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Table of Contents
Year : 2020  |  Volume : 2  |  Issue : 1  |  Page : 55-60

Immediate and Short-Term Effect of Virtual Reality Training on Pain, Range of Motion, and Kinesiophobia in Patients with Cervical Spondylosis

Department of Musculoskeletal Physiotherapy, Sancheti Institute of Orthopaedic and Rehabilitation, Maharashtra, India

Date of Submission25-Oct-2019
Date of Decision07-Nov-2019
Date of Acceptance04-Feb-2020
Date of Web Publication03-Jul-2020

Correspondence Address:
Dr. Madhumanti Mukherjee
Department of Musculoskeletal Physiotherapy, Sancheti College of Physiotherapy, 11/12, Thube Park, Shivaji Nagar, Pune - 411 005, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_73_19

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Context: Neck problems are the second most reported musculoskeletal condition. Neck injuries and pain are the common and frequent causes of absenteeism and disability. These conditions have a negative impact on individuals' activities of daily living.
Aim: The aim of this study is to compare the effectiveness of virtual reality training (VRT) along with conventional physiotherapy over conventional treatment alone on pain, range of motion (ROM), and kinesiophobia in the patients with cervical spondylosis.
Setting and Design: This was a randomized control trial done at the tertiary care hospital, Pune, India.
Materials and Methods: Forty-four participants were randomly allocated using the chit method to the conventional group (n = 22) and conventional plus VRT group (n = 22). VRT was given using an immersive virtual reality headset. The outcomes assessed were pain using the Numeric Rating Scale and cervical ROM (all movements) using universal goniometer and kinesiophobia. Pain and ROM were assessed on the immediate (day 1) and short-term (day 3) basis while kinesiophobia was assessed only on day 3.
Statistical Analysis Used: Statistical analysis was performed using the Statistical Package for the Social Sciences software version 16.0.
Results: Intragroup analysis revealed a statistically significant difference in the immediate and short-term assessment in both the groups for all the variables (P ≤ 0.05). However, intergroup analysis revealed that VRT is effective in alleviating pain in the immediate (P = 0.02) and short-term (P = 0.00) analysis and improving rotation (left rotation [ P = 0.04]; right rotation [ P = 0.01]) and side flexion (left side flexion [ P = 0.00]; and right side flexion [0.01]) ranges. The results were insignificant for flexion, extension, and kinesiophobia.
Conclusion: The present study concluded that both the protocols are effective in reducing pain and improving ROM. VRT was better in reducing pain than conventional treatment on the immediate and short-term basis. However, VRT group was not effective in improving ROM on an immediate basis. Both the treatment methods were equally effective in reducing kinesiophobia.

Keywords: Cervical spondylosis, Kinesiophobia, Virtual reality training

How to cite this article:
Mukherjee M, Bedekar N, Sancheti PK, Shyam A. Immediate and Short-Term Effect of Virtual Reality Training on Pain, Range of Motion, and Kinesiophobia in Patients with Cervical Spondylosis. Indian J Phys Ther Res 2020;2:55-60

How to cite this URL:
Mukherjee M, Bedekar N, Sancheti PK, Shyam A. Immediate and Short-Term Effect of Virtual Reality Training on Pain, Range of Motion, and Kinesiophobia in Patients with Cervical Spondylosis. Indian J Phys Ther Res [serial online] 2020 [cited 2023 Jun 2];2:55-60. Available from: https://www.ijptr.org/text.asp?2020/2/1/55/288868

  Introduction Top

Cervical spondylosis involves a sequence of degenerative changes in the spinal structure.[1] The clinical features of cervical spondylosis embody pain, stiffness, loss of range of motion (ROM), and loss of function. The degenerative cervical disc is liable to pain which may be aggravated by disc stimulation or distention.[2] These conditions affect an individuals' ability to do work and perform daily activities effectively.

