
==== Front
Interv Pain Med
Interv Pain Med
Interventional Pain Medicine
2772-5944
Elsevier

S2772-5944(23)00007-9
10.1016/j.inpm.2023.100181
100181
Correspondence
Virtual reality therapy for myofascial pain: Evolving towards an evidence-based non-pharmacologic adjuvant intervention
Wang Erik F.
Department of Anesthesiology, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
Jotwani Rohan roj9068@med.cornell.edu
∗
Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
∗ Corresponding author. Weill Cornell Medicine, 525 East 68th Street, Box 124, NY, 10065, USA. roj9068@med.cornell.edu
24 2 2023
3 2023
24 2 2023
2 1 10018120 11 2022
17 1 2023
19 1 2023
© 2023 The Authors
2023
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Myofascial pain syndrome (MPS) is a highly prevalent and burdensome cause of pain globally, representing a major focus of chronic pain management. Management of MPS is highly variable, with therapies ranging from interventional approaches to physical therapy. Virtual reality (VR) is a novel form of therapy being actively explored as an adjuvant to procedural sedation in the acute pain setting, and increasingly as a means of chronic pain management through programs that facilitate pain education, physical therapy and mindfulness, among other approaches. However, to date, there are minimal clinical studies assessing VR therapy within the context of MPS treatments. Given the existing volume of work published in the acute pain setting and the translational work exploring VR and neuroplasticity in chronic pain, we make the case here that it is an appropriate time to consider exploring VR therapy as a non-pharmacological adjuvant treatment for MPS.

Keywords

Extended reality
Virtual reality
Myofascial pain syndrome
Digital therapeutics
Trigger point injections
==== Body
pmcMyofascial pain syndrome (MPS) is a musculoskeletal condition characterized by hypersensitive and irritable myofascial trigger points (MTrPs) present in taut bands of skeletal muscle tissue. It has a lifetime prevalence approaching 85% in the general population, with the estimated prevalence of active MTrPs managed in specialty clinics ranging from 46% to as much as 90% [1,2]. Consequently, MPS is a common contributor to chronic pain, yet its pathophysiology remains relatively poorly understood, with likely etiologies stemming from trauma, deconditioning, spinal pathology, repetitive misuse or strain. MPS is considered to be among the leading causes of musculoskeletal pain, translating to one of the leading costs of illness in developed countries like Canada [1,3]. The mean prevalence of MPS in adults 30–60 years is reported to be around 37% in men and 65% in women, however this reaches 85% in the elderly population across both sexes [4]. As the world population ages, with the ratio of people 65 years or older to those aged 15–64 years projected to double in developed countries by 2050, MPS is likely to only become an increasingly prevalent culprit of chronic pain [5]. Thus, we posit that MPS represents a major burden for pain practitioners and society, in general.

Approaches to management of chronic pain associated with MPS are varied, including injections, manual and massage therapy, physical therapy, dry needling, stretching, laser therapy and electrical stimulation, individually and in assorted combinations [[6], [7], [8], [9]]. Regarding trigger point injections (TPIs) in particular, there exists a wide variety of opinions pertaining to optimal technique and even efficacy in general, as many practitioners consider dry needling as effective as TPIs using local anesthetic [9]. A 2009 systematic review by Scott et al. examined 15 randomized control trials and determined that there was no clear evidence of either benefit or ineffectiveness of TPIs compared to other treatments for musculoskeletal pain [9]. Many chronic pain interventions have demonstrated fair to strong efficacy in various clinical contexts, such as facet joint injections and medial branch blocks for facet arthropathy and epidural steroid injections in short-term radicular pain, particularly in the setting of low back pain [10,11]. In comparison, the common interventions for MPS such as TPIs, cupping and dry needling have lacked both consistent, high-quality evidence of efficacy as well as agreement among providers regarding application practices [6,9,10]. As the current arsenal of treatments for MPS is wide-ranging and applied somewhat inconsistently, it behooves practitioners treating MPS to continue exploring alternate or updated methods for approaching management.

