Virtual reality (VR) is an emerging technology that involves the interaction between a user and a computer with real time simulation of environments, functional activities, exercises and games. (Rutkowski et al., 2020). The definition of VR is based on the concept of “presence” which relates to the sense or feeling of being in an all-surrounding environment. There are currently 4 main types of VR:

1. Non-immersive VR
2. Immersive VR
3. Augmented VR
4. Mixed VR

 
The sense of ‘presence’ depends on the level of VR immersion. This is dependent upon the type of system used. In healthcare, VR is generally referred to as “specialized” VR (i.e. specifically developed therapeutic VR systems) or gaming VR (i.e. commercial VR-game consoles).

Mechanisms
The rationale for the use of VR is that enhanced stimulation provided by an artificially generated environment leads to activation of motor learning processes by influencing exteroception and enhancing the feed-forward mechanism of motor planning through goal directed activities. Repetition of efficient movement may then lead to motor re-learning which may transfer to functional activities. The thinking is that the VR environment has the potential to stimulate supervised and reinforcement learning, based on  augmented visual, acoustic and sensitive feedback.

Clinical applications
To date VR has more commonly been used in neurologic rehabilitation (stroke mostly) where VR has resulted in greater improvements in upper limb function compared with conventional rehabilitation. (Rutkowski et al., 2020) It has also been reported in a small number of studies in the geriatric population (falls) and paediatric population (Developmental Coordination Disorder, Cerebral Palsy) where evidence of improvement compared with conventional treatment for lower limb function, gait and balance is not growing and still conflicting.

A few studies have been published investigating its use for orthopaedic rehabilitation. (Gumaa & Rehan Youssef, 2019). To date, virtual reality has not shown any significant benefit compared with conventional rehabilitation for RA, knee OA, ankle instability and following ACL reconstruction and there is insufficient evidence to draw any conclusions in fibromyalgia, back pain and following knee arthroplasty.(Rutkowski et al., 2020)

Given it’s application to improving movement planning and motor control, I wondered whether there were applications for the shoulder instability population, specifically for those with atraumatic instability, or post-immobilisation following traumatic instability or surgical stabilisation. In these patient groups, there may be inhibition of important stabiliser muscles at motor cortex level. I didn’t find any studies on shoulder instability, but I found one study in which VR had been used in rehabilitation for subacromial impingement syndrome (SAIS).

Virtual Reality for Subacromial Impingement Syndrome
Virtual reality using Nintendo Wii (boxing, bowling and tennis accompanied by an avatar) was compared with capsular stretching, pectoral stretching, scapula strengthening and bilateral shoulder elevation exercises (Pekyavas & Ergun, 2017) in 30 patients with SAIS. Pain intensity was significantly improved in both groups, however the VR group reported statistically significant improvements in night pain VAS, and pain with Neer, Scapula Assistance and Scapula retraction test compared with the control treatment group.

There was also a case report of significant shoulder pain in a hemiplegic patient that was preventing rehabilitation. The pain improved with the concurrent application of VR during passive mobilisation and stretching enabling progression with rehabilitation suggesting VR may have central effects on pain mechanisms. (Funao et al., 2021)

Doseage
Doseage was variable across all studies:

• Time: 20 mins to 3 hrs training duration
• Sessions: 10 sessions (minimum)
• Frequency: 2-5x per week
• Type: Specialised/custom vs commercial systems

Summary
My motivation for looking into this was to find out whether VR training may be a useful adjunct to neuromuscular rehabilitation for people with motor control impairments around the shoulder (e.g shoulder instability, scapula dyskinesis, persistent shoulder girdle pain). What I have taken out of what I have found is:

• A lot more research is needed. There is very little in the orthopaedic literature, and nothing (that I could find) in the shoulder instability population to say whether VR enhances conventional rehabilitation for pain, instability events or measures of sensorimotor function.
• There are questions as to whether the improvements seen in VR ‘environment and task-specific’ activities transfer to real-world activities.
• The different levels of VR immersion are likely to have different neuromuscular effects which could make it more or less useful for individual patients depending on their specific neuromuscular impairments.
• Not enough is known about minimum effective doseage at present.
• There may be some applications for the management of shoulder pain. The mechanisms for this may include both central and peripheral mechanisms. This may be useful where pain has precluded rehabilitation using other methods although more specific mechanisms may need to be explored to refine patient selection.