Recent literature has supported a holistic approach in the treatment of neck pain, with exercise as crucial component within a biopsychosocial chassis.[3] Manual therapy, muscle energy techniques, numerous electrotherapeutic modalities, and exercises have been used to treat cervical spondylosis. Patients reporting of neck pain have shown problems with cervical movement kinematics such as ROM and stability of neck motion, which can weaken their capacity to react to surrounding stimuli.[4],[5],[6],[7] Such kinematic debilitations are hypothesized to play a part in the activities of daily living, such as driving. Fear of movement could also be a factor responsible for such debilitations in some patients reporting neck pain.[8],[9] Considering the functional significance of cervical kinematics, exercise interventions that focus on such training are potentially pertinent, and investigation should be done for their usefulness in the management of chronic neck pain resulting due to cervical spondylosis.

Virtual reality (VR) uses the computer software to display the virtual environments. A head-mounted display is used to exhibit the image to the user. The images seen by the user are linked with the user's head position. Immersion is one of the concepts that allow VR environment to distract the patients.[10] When immersion is high, the user's attention is centered on the virtual environment, causing distraction from other things, such as pain. VR creates a nonpharmacologic form of analgesia by altering the activity of the body's intricate pain modulation system.

It was found that there is a dearth of the research in the use of virtual reality training (VRT) in the patients with cervical spondylosis. Hence, a need was felt to establish the interventions using VRT to observe the immediate and short-term effects of VRT which can be used in any setup to effectively manage disability due to neck pain in population and to compare it with the conventional treatment given to cervical spondylosis patient.


The primary objective of this study was to evaluate the immediate and short-term effect of VRT in comparison with conventional treatment on pain and ROM. The secondary objective of this study was to compare the short-term effect of kinesiophobia between the two groups.

  Materials and Methods Top

Study design and settings

This study was approved by the Institutional Ethical Committee in accordance with the applicable regulations. This trial was registered at Clinical Trials Registry, India (CTRI). Trial Registration: CTRI/2018/07/014733. It was a randomized, controlled trial wherein the patients of age 30 and above diagnosed by orthopedician as subacute and chronic cases of cervical spondylosis without radiculopathy were included in the study. The study was conducted at the tertiary care hospital in Pune, Maharashtra, India. Participants reporting of motion sickness, diagnosed cervical vertebra fracture, reporting pain >8 on the Numeric Rating Scale (NRS), having cervical rib, diagnosed with mechanical neck pain, and reporting of motion sickness were excluded from the study. The sample size was calculated using the standard formula for randomized control trials where, Zα/2 =1.96 and Zþ/2 =1.64.[11] Informed consent was obtained from the participants. Twenty-two participants were allotted to each group [Figure 1]. A random sampling method was used. Allocation to the group was done using the chit method. Twenty-two chits of each Group A and B were made, and every patient was asked to pick a chit. Participants were put in two groups: Group A conventional and Group B conventional + VRT according to chit picked by them.
Figure 1: Flowchart illustrating the process of the study

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Outcome assessment

Pain was assessed using the Numeric Pain Rating Scale.[12] ROM was assessed using the universal goniometer.[13] The Tampa Scale of kinesiophobia (TSK) was used to assess kinesiophobia.[14] A pilot study was done on three participants to format the protocol and safety of participants. Preassessment was done by the blinded assessor. Both group's participants were asked to fill TSK before starting the treatment. TSK was given again to fill to both the groups after the 3rd treatment session. Posttreatment outcome measurements were done on the 1st day, i.e., immediate and on the 3rd day, i.e., short-term assessment by blinded assessor. One group received conventional treatment, and other received conventional plus VRT for 3 consecutive days a week.

Intervention procedure

Group A (conventional group): both groups were given a hot pack to reduce muscle spasm for 10 min before every session for 3 consecutive days.[15] The hot pack was given postcontraindication assessment, i.e., thermal sensation assessment. The conventional group included active cervical ROM exercises in pain-free limit, scapular retraction in sitting, upper trapezius stretching, and cervical core exercise.[16] These exercises were done for ten repetitions, 1 set. Scapular sets and cervical core had 10 s hold time. Upper trapezius stretching was done for three repetitions each side with 30 s hold. Conventional treatment was given for 15 min. The short-term assessment duration (3 days) was decided in accordance with a previous study.[17]