Virtual reality (VR) has been increasingly implemented in recent years in both acute and chronic pain settings. VR presents the patient with a simulated experience that employs pose tracking and three-dimensional near-eye displays to provide the immersive feel of a virtual world. In the setting of acute pain, the simulation often provides a more peaceful environment that distracts the patient from a stimulus. In the setting of chronic pain, the simulation is likely to be more variable, but in addition to providing a distraction method during procedures, may include a simulated game to facilitate movement, an exploration of a simulated nervous system to provide pain education, a remote location to practice deep breathing exercises, or a combination of all the above. Nonetheless, there does not currently appear to be any clear standardization or protocolization in the application of VR for management in either the acute or chronic pain settings. A handful of studies have examined the benefit of VR simulation as a distraction technique to modulate acute pain during procedures [12], or as an alternative to conventional exercise regimens in physical therapy settings [13], however there is a paucity of research considering VR as a nonpharmacological independent or adjuvant treatment for MPS.

Numerous studies on VR in acute pain have delved into its use in a variety of procedural scenarios, with the literature demonstrating benefits stemming from distraction, and facilitating an immersive experience that can reduce pain, anxiety and anger levels [14]. VR has found utility in a range of situations from pediatric needle procedures, to labor contractions and episiotomy repairs, to burn dressing changes and wound debridement, with studies reporting as much as a 25% decrease in pain scores during the procedure compared to control [[15], [16], [17]]. Although findings have been varied regarding decreases in opioid use, numerous studies have reported higher patient satisfaction scores with VR use versus no distraction-based intervention [15,17].

Exploration of VR in the clinical treatment of chronic pain has been less consistent and more varied when compared against studies in acute pain settings, where it is primarily implemented as a short-term distraction tool. Findings in chronic pain have ranged from minimal benefit of VR single therapeutic sessions [18] to effective reduction of chronic pain following longer-term VR exposures [19]. Long-term neuroplasticity has also been theorized as a target for the beneficial effects of VR implementation in chronic pain [20]. Translational VR studies have evaluated this etiology of relief in the management of MPS, suggesting that long-term VR use can facilitate changes in sensory and motor brain regions that provide lasting improvements in pain symptoms, and various studies have proposed ongoing pain relief from mechanisms related to “gate theory control” [[21], [22], [23]]. Further translational studies have postulated measurements of these changes, including the modulation of late perceptual pain processing and pre-perceptual brain responses to pain on EEG [24,25]. Related neurophysiological responses involved in studies exploring these changes include lower breathing frequency as well as reduced heart rate variability following noxious stimuli [25]. Studies examining VR interventions in phantom limb pain have also explored their impact on a “sense of embodiment,” perhaps enhancing a sense of agency and ownership over the body as another mechanism to reducing chronic pain; this is theorized to involve the realignment of a mismatch between the physical being and the mental projection of one's physical being [26,27]. Investigating a link specifically between MPS symptoms and perceived sense of ownership or agency over one's body could further VR's potential therapeutic application in MPS.

Within the field of physiotherapy, regimens of VR are actively being studied and compared to conventional approaches. The combination of exercises for strength and flexibility, along with mindfulness, have been implemented as part of the VR sessions in existing studies that overlap with conventional physical therapy (PT) programs [19,20]. Certain protocols have demonstrated noninferiority of consistent VR-based exercise programs in comparison to standard exercise and therapy regimens [13,28]. VR has already been implemented for rehabilitation in patients with neurological disability, as well as for early mobilization in postoperative cardiac surgery patients, with promising effect [29,30]. Within the field of PT as it relates to MPS, VR has the potential for further integration as it is becoming increasingly accessible and lower cost to implement [29]. For certain individuals, it may function as an adjuvant of physical activity that is more engaging in the long term than following standard home exercise plans.

Nonetheless, despite promising findings in relation to effects on neuroplasticity and improving motivation and participation in exercise, VR has not independently been clinically assessed against or as an adjuvant to conventional interventional techniques such as TPIs as a feasible therapy in MPS management. Future trials could start by assessing the effect of regular, scheduled VR therapeutic sessions on myofascial pain outcomes versus sham VR, for example. A similar trial conducted by Garcia et al. compared the EaseVRx program against sham VR for chronic low back pain in 179 patients over the course of 56 daily sessions [31]. The VR program was superior to sham VR for primary outcomes including reduced pain intensity and pain-related interference with activity, mood, sleep and stress, but not for pain catastrophizing, pain self-efficacy, pain acceptance, or prescription opioid use. The same team recently expanded upon this study to assess durability of their findings, with 50% of participants maintaining clinically meaningful reductions in pain interference 18 months post-intervention [32]. This randomized control trial represents the start of chronic pain-specific trials aimed at FDA approvable digital therapeutics for certain diagnoses. Limitations of the study include an inherent bias toward more technologically savvy patients for recruitment and reliance on patient-reported data for both initial establishment of symptoms and diagnoses, as well as for assessing pain response. Future explorations may eventually involve comparison of VR with standard of care therapies utilized by pain practitioners, and certain methodological limitations may be more easily minimized as similar studies become more commonly employed and refined. However, the first step forward is continuing the evolution of the scope in research involving VR simulation beyond its use as a distraction tool in pain medicine with further focus on it as a viable treatment modality for specific chronic pain diagnoses.

