Background & Aims

Clinical presentation of chronic shoulder pain reflects the multi-dimensionality and complexity of the pain “experience”. Movement-evoked pain (MEP) can be defined as pain experienced during movement in a specific context. MEP involves multiple factors, potentially leading to fear-avoidance behavior, where any motor behavior of the arm can be triggered as a predictive cue for pain, highlighting the need for exposure and safety learning. Immersive virtual reality (IVR), combined with graded shoulder tasks and Terminal Visual Feedback Therapy (TVFT), may offer pain relief and cognitive-behavioral changes, especially for chronic shoulder pain patients.
This study aims to investigate the impact of Terminal Visual Feedback Therapy (TVFT) post immersive virtual reality (IVR-TVFT) on pain, grip strength, and shoulder flexion range in chronic shoulder pain patients compared to sham TVFT. Additionally, it aims to find psychosocial mediators and assess psychological and behavioral changes.

Methods

This is an 18-month randomized clinical trial (RCT) at a Spanish University, involving 34 participants with musculoskeletal shoulder pain utilizes two study groups (TVFT and Sham TVFT) in a 1:1 ratio. The trial will adhere to CONSORT guidelines, TIDIER checklist and VR-CORE guidelines. Participants are randomly assigned, blinded to treatment allocation.

Both groups receive an IVR intervention-based Pain Neuroscience Education and Graded Exposure Movement Therapy. IVR-TVFT group (n=17) undergoes shoulder flexion exposure recorded on a video, while the control group (n=17) experiences sham TVFT with nature landscapes. Outcome measures include pain-free shoulder flexion, pain during movement, pain, and hand grip, assessed at baseline, post-IVR, post-TVFT, and 1-week follow-up. Secondary outcomes include demographic data and PROMs exploring psychological factors. Qualitative analysis of participants’ experiences pre and post-intervention is conducted through semi-structured interviews.

Results

Descriptive statistics summarize results, and inferential analyses use parametric or non-parametric methods based on data distribution. Qualitative analysis involves transcription, data extraction, coding, and comparison. This comprehensive study aims to evaluate the effectiveness of IVR-TVFT in managing chronic musculoskeletal shoulder pain, combining quantitative and qualitative analyses for a holistic understanding of outcomes and boosting the strength of results.
This study aims to discern the specific effects of VR exposure and TVFT through comprehensive measurements at each stage. The research proposes a cost-effective clinical strategy for altering avoidance behaviors in chronic shoulder pain patients, potentially offering a practical and accessible approach for healthcare providers.

Conclusions

Movement-evoked pain (MEP) is linked to pain-related fear and catastrophizing in musculoskeletal pain. Likewise, these patients often exhibit attention bias towards pain-related stimuli, emphasizing the role of expectations in inhibitory learning. TVFT may serve as experiential learning, challenging expectations related to shoulder flexion in IVR graded exposure. This approach may modify attentional bias and pain-related avoidance, improving treatment expectations and patient prognosis.
Previous studies have highlighted the hypoalgesic potential and de-coupling between pain avoidance behaviour, movement-related fear and pain expectancy in chronic low back pain following IVR. Evidence of IVR in shoulder pain management is emerging, however the impact on MEP on shoulder flexion task remains unclear. In conclusion, this study will examine the efficacy of TVFT following a specific IVRR intervention on MEP and avoidance behaviour in patients with chronic shoulder pain.

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Presenting Author

Javier Guerra Armas

Poster Authors

Javier Guerra

MSc

Universidad de Málaga

Lead Author

E-mail

Mar Flores-Cortés

University of Málaga

Lead Author

E-mail

Ann Meulders

PhD

Experimental Health Psychology, Maastricht University, The Netherlands; Research Group Health Psycho

Lead Author

E-mail

Roy La Touche PT

PhD

Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle. Universidad Autó

Lead Author

E-mail

Topics

  • Trial Design