What is the problem?
During treatment and rehabilitation of amputation patients, the wounded suffer from physical and phantom pain — pain perceived as if from a part of the body that no longer exists.
Doctors explain that in the early rehabilitation period, when the postoperative wound has not yet healed, they cannot restore the activity of the limb. Still, they can contribute to faster healing, formation of a stump scar on the part of the limb that remains after amputation, and prevent the development of contractures, or restriction of joint mobility. Abuse of opioid pain relievers at this stage not only leads to addiction but also slows wound healing.
In addition, patients may be in a difficult emotional state. It is often hard for them to communicate and cooperate for further rehabilitation.
What is the solution?
Svitlana Barabash is an occupational therapist at the Institute of Traumatology and Orthopedics, working in the rehabilitation department. Leonid is one of her patients with complex multiple trauma, phantom pain, and sleep disorders. To facilitate rehabilitation, doctors often use mirror therapy, where the patient performs a movement with a healthy limb and looks at its reflection in a mirror. However, in the case of Leonid, it was impossible to apply mirror therapy — the patient's preserved right leg is plastered, and there is a vacuum-assisted closure (VAC) system used to clean the wound surface and accelerate healing on the amputated one.
Piotr Armianovski is an artist and documentary filmmaker. Since 2020, he has been engaged in projects related to virtual reality. In particular, with his team, he creates films that can then be viewed through a VR helmet. Among them are tours of the glass bridge in Kyiv and Poznań Castle.
How are these two stories related?
In the summer, Armianovski visited a friend who had a battle injury and was Leonid's roommate. He took a virtual reality (VR) helmet with him and offered it to Leonid to try. The operating doctor agreed to this, and after the first session, the patient felt significant relief. In particular, the patient's sleep improved significantly.
Having seen such an effect, Armianovski enlisted volunteers the next day to help purchase a VR helmet for the hospital to continue the therapeutic sessions. In Leonid's case, this was the only effective tool that helped him to avoid taking opioids.
For the first month, doctors conducted VR therapy with Leonid almost daily. Starting from the second month, when the patient was transferred to the rehabilitation department and could partially lean on the preserved limb, the number of sessions was reduced to three times a week. Barabash explains that this was done to consolidate the therapy's effect. Phantom pains became less pronounced — from eight points decreased to three to four points according to the visual-analog pain scale (VAS), and appeared only periodically — in the evening and when the weather changed.
How does it work?
Acquaintance with technology
Barabash became responsible for conducting VR therapy sessions. Nataliia Borzykh, the head of the rehabilitation department of the Institute of Traumatology and Orthopedics, also facilitated further testing of the virtual reality technique.
From the beginning of the summer of 2022, virtual reality therapy began to be used in the hospital. A multidisciplinary team worked on setting up the processes, and Armianovski, who became the project's initiator, visited to set up certain options. Armianovski taught doctors and patients how to use the VR helmet, joysticks, and launch programs.
In addition, several doctors and physical therapists have gone through the standard training program on the First Steps for Quest VR helmet to give them an idea of what to expect when working with the patient. Over time, two more specialists joined the VR sessions in the rehabilitation department.
Testing and experiments
Before the VR therapy sessions, the doctors conducted a survey among the patients — in particular, to determine the pain levels according to VAS, and the somatic condition of the patient. Also, before starting the program, they were interested in whether there were complaints of dizziness and nausea, how well-developed their vestibular apparatus was, and whether there were vision problems — because sometimes, such sessions with VR helmets cause nausea in patients.
With the introduction of technology, physical therapists and occupational therapists began measuring blood pressure and heart rate before and after a session. Doctors needed feedback from the very first minute of the session — work with VR helmets was continued only at the patient's request, and if they did not feel any deterioration. During the entire session, the doctor must be next to the patient — to help during the therapy or to stop the session if necessary.
A team of doctors tested dozens of programs to find the best ones to help patients regain motor activity using game methods. Barabash says Epic roller coasters, Echo VR, Liminal, and Creed: Rise to Glory were the most effective.
The occupational therapist explains that other specialists can rely on these experiments, applying VR therapy for different purposes and groups of patients. At the same time, because physical therapists working in hospitals in various regions of Ukraine are overloaded with work from the number of patients, they do not have enough time to carry out basic physiotherapeutic interventions. Therefore, there is a lack of specialists who could conduct therapy using virtual reality in their hospitals, even with the experience of the orthopedic institute, which doctors of other medical institutions can safely take over.