Overall, the question we posit is whether VR has a future place as a nonpharmacological adjunct alongside current standard-of-care treatments or if it could even potentially be effectively used in lieu of them. The past decade has shown a great deal of investment for VR as a tool in the acute pain medicine, pain psychology and physiotherapy settings that is suggestive of VR's future utility for MPS. As demonstrated in recent studies, VR has shown potential for therapeutic application in chronic low back pain, however has yet to see similar exploration in MPS, where common interventions continue to lack consistent evidence of efficacy as well as consensus among providers regarding best applications [31,32]. Thus, with MPS being a cause of chronic pain that is simultaneously highly prevalent and burdensome but also lacking consistency in evidence-based utilization of interventions, it seems now is an appropriate time to transition resources devoted to studying VR as a therapeutic option.

Declaration of competing interest

Rohan Jotwani is a Scientific Advisor to Medis Media, but he owns no shares/financial interests with the organization and receives no funding from the organization.

Erik Wang has no conflicts of interest to report.
==== Refs
References

1 Borg-Stein J. Iaccarino M.A. Myofascial pain syndrome treatments Phys Med Rehabil Clin 25 2 2014 May 357 374 10.1016/j.pmr.2014.01.012 Epub 2014 Mar 17. PMID: 24787338
2 Fleckenstein J. Zaps D. Rüger L.J. Lehmeyer L. Freiberg F. Lang P.M. Irnich D. Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: results of a cross-sectional, nationwide survey BMC Muscoskel Disord 11 2010 Feb 11 32 10.1186/1471-2474-11-32 PMID: 20149248; PMCID: PMC2836281
3 Srbely J.Z. New trends in the treatment and management of myofascial pain syndrome Curr Pain Headache Rep 14 5 2010 Oct 346 352 10.1007/s11916-010-0128-4 PMID: 20607458 20607458
4 Giamberardino M.A. Affaitati G. Fabrizio A. Costantini R. Myofascial pain syndromes and their evaluation Best Pract Res Clin Rheumatol 25 2 2011 Apr 185 198 10.1016/j.berh.2011.01.002 PMID: 22094195 22094195
5 Podichetty V.K. Mazanec D.J. Biscup R.S. Chronic non-malignant musculoskeletal pain in older adults: clinical issues and opioid intervention Postgrad Med 79 937 2003 Nov 627 633 10.1136/pmj.79.937.627 PMID: 14654573; PMCID: PMC1742882
6 Charles D. Hudgins T. MacNaughton J. Newman E. Tan J. Wigger M. A systematic review of manual therapy techniques, dry cupping and dry needling in the reduction of myofascial pain and myofascial trigger points J Bodyw Mov Ther 23 3 2019 Jul 539 546 10.1016/j.jbmt.2019.04.001 Epub 2019 Apr 4. PMID: 31563367 31563367
7 Lew J. Kim J. Nair P. Comparison of dry needling and trigger point manual therapy in patients with neck and upper back myofascial pain syndrome: a systematic review and meta-analysis J Man Manip Ther 29 3 2021 Jun 136 146 10.1080/10669817.2020.1822618 Epub 2020 Sep 22. PMID: 32962567; PMCID: PMC8183542 32962567
8 Sumen A. Sarsan A. Alkan H. Yildiz N. Ardic F. Efficacy of low level laser therapy and intramuscular electrical stimulation on myofascial pain syndrome J Back Musculoskelet Rehabil 28 1 2015 153 158 10.3233/BMR-140503 PMID: 25061034 25061034
9 Scott N.A. Guo B. Barton P.M. Gerwin R.D. Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review Pain Med 10 1 2009 Jan 54 69 10.1111/j.1526-4637.2008.00526.x Epub 2008 Nov 5. PMID: 18992040 18992040