VRT was given with the help of Immersive Black Bug Virtual Reality Glasses 3D VR Box 2.0 Headsets. It has 42-mm diameter spherical resin lens material. The VR box is compatible with all Android and iOS phones measuring between 4.7″ and 6.0″ screen [Figure 2]. The participants were made to sit on a chair having back support, and care was taken to prevent thoracic movements with verbal cues by the therapist. The mobile phone which was used was OPPO F7. It has a 15.82 cm display. The screen resolution of the phone is 1080*2280 pixels and runs on the Android version 8.1 (Oreo, API 27) developed by Google. operating system. Game used for VRT was VR bike real-world racing which is available on the Google Play Store in games section without any charges. VRT was given for 10 min. The VR game required active cervical ROM to play the game which is sensed by the gyroscope inside. Participants were asked if they felt any discomfort or increase in symptoms while using VR.
Figure 2: Patient using head-mounted virtual reality headset for virtual reality training during treatment session

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Statistical analysis

The Statistical Package for the Social Sciences software SPSS for Windows, Version 16.0. (SPSS Inc., Chicago, IL, USA) was used for the analysis of the data collected. Data were explored for normality. All the variables were found to be normally distributed. Within group analysis for immediate and short-term effects on pain, ROM and kinesiophobia were performed using the Friedman's ANOVA test, repeated measures ANOVA test, and Wilcoxon signed-rank test, respectively. Intergroup immediate and short-term effect on pain, kinesiophobia, and ROM was assessed using the Mann–Whitney U-test and unpaired t-test, respectively. A statistically significance level was set as P ≤ 0.05.

  Results Top

Demographic data

In the conventional group, a total of 22 participants were recruited, of which 13 were female and 9 were male. The mean age under this group was 54.81 ± 13 years. In the VRT group, 22 participants were recruited, of which 8 were female and 14 were male. The mean age under this group was 55.81 ± 15 years. [Table 1] shows the inferential statistics of demographic data with mean ± standard deviation values.
Table 1: Descriptive statistics

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The intragroup analysis of both the groups has shown a statistically significant difference, i.e., P ≤ 0.05 for pain, kinesiophobia, and all ranges of cervical spine [Table 2] and [Table 3]. The intergroup analysis shows that both immediate (P = 0.02) and short-term (P = 0.0) values of pain have a significant difference. However, when assessed for cervical flexion and extension ROM, both immediate and short-term values were insignificant, i.e., P ≥ 0.05. Intergroup analysis showed significant results for both side rotations (P = left rotation 0.04 and right rotation 0.01) and lateral flexion (P = left side flexion [0.00] and right side flexion [0.01]) when assessed on the short-term basis. The results were insignificant on the immediate assessment. Intergroup analysis of kinesiophobia also yielded insignificant results [Table 4].
Table 2: Conventional intragroup analysis

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Table 3: Virtual reality training intragroup analysis

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Table 4: Intergroup analysis

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  Discussion Top

In this study, significant pain reduction was observed in the VRT group. This result is in accordance with other studies that suggest a deeper form of distraction produced with VR experiences which attenuates the pain. VRT has been used successfully in various types of subjects for pain relief. Distraction has been proven as the main principle behind pain relief when VRT is used.[18] Hoffman et al., in their study, explored the effect of VRT on pain reduction with repeated use. This study was conducted in a burn care unit where the participants performed ROM exercises of injured extremity under supervision on 3 separate days each. The results were statistically significant for reduced pain ratings when the participants were using VR.[17]

In this study, active cervical ROM has also been assessed. In the conventional group, intragroup analysis has shown a significant difference. The result can be attributed to the use of hot pack along with exercises that reduces stiffness, improves viscoelastic property of collagen tissue, thereby improving ROM.[15] In the present study, both the conventional and the VRT group participants received a hot pack before the intervention. The therapeutic effects of hot pack[15] have effectively reduced pain and spasm in both the groups.

