex Ridge game alone (group A: P=.76; group B: P<.001; and group C: P=.03), showing significant and better results than all other groups.

    One of the reasons for using VR games is that it induces a postexercise hypoalgesic effect and a significant reduction in thinking of pain, which further enhances its implication in clinical studies for pain management [12]. This study correlated with our study, as the Body Ball and Reflex Ridge VR games along with exercises are intended to allow movements in the lumbar region within a virtual environment, and the involvement of participants while playing the game elicits enthusiasm and eagerness to perform activity throughout the session. In our study, low back disability index differences in the groups had P values <.05, showing improvement in all 4 groups. Yilmaz Yelva et al [15] stated that VR had a positive impact on pain and kinesiophobia in individuals with chronic pain. In their study among patients with subacute and chronic nonspecific LBP, virtual walking integrated with physiotherapy decreased pain and improved function in the short term. Their findings are similar to our study, but the games administered were different. Wiederhold et al [31] stated that VR as a distraction technique is effective in reducing pain intensity and discomfort with significance ranging from P=.05 to P=.001. A previous study has shown significant effects of VR exercises for improving pain, disability, and ROM but has not compared which VR exercise game is more feasible and effective [23]. In our study, the lumbar ROM—including flexion, extension, and lateral flexion on both sides—improved in all groups, but intragroup comparisons showed that group D with a combination of VR and exercise had superior effects in improving the lumbar ROM with significant pre- and posttest differences. This finding demonstrated that the VR exercises had an additive effect and led us to assume that these exercises can be an option for the treatment of LBP, similar to the effects seen in core stability exercises [32]. This emerging technology has been used for the nonpharmacological management of LBP and resulted in less use of nonsteroidal anti-inflammatory drugs. VR has been considered as an analgesic as it works based on the distraction phenomenon to decrease pain [33]. VR exercises compared to traditional exercises exert a positive impact on psychological, physiological, and rehabilitative outcomes, but there is a need trial different games to better rehabilitation programs [34].

    Despite the novelty of the technique, different VR games may lead to rapid pain relief in addition to routine management strategies. Different VR games in different age groups and clinical trials are recommended for better generalization of the results.

    Limitations

    The study conditions and participant characteristics may not represent the broader population of interest due to limited generalizability to other populations and settings. There was no random assignment of participants and this lack of randomization can introduce selection bias. Despite these limitations, a quasi-experimental study is valuable especially in a situation where a randomized controlled trial was not feasible due to the COVID-19 pandemic.

    Conclusion

    VR exercises are effective as treatment strategies in the management of LBP. Both VR games had significant effects in improving lumbar ROM, pain intensity, and low back disability, but a combination of the Reflex Ridge and Body Ball games along with back-strengthening exercises was found to be more effective.

    Acknowledgments

    We are thankful to Dr Umair Ahmad and Dr Asad Shah Gillani for their support and guidance throughout the study. All authors declared that they had insufficient funding to support open access publication of this manuscript, including from affiliated organizations or institutions, funding agencies, or other organizations. JMIR Publications provided article processing fee (APF) support for the publication of this article.

    Conflicts of Interest

    None declared.