10 El-Tallawy S.N. Nalamasu R. Salem G.I. LeQuang J.A.K. Pergolizzi J.V. Christo P.J. Management of musculoskeletal pain: an update with emphasis on chronic musculoskeletal pain Pain Ther 10 1 2021 Jun 181 209 10.1007/s40122-021-00235-2 Epub 2021 Feb 11. PMID: 33575952; PMCID: PMC8119532 33575952
11 Manchikanti L. Kaye A.D. Soin A. Albers S.L. Beall D. Latchaw R. Sanapati M.R. Shah S. Atluri S. Abd-Elsayed A. Abdi S. Aydin S. Bakshi S. Boswell M.V. Buenaventura R. Cabaret J. Calodney A.K. Candido K.D. Christo P.J. Cintron L. Diwan S. Gharibo C. Grider J. Gupta M. Haney B. Harned M.E. Helm S. Ii Jameson J. Jha S. Kaye A.M. Knezevic N.N. Kosanovic R. Manchikanti M.V. Navani A. Racz G. Pampati V. Pasupuleti R. Philip C. Rajput K. Sehgal N. Sudarshan G. Vanaparthy R. Wargo B.W. Hirsch J.A. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American society of interventional pain physicians (ASIPP) guidelines facet joint interventions 2020 guidelines Pain Physician 23 3S 2020 May S1 S127 PMID: 32503359 32503359
12 Mallari B. Spaeth E.K. Goh H. Boyd B.S. Virtual reality as an analgesic for acute and chronic pain in adults: a systematic review and meta-analysis J Pain Res 12 2019 Jul 3 2053 2085 10.2147/JPR.S200498 PMID: 31308733; PMCID: PMC6613199 31308733
13 Bağcıer F. Batıbay S. The effects of virtual reality-based wii fit yoga on pain, functionality and trigger points in non-specific chronic low back pain patients: a randomized controlled trial Bosphorus Med J 7 3 2020 75 81
14 Sikka N. Shu L. Ritchie B. Amdur R.L. Pourmand A. Virtual reality-assisted pain, anxiety, and anger management in the emergency department Telemed J e Health 25 12 2019 Dec 1207 1215 10.1089/tmj.2018.0273 Epub 2019 Feb 20. PMID: 30785860 30785860
15 Walther-Larsen S. Petersen T. Friis S.M. Aagaard G. Drivenes B. Opstrup P. Immersive virtual reality for pediatric procedural pain: a randomized clinical trial Hosp Pediatr 9 7 2019 Jul 501 507 10.1542/hpeds.2018-0249 Epub 2019 Jun 3. PMID: 31160472 31160472
16 Wong M.S. Spiegel B.M.R. Gregory K.D. Virtual reality reduces pain in laboring women: a randomized controlled trial Am J Perinatol 38 S 01 2021 Aug e167 e172 10.1055/s-0040-1708851 Epub 2020 Jun 2. PMID: 32485759 32485759
17 Tashjian V.C. Mosadeghi S. Howard A.R. Lopez M. Dupuy T. Reid M. Martinez B. Ahmed S. Dailey F. Robbins K. Rosen B. Fuller G. Danovitch I. IsHak W. Spiegel B. Virtual reality for management of pain in hospitalized patients: results of a controlled trial JMIR Ment Health 4 1 2017 Mar 29 e9 10.2196/mental.7387 PMID: 28356241; PMCID: PMC5390112 28356241
18 Jin W. Choo A. Gromala D. Shaw C. Squire P. A virtual reality game for chronic pain management: a randomized, controlled clinical study Stud Health Technol Inf 220 2016 154 160 PMID: 27046570
19 Sarig Bahat H. Takasaki H. Chen X. Bet-Or Y. Treleaven J. Cervical kinematic training with and without interactive VR training for chronic neck pain - a randomized clinical trial Man Ther 20 1 2015 Feb 68 78 10.1016/j.math.2014.06.008 Epub 2014 Jul 5. PMID: 25066503 25066503
20 Austin P.D. The analgesic effects of virtual reality for people with chronic pain: a scoping review Pain Med 23 1 2022 Jan 3 105 121 10.1093/pm/pnab217 PMID: 34260724 34260724