Will I be buying a VR set for my shoulder patients?
Not yet, but I’ll be watching the literature closely, and if anyone is looking for a research project, how about looking at the use of VR in the shoulder instability population? 😉

References
Funao, H., Tsujikawa, M., Momosaki, R., & Shimaoka, M. (2021, Jul). Virtual reality applied to home-visit rehabilitation for hemiplegic shoulder pain in a stroke patient: a case report. J Rural Med, 16(3), 174-178. https://doi.org/10.2185/jrm.2021-003
 
Gumaa, M., & Rehan Youssef, A. (2019). Is Virtual Reality Effective in Orthopedic Rehabilitation? A Systematic Review and Meta-Analysis. Physical Therapy, 99(10), 1304-1325. https://doi.org/10.1093/ptj/pzz093
 
Pekyavas, N. O., & Ergun, N. (2017, May). Comparison of virtual reality exergaming and home exercise programs in patients with subacromial impingement syndrome and scapular dyskinesis: Short term effect. Acta Orthop Traumatol Turc, 51(3), 238-242. https://doi.org/10.1016/j.aott.2017.03.008
 
Rutkowski, S., Kiper, P., Cacciante, L., Cie?lik, B. a. e., Mazurek, J., Turolla, A., & Szczepa?ska-Gieracha, J. (2020, 11/19). Use of virtual reality-based training in different fields of rehabilitation: A systematic review and meta-analysis. Journal of Rehabilitation Medicine, 52(11), 1-16. https://doi.org/10.2340/16501977-2755

Musculoskeletal physiotherapists have a therapeutic ‘bag of tricks’ that includes a range of interventions such as advice, pain science education, acupuncture, exercise and manual therapy to name a few. What turns a ‘trick’ into an effective ‘treatment’ is its application within a biopsychosocial framework, guided by clinical reasoning, informed by evidence within a person-centered, shared decision-making model of care.

Manual therapy as a “low-value” treatment
Manual therapy has been the subject of mounting criticism for being a passive, low value intervention that has potentially nocebic effects, that can create dependency, foster maladaptive beliefs and create unrealistic expectations of treatment. This assumes that manual therapy is applied indiscriminately, in isolation, without clinical reasoning or context. If that is the case, I would be the first to agree that manual therapy, and any other treatment applied in this way, literally becomes another ‘trick’ of the trade.

So what turns our manual therapy ‘tricks’ into an effective treatment for shoulder pain?

Identifying “Responders”
Like every other physical therapy intervention, manual therapy should be selected based on clinical reasoning throughout the assessment, diagnosis and treatment planning process to identify those people who are most likely to benefit from it.  Deciding whether manual therapy may be an effective treatment tool starts during the assessment.

In my experience, the ability to modify a persons’ symptoms during the movement-based assessment suggests the person may benefit from the inclusion of manual therapy as an adjunct to their treatment programme. Indeed, evidence has shown that the ability to change shoulder symptoms and/or range of motion of shoulder elevation with manual facilitation of the scapula was associated with better functional outcomes of treatment for shoulder pain. 1  

There are many forms of manual therapy ‘symptom modification’ techniques described for shoulder girdle pain 2-4  These are applied during the provocative movement (usually flexion or abduction) to the shoulder and surrounding areas (e.g cervicothoracic spine) and change in pain is measured. An improvement in pain with a manual therapy technique suggests a mechanical/nociceptive (vs nociplastic or neuropathic) flavour to the pain phenotype. Based on our understanding of nociplastic and neuropathic pain mechanisms, it is unlikely either of these would exhibit an immediate reduction in pain with a manual therapy intervention.

Mechanisms of symptom improvement
While our early assumptions were grounded in the biomechanical model, we now know that combinations of neurophysiologic changes, endogenous pain control mechanisms, placebo and contextual effects can all interact to result in improvements in pain with manual therapy. While we may never be certain which of the myriad mechanisms is responsible for the improvement for any given person, an improvement suggests the person may ‘respond’ to manual therapy.

Does the mechanism matter? No, but it matters how we explain the improvement to the patient to avoid maladaptive beliefs about the manual therapy “magic trick” that may create unrealistic expectations, lead to unnecessary health-seeking behaviour or foster dependency.

Manual therapy as a treatment for shoulder pain
The addition of manual therapy has been shown to improve treatment outcomes for pain and function for people with subacromial pain 5  and frozen shoulder.6  Scapula, humeral and cervicothoracic manual therapy techniques can be valuable adjuncts to treatment when they reduce pain and facilitate functional movement. Once functional movement is established, load can then be increased to build capacity within a multi-modal, movement and exercise-based programme.

There are other ‘non-specific’ benefits too. The application of manual therapy creates space within the clinical encounter to hear the patients’ story and develop the therapeutic alliance. The enhanced level of trust this affords often leads to the disclosure of other, more personal information, that may also influence treatment outcomes.