    1. Fatoye F, Gebrye T, Odeyemi I. Real-world incidence and prevalence of low back pain using routinely collected data. Rheumatol Int. Apr 8, 2019;39(4):619-626. [CrossRef] [Medline]
    2. Kongsted A, Kent P, Axen I, Downie AS, Dunn KM. What have we learned from ten years of trajectory research in low back pain? BMC Musculoskelet Disord. May 21, 2016;17(1):220. [FREE Full text] [CrossRef] [Medline]
    3. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet. Jun 09, 2018;391(10137):2356-2367. [FREE Full text] [CrossRef] [Medline]
    4. Meucci RD, Fassa AG, Faria NMX. Prevalence of chronic low back pain: systematic review. Rev Saude Publica. 2015;49:1. [FREE Full text] [CrossRef] [Medline]
    5. Riley SP, Bialosky J, Coronado RA. Are changes in fear-avoidance beliefs and self-efficacy mediators of function and pain at discharge in patients with acute and chronic low back pain? J Orthop Sports Phys Ther. Jun 2020;50(6):301-308. [CrossRef] [Medline]
    6. Thomas JS, France CR, Applegate ME, Leitkam ST, Walkowski S. Feasibility and safety of a virtual reality dodgeball intervention for chronic low back pain: a randomized clinical trial. J Pain. Dec 2016;17(12):1302-1317. [FREE Full text] [CrossRef] [Medline]
    7. Tack C. Virtual reality and chronic low back pain. Disabil Rehabil Assist Technol. Aug 20, 2021;16(6):637-645. [CrossRef] [Medline]
    8. Alemanno F, Houdayer E, Emedoli D, Locatelli M, Mortini P, Mandelli C, et al. Efficacy of virtual reality to reduce chronic low back pain: Proof-of-concept of a non-pharmacological approach on pain, quality of life, neuropsychological and functional outcome. PLoS One. May 23, 2019;14(5):e0216858. [FREE Full text] [CrossRef] [Medline]
    9. Wittkopf PG, Lloyd DM, Coe O, Yacoobali S, Billington J. The effect of interactive virtual reality on pain perception: a systematic review of clinical studies. Disabil Rehabil. Dec 08, 2020;42(26):3722-3733. [FREE Full text] [CrossRef] [Medline]
    10. Lin H, Li Y, Hu W, Huang C, Du Y. A scoping review of the efficacy of virtual reality and exergaming on patients of musculoskeletal system disorder. J Clin Med. Jun 04, 2019;8(6):791. [FREE Full text] [CrossRef] [Medline]
    11. Hayashi K, Aono S, Shiro Y, Ushida T. Effects of virtual reality-based exercise imagery on pain in healthy individuals. Biomed Res Int. Apr 17, 2019;2019:5021914. [FREE Full text] [CrossRef] [Medline]
    12. Matheve T, Bogaerts K, Timmermans A. Virtual reality distraction induces hypoalgesia in patients with chronic low back pain: a randomized controlled trial. J Neuroeng Rehabil. Apr 22, 2020;17(1):55. [FREE Full text] [CrossRef] [Medline]
    13. Ahern MM, Dean LV, Stoddard CC, Agrawal A, Kim K, Cook CE, et al. The effectiveness of virtual reality in patients with spinal pain: a systematic review and meta-analysis. Pain Pract. Jul 21, 2020;20(6):656-675. [CrossRef] [Medline]
    14. Gumaa M, Rehan Youssef A. Is virtual reality effective in orthopedic rehabilitation? a systematic review and meta-analysis. Phys Ther. Oct 28, 2019;99(10):1304-1325. [CrossRef] [Medline]
    15. Yilmaz Yelvar GD, Çırak Y, Dalkılınç M, Parlak Demir Y, Guner Z, Boydak A. Is physiotherapy integrated virtual walking effective on pain, function, and kinesiophobia in patients with non-specific low-back pain? randomised controlled trial. Eur Spine J. Feb 15, 2017;26(2):538-545. [CrossRef] [Medline]
    16. Nambi G, Abdelbasset WK, Alrawaili SM, Alsubaie SF, Abodonya AM, Saleh AK. Virtual reality or isokinetic training; its effect on pain, kinesiophobia and serum stress hormones in chronic low back pain: a randomized controlled trial. Technol Health Care. Jan 15, 2021;29(1):155-166. [CrossRef] [Medline]
    17. Mihajlovic Z, Popovic S, Brkic K, Cosic K. A system for head-neck rehabilitation exercises based on serious gaming and virtual reality. Multimed Tools Appl. Nov 7, 2017;77(15):19113-19137. [CrossRef]
    18. Tabak M, Cabrita M, Schüler T, Hörst D, Heuven R, Kinast B, et al. "Dinner is ready!": virtual reality assisted training for chronic pain rehabilitation. Presented at: CHI PLAY '17 Extended Abstracts: Extended Abstracts Publication of the Annual Symposium on Computer-Human Interaction in Play; October 15-18, 2017, 2017;283-289; Amsterdam, the Netherlands. [CrossRef]
    19. Xie B, Zhang Y, Huang H, Ogawa E, You T, Yu L. Exercise intensity-driven level design. IEEE Trans Visual Comput Graphics. Apr 2018;24(4):1661-1670. [CrossRef]