Active cervical ROM exercises aimed at restoring or improving ROM are most commonly suggested exercises for cervical conditions.[19] In one of the similar studies conducted, participants were made to perform neck flexion, ipsilateral neck rotation toward painful side, contralateral bending using opposite hand in diagonal direction to stretch upper trapezius muscle, and the authors concluded that both the stretching methods in their study were effective in improving rotation ROM in unilateral neck pain.[20]

Joshi et al., in their study, have mentioned in their study that key postural muscles, namely trapezius, levator scapulae, and serratus anterior have attachments spanning cervical and thoracic regions. Dysfunction of these muscles maybe caused due to postural impairment in thoracic spine, ultimately leading to altered mechanical loading of the cervical spine.[21] In the present study, the authors have incorporated scapular retraction with depression, and the results on its effect on pain and ROM are in accordance with the above-mentioned studies.

In this study, cervical core exercise has also been included. Since cervical, thoracic, and lumbar spine are interconnected,[22] thoracic spine column influences cervical kinematics through cervicothoracic junction.[23] Increased kyphosis is an important factor in the development of forward head posture. Forward head posture has been associated with reduced cervical ranges and thus contributing to pain as forward head posture increases compressive loading on the cervical spine and abnormal stresses on its posterior noncontractile elements.[21]

All the ranges of cervical motions in conventional and VRT intragroup analysis are statistically significant (flexion, extension, both rotations, and both lateral flexion) both during immediate and short-term assessment. However, when assessed for immediate and short-term differences in ROM in intergroup analysis, flexion and extension both values were not significant. This shows that VRT does not provide significant results for flexion and extension, though it is important to put on note that the game which the participants played in the present study required them to do more of rotations and lateral flexion. Flexion was detected as deceleration, and extension was detected as acceleration by the gyroscope. Hence, it can be the reason for the insignificant values for flexion and extension.

The nature of the game yielded results for both rotation and lateral flexion when assessed on short-term basis. Sarig Bahat et al., in their study, have mentioned that the group in which they had given kinematic training plus VRT yielded from 10° up to 38° in both directions. Flexion also improved in prepostanalysis.[11] One thing which has to be noted is that the intervention was 4–6 supervised sessions for 30 min each over a period of weeks. In this study, we have given 10 min of VRT along with conventional exercise for 3 consecutive days. The short duration of treatment could also be the reason for insignificant values in the immediate analysis.

In this study, kinesiophobia was assessed on the 1st day and 3rd day using TSK. Intragroup analysis in both groups shows a significant difference. Sarig Bahat et al., in their study, have also assessed kinesiophobia. They too observed no difference in the fear of movement. They have hypothesized that due to the lack of considerable fear of movement, they could not observe the difference in kinesiophobia values.[11]

In this study, long-term follow-up was not done because of the nature of the study. Patients having 8 <NRS were not included as not many studies were available on patients with cervical spondylosis using VRT. In future, more studies can be done using VRT with a long-term follow-up, and compliance can be checked in patients with cervical spondylosis. Studies can also be done to assess the combined motions of cervical spine post-VRT.

The results of the present study are in accordance with the alternate hypothesis which says VRT along with conventional treatment improves ROM and reduces pain in patients having cervical spondylosis in comparison with only conventional treatment.

  Conclusion Top

Both the treatment methods, i.e., conventional and VRT, were effective in reducing pain and improving cervical ranges in participants with cervical spondylosis. However, VRT is more effective than conventional treatment alone in the reduction of pain immediately (day 1) and in short term (day 3). VRT also demonstrated improvements in ranges of bilateral cervical rotations and lateral flexion on the short-term basis (day 3) while there was no improvement observed immediate posttreatment (day 1). Both the treatment methods were equally effective in reducing kinesiophobia.

VRT is a treatment technology that is available in the market at a very cost-effective price with the ease of application and handling. Though for better experiences, more sophisticated versions of VRT can be chosen.


We would like to thank all the people who were involved in this study. We are grateful to the participants who consented to be participants in this study. We deeply appreciate the contribution of Dr. Rachana Nikam, Dr. Dhara Kapoor for guiding with the analysis and proof-reading. We are grateful to the blind assessor for the assessment of each participant.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflict of interest.

  References Top

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  [Figure 2], [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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