The ability to change symptoms gives the person hope that there may be a way to improve their symptoms, the level of trust in the practitioner increases and I find I get instant engagement with the treatment and exercise rehabilitation plan from that point on. The person is more confident to move, is less fearful that ‘something serious is wrong’ and when they can replicate this at home it gives them a self-management strategy for symptom improvement.

Case examples:
Here are two recent examples of patients I have seen who responded well to manual therapy:

1. A 24-year-old professional athlete who had completed 4 months of ‘hands-off’ treatment including exercise and was still unable to perform his overhead sporting activity because of end-range pain in shoulder elevation. After two sessions of acromioclavicular joint mobilisation, he had pain free elevation and returned to sport.
2. A 76-year-old woman with an irreparable cuff tear with significant disability due to pseudoparalysis. Deltoid re-training was difficult due to pain with attempted arm elevation. Posterior humeral glides (WMW) abolished her pain, and she regained full active shoulder elevation after 4 weeks of manual therapy combined with exercise-based rehabilitation.

Trick or Effective Treatment?
Manual therapy can be an effective adjunct to treatment for people with shoulder pain when delivered within a multi-modal programme. When applied within a clinical reasoning model and aligned with the persons beliefs and realistic expectations it can be an effective treatment to help reduce symptoms and facilitate improvements in movement and function. Don’t treat manual therapy like a “trick” and you may start to see it as an effective treatment for the right person.

References
1.     Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: A multicentre longitudinal cohort study. British Journal of Sports Medicine. 2016.
2.     Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine. 2009;43(4):259-64.
3.     Satpute K, Reid S, Mitchell T, Mackay G, Hall T. Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis. J Man Manip Ther. 2022;30(1):13-32.
4.     Aytona MC, Dudley K. Rapid resolution of chronic shoulder pain classified as derangement using the McKenzie method: a case series. J Man Manip Ther. 2013;21(4):207-12.
5.     Pieters L, Lewis J, Kuppens K, Jochems J, Bruijstens T, Joossens L, et al. An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain. J Orthop Sports Phys Ther. 2020;50(3):131-41.
6.     Noten S, Meeus M, Stassijns G, Van Glabbeek F, Verborgt O, Struyf F. Efficacy of Different Types of Mobilization Techniques in Patients With Primary Adhesive Capsulitis of the Shoulder: A Systematic Review. Archives of Physical Medicine and Rehabilitation. 2016;97(5):815-25.

A few weeks ago I wrote a post about the level of clinical competency required at specialist levels of physiotherapy practice which generated a bit of interest. I mentioned that my experience of working at this level (compared with other levels of practice) is the expectation that the specialist physiotherapist will have a solution we are others have failed. Often we are ‘expected to know’. 

In the previous post I discussed some of the factors that contribute to ‘complexity’. So how do I approach and interpret my assessment and make decisions about appropriate treatment given that many people I see have already had many investigations and treatment, often from very competent professionals?

In my practice, people tend to fall into one of two groups:

1. Missed diagnosis (e.g frozen shoulder) or treatable impairment such as loss of ROM, muscle function or cognitive/psychosocial modifiers such as patient beliefs and expectations.
2. Complex rehabilitation presentations. These are less common conditions (e.g symptomatic os acromiale) or those with persistent pain or sensorimotor deficits. This group requires a higher level of clinical reasoning including diagnostic reasoning and rehabilitation expertise.

With these two groups in mind, I’ve put together some of the common processes I have found helpful for guiding my decision-making when seeing specialist patients.

1. Assume nothing.
2. Find out what the patient and referrer want (sometimes not the same thing).
3. Do the basics extremely well:
   • Diagnosis: exclude significant conditions that need onward referral.
   • Treatment: Assess for specific physical impairments (e.g ROM, muscle function) that might influence symptoms or function.
4. Identify persistent pain mechanisms (e.g neuropathic or nociplastic pain) and other health or psychosocial “modifiers” that may be influencing response to treatment.
5. Understand the clinical pathways for specific conditions and the role of physiotherapy in the context of non-surgical and surgical treatment.
6. If not improving, get another opinion. Build a local, multi-disciplinary referral network that you can refer to for advice or further assessment and/or management.

​I’d love to hear whether other Specialist Physiotherapists have any other tips, or whether this helps other physiotherapists out there to organise your thinking and develop a framework for troubleshooting challenging clinical presentations.
If you’re interested in hearing more about how to reason through challenging clinical situations you may be interested in this recorded webinar hosted by Physio Academy.
Problem Solving the Problem Shoulder: 3 Reasons They’re Not Improving