    20. Bakar Y, Tuğral A, Özel A, Altuntaş YD. Comparison of a 12-week whole-body exergaming program on young adults: differentiation in flexibility, muscle strength, reaction time, and walking speed between sexes. Clin Nurs Res. Sep 06, 2020;29(7):424-432. [CrossRef] [Medline]
    21. Matamala-Gomez M, Donegan T, Bottiroli S, Sandrini G, Sanchez-Vives MV, Tassorelli C. Immersive virtual reality and virtual embodiment for pain relief. Front Hum Neurosci. Aug 21, 2019;13:279. [FREE Full text] [CrossRef] [Medline]
    22. Gillani S, Ain QU, Rehman S, Masood T. Effects of eccentric muscle energy technique versus static stretching exercises in the management of cervical dysfunction in upper cross syndrome: a randomized control trial. J Pak Med Assoc. Mar 2020;70(3):394-398. [FREE Full text] [CrossRef] [Medline]
    23. Afzal MW, Ahmad A, Mohseni Bandpei MA, Gilani SA, Hanif A, Waqas MS. Effects of virtual reality exercises and routine physical therapy on pain intensity and functional disability in patients with chronic low back pain. J Pak Med Assoc. Mar 2022;72(3):413-417. [FREE Full text] [CrossRef] [Medline]
    24. O'Donovan C, Hirsch E, Holohan E, McBride I, McManus R, Hussey J. Energy expended playing Xbox Kinect™ and Wii™ games: a preliminary study comparing single and multiplayer modes. Physiotherapy. Sep 2012;98(3):224-229. [CrossRef] [Medline]
    25. Shafshak TS, Elnemr R. The visual analogue scale versus numerical rating scale in measuring pain severity and predicting disability in low back pain. J Clin Rheumatol. Oct 01, 2021;27(7):282-285. [CrossRef] [Medline]
    26. Lee C, Fu T, Liu C, Hung C. Psychometric evaluation of the Oswestry Disability Index in patients with chronic low back pain: factor and Mokken analyses. Health Qual Life Outcomes. Oct 03, 2017;15(1):192. [FREE Full text] [CrossRef] [Medline]
    27. Grönblad M, Hupli M, Wennerstrand P, Järvinen E, Lukinmaa A, Kouri J, et al. Intercorrelation and test-retest reliability of the Pain Disability Index (PDI) and the Oswestry Disability Questionnaire (ODQ) and their correlation with pain intensity in low back pain patients. Clin J Pain. Sep 1993;9(3):189-195. [CrossRef] [Medline]
    28. Nuhmani S, Khan MH, Kachanathu SJ, Bari MA, Abualait TS, Muaidi QI. Reliability and validity of smartphone applications to measure the spinal range of motion: a systematic review. Expert Rev Med Devices. Sep 11, 2021;18(9):893-901. [CrossRef] [Medline]
    29. Saur PMM, Ensink FM, Frese K, Seeger D, Hildebrandt J. Lumbar range of motion: reliability and validity of the inclinometer technique in the clinical measurement of trunk flexibility. Spine (Phila Pa 1976). Jun 01, 1996;21(11):1332-1338. [CrossRef] [Medline]
    30. Park JH, Lee SH, Ko DS. The effects of the Nintendo Wii exercise program on chronic work-related low back pain in industrial workers. J Phys Ther Sci. Aug 2013;25(8):985-988. [FREE Full text] [CrossRef] [Medline]
    31. Wiederhold BK, Gao K, Sulea C, Wiederhold MD. Virtual reality as a distraction technique in chronic pain patients. Cyberpsychol Behav Soc Netw. Jun 2014;17(6):346-352. [FREE Full text] [CrossRef] [Medline]
    32. Granacher U, Lacroix A, Muehlbauer T, Roettger K, Gollhofer A. Effects of core instability strength training on trunk muscle strength, spinal mobility, dynamic balance and functional mobility in older adults. Gerontology. Oct 24, 2013;59(2):105-113. [CrossRef] [Medline]
    33. Bordeleau M, Stamenkovic A, Tardif P, Thomas J. The use of virtual reality in back pain rehabilitation: a systematic review and meta-analysis. J Pain. Feb 2022;23(2):175-195. [CrossRef] [Medline]
    34. Qian J, McDonough DJ, Gao Z. The effectiveness of virtual reality exercise on individual's physiological, psychological and rehabilitative outcomes: a systematic review. Int J Environ Res Public Health. Jun 10, 2020;17(11):4133. [FREE Full text] [CrossRef] [Medline]

    ‎
    LBP: low back pain
    ODI: Oswestry disability index
    ROM: range of motion
    VR: virtual reality

    Edited by M Mulvenna; submitted 01.11.22; peer-reviewed by J Ciążyńska, N García-Dopico; comments to author 15.03.23; revised version received 15.04.23; accepted 15.08.23; published 15.09.23.

    Copyright

    ©M Waqar Afzal, Ashfaq Ahmad, Hafiz Muhammad Bilal Hanif, Nauman Chaudhary, Syed Amir Gilani. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 15.09.2023.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Rehabilitation and Assistive Technology, is properly cited. The complete bibliographic information, a link to the original publication on https://rehab.jmir.org/, as well as this copyright and license information must be included.