21 Botelho L. Angoleri L. Zortea M. Deitos A. Brietzke A. Torres I.L.S. Fregni F. Caumo W. Insights about the neuroplasticity state on the effect of intramuscular electrical stimulation in pain and disability associated with chronic myofascial pain syndrome (MPS): a double-blind, randomized, sham-controlled trial Front Hum Neurosci 12 2018 Oct 16 388 10.3389/fnhum.2018.00388 PMID: 30459575; PMCID: PMC6232764 30459575
22 Shah J.P. Danoff J.V. Desai M.J. Parikh S. Nakamura L.Y. Phillips T.M. Gerber L.H. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points Arch Phys Med Rehabil 89 1 2008 Jan 16 23 10.1016/j.apmr.2007.10.018 PMID: 18164325 18164325
23 Cheung K.L. Tunik E. Adamovich S. Boyd L. Neuroplasticity and virtual reality Weiss P. Keshner E.A. Levin M.F. Virtual reality for physical and motor rehabilitation 2014 Springer Sciences New York
24 Lier E.J. Oosterman J.M. Assmann R. de Vries M. van Goor H. The effect of Virtual Reality on evoked potentials following painful electrical stimuli and subjective pain Sci Rep 10 1 2020 Jun 3 9067 10.1038/s41598-020-66035-4 PMID: 32494060; PMCID: PMC7270181 32494060
25 Rousseaux F. Panda R. Toussaint C. Bicego A. Niimi M. Faymonville M.E. Nyssen A.S. Laureys S. Gosseries O. Vanhaudenhuyse A. Virtual reality hypnosis in the management of pain: self-reported and neurophysiological measures in healthy subjects Eur J Pain 2022 Oct 5 10.1002/ejp.2045 Epub ahead of print. PMID: 36196745
26 Tong X. Wang X. Cai Y. Gromala D. Williamson O. Fan B. Wei K. I dreamed of my hands and arms moving again": a case series investigating the effect of immersive virtual reality on phantom limb pain alleviation Front Neurol 11 2020 Aug 25 876 10.3389/fneur.2020.00876 PMID: 32982914; PMCID: PMC7477390 32982914
27 Osumi M. Inomata K. Inoue Y. Otake Y. Morioka S. Sumitani M. Characteristics of phantom limb pain alleviated with virtual reality rehabilitation Pain Med 20 5 2019 May 1 1038 1046 10.1093/pm/pny269 PMID: 30576543 30576543
28 Kim S.S. Min W.K. Kim J.H. Lee B.H. The effects of VR-based wii fit yoga on physical function in middle-aged female LBP patients J Phys Ther Sci 26 4 2014 Apr 549 552 10.1589/jpts.26.549 Epub 2014 Apr 23. PMID: 24764631; PMCID: PMC3996419 24764631
29 Mat Rosly M. Mat Rosly H. Davis Oam G.M. Husain R. Hasnan N. Exergaming for individuals with neurological disability: a systematic review Disabil Rehabil 39 8 2017 Apr 727 735 10.3109/09638288.2016.1161086 Epub 2016 Apr 25. PMID: 27108475 27108475
30 Borges M.G.B. Borges D.L. Ribeiro M.O. Lima L.S.S. Macedo K.C.M. Nina V.J.D.S. Early mobilization prescription in patients undergoing cardiac surgery: systematic review Braz J Cardiovasc Surg 37 2 2022 May 2 227 238 10.21470/1678-9741-2021-0140 PMID: 35244377; PMCID: PMC9054150 35244377
31 Garcia L.M. Birckhead B.J. Krishnamurthy P. Sackman J. Mackey I.G. Louis R.G. Salmasi V. Maddox T. Darnall B.D. An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: double-blind, randomized, placebo-controlled trial conducted during COVID-19 J Med Internet Res 23 2 2021 Feb 22 e26292 10.2196/26292 PMID: 33484240; PMCID: PMC7939946
32 Maddox T. Garcia H. Ffrench K. Maddox R. Garcia L. Krishnamurthy P. Okhotin D. Sparks C. Oldstone L. Birckhead B. Sackman J. Mackey I. Louis R. Salmasi V. Oyao A. Darnall B. In-home virtual reality program for chronic low back pain: durability of a randomized, placebo-controlled clinical trial to 18 months post-treatment rapm-2022-104093 Reg Anesth Pain Med 2022 Nov 25 10.1136/rapm-2022-104093 Epub ahead of print. PMID: 36427904
