Delivering Immersive Virtual Reality as an Intervention to Patients with Chronic Low Back Pain in The Kingdom of Saudi Arabia: A Mixed-Methods Feasibility Study

Abstract

Background: Chronic low back pain (CLBP) has been recognised as a leading cause of disability in adults for three decades. Literature constantly calls for improved CLBP healthcare services. Immersive virtual reality (IVR) can encourage patients with CLBP to engage in exercise regimes and remain active, but the feasibility of IVR in the Kingdom of Saudi Arabia (KSA) among patients with CLBP is unknown.

Aims: To investigate the feasibility of delivering IVR to patients with CLBP in the KSA.

Method: Two studies were conducted. Part 1: an umbrella review of systematic reviews (SRs) aimed to identify, summarise, synthesise and critically appraise existing SRs regarding the effectiveness of VR in individuals with chronic MSK pain and disability, focusing on CLBP. The results of this previous review, along with patients and public involvement, informed the design of a protocol for testing the feasibility of delivering IVR to treat patients with CLBP in the Saudi context. Part 2: a sequential explanatory mixed-methods feasibility study aimed to examine predefined progression criteria of the feasibility of delivering IVR to a sample of individuals with CLBP and explore their experiences along with relevant healthcare practitioners in the Saudi context in outpatient department (OPD) settings. The feasibility study adopted a sequential explanatory mixed-methods design comprising two phases: the quantitative (Phase 1) and qualitative (Phase 2).

Findings: Part 1: the overall confidence in the identified SRs ranged from low to critically low, whereas the certainty in the body of evidence ranged from moderate to very low. Although the results suggest that VR, either as an alternative form of treatment or in combination with other interventions, may provide a short-term positive impact on patient-reported outcomes for pain in patients with chronic primary MSK pain, it remains uncertain which specific VR intervention shows the most promise, as the included SRs grouped various types of VR together. However, results on patient-reported outcomes for disability and kinesiophobia were inconsistent. Adverse events included motion sickness, nausea, and vertigo. Part 2, Phase 1: the recruited patients included 31 males and two females over 12 weeks. The feasibility a priori criteria were met for recruitment, retention, dropout, completeness of questionnaire data, and treatment compliance and fidelity. No serious adverse events were experienced among patients. However, some incidences of non-serious, short-lasting, minor adverse events were reported. Part 2, Phase 2: analysis of qualitative data from interviews with eight male patients and three physiotherapists (the latter of whom comprised two males and one female) revealed four overlapping themes: sociocultural considerations, facilitators, barriers, and feasibility. Sociocultural considerations included visual (e.g., avatar outfit), auditory (e.g., music), contextual (e.g., same-gender IVR administrator), and IVR-specific factors (e.g., feeling ashamed to play like a child). From the patients’ perspectives, the study process and materials were described as feasible, and recommendations were discussed for IVR implementation. From the physiotherapists’ perspectives, recommendations for the success of IVR integration into the KSA healthcare system included using multiple devices and an efficient scheduling system. Facilitators, from the patients’ perspectives, included ‘positive IVR experience,’ and ‘IVR is motivational.’ Additionally, from patients’ and physiotherapists’ perspectives, facilitators included ‘IVR is therapeutically useful, easy to use, and tolerable.’ Barriers to delivering IVR, from the patients’ perspectives, were ‘personal challenges’ related to time and travel. Furthermore, the physiotherapists-related barrier was ‘time-consuming for physiotherapists.’ Moreover, from both patients’ and physiotherapists’ perspectives, barriers included ‘lack of knowledge’ and ‘support and infrastructure issues.’

Implications: The results indicate that IVR was feasible, acceptable, and tolerable among patients with CLBP and healthcare professionals in the KSA within OPD settings. IVR can be utilised to support patients’ engagement in physiotherapy OPD settings. Further research focusing on the effectiveness is warranted in this field. Furthermore, further mixed-methods research within the context of this study and other MSK conditions is warranted in the Saudi Context to reveal more sociocultural considerations.