To effectively provide VR testing and therapy to all patients who need it, physical therapists must work overtime as they only have enough time to perform essential physical therapy treatments. In addition, the institution's management should be loyal to conducting and testing VR therapy, and open vacancies are needed for specialists in the field of rehabilitation ready to learn and work with new equipment.
Who is VR therapy suitable for?
Virtual reality therapy may help patients with phantom limb pain in the early postoperative period, especially when it is impossible to carry out mirror therapy.
At the Institute of Traumatology and Orthopedics, the target group for VR was:
- patients with amputation and phantom pain syndrome in the early postoperative period;
- patients who had traumatic damage to both lower limbs and could not move with the help of additional means of support;
- patients who had a neuropathic pain syndrome that is difficult to neutralize with painkillers;
- patients who had chronic pain syndrome in the remote postoperative period.
VR therapy is already part of the treatment protocol for phantom pain, and therefore, this therapy is an evidence-based method that can be used. However, it is necessary to implement VR therapy with an individual approach determined by a physical and rehabilitative medicine doctor.
At the same time, VR therapy is contraindicated for patients with mental disorders and those who have not recovered from anesthesia or have a confused consciousness.
VR can be used to rehabilitate those patients who take opioids — but only with the permission of the operating physician. In addition to VR therapy, the patient can receive psychotherapy sessions and perform therapeutic exercises for intact body segments.
Methods of VR therapy
VR technologies are used in various spheres of life — currently, there are both educational and game programs for working with a VR helmet. In particular, there are special programs designed for rehabilitation, but here, only a VR helmet is not enough — for their use, a separate room must be set up. This is a high level of technology involving equipment with biofeedback, sensor platforms, and VR programs that accelerate adaptation to bionic prostheses. To equip such a facility, significant funding is required.
Currently, the institute only has a VR helmet and applications that can be downloaded from the application library. Programs chosen as an application for rehabilitation help immerse the patient in the virtual space and shift the focus of attention from pain to virtual objects.
According to Barabash, domestic engineers in Ukraine are already developing a program with biological feedback. Thanks to an electromagnetic system using sensors for leg muscles, the program generates an image of a phantom limb, a lost limb that a person continues to feel, and the patient can move it in virtual space with the help of the muscles of the stump.
Такий програмно-апаратний комплекс створив науковець-інженер Андрій Поліщук. З його допомогою користувач може бачити себе, втрачену кінцівку та її рухи на моніторі, як у дзеркалі. Також віртуальну кінцівку можна спостерігати через гарнітуру віртуальної/доповненої реальності на смартфоні.
Scientist-engineer Andrii Polishchuk created such a software and hardware complex. With its help, the user can see themself, the lost limb, and its movements on the monitor, as if in a mirror. A virtual limb can also be viewed through a smartphone's virtual and augmented reality headset.
Patients who have immobilized their damaged lower limbs above the amputation site — this is necessary for fractures and soft tissues to unite— can get a virtual reality experience directed not at the motor component but the psychotherapeutic component. For example, VR therapy with biofeedback requires access to the skin, free from immobilization, for applying electrodes (sensors) to active muscles. Therefore, it is not used in the early postoperative period in the hospital but in the subsequent stages of therapeutic treatment in rehabilitation centers and sanatoriums.
What can go wrong?
An unstable internet connection turned out to be one of the problems of using VR. The first patients were in the surgical department of inpatient treatment and used the mobile internet to launch the program. Due to its interruptions, the program sometimes stopped or did not launch at all — because of this, the team spent a lot of time on configuring settings.
Only a specialist in the field of rehabilitation can conduct sessions. A person who does not have a medical diploma cannot be involved in the systematic implementation of this procedure. That is, it is impossible to involve volunteers in rehabilitation.
Barabash lists some disadvantages of using VR, among which is a limited number of specialized programs that could be used in rehabilitation. Moreover, most programs are paid or have a free trial period, which is limited in time. Some programs that claimed to be rehabilitative did not meet the criteria after inspection and testing. They could either not work at all or did not have further development and technical support — most often, these are programs for occupational therapy. The use of VR should be limited in time — the procedure should last about 20 minutes, and the physical therapist should not leave the patient alone with the equipment.
Does it really work?
Doctors have focused particular attention on the ability of VR to reduce pain, thanks to the patient's strong emotional experience of the realism of the virtual space.
Thanks to VR, doctors reportedly achieved a decrease in the intensity of pain and an improvement in the patient's psycho-emotional state In the early postoperative period. After that, the patient is ready for communication and cooperation to set rehabilitation goals for their further recovery.
360° VR programs also have an analgesic effect than can allow patients to travel through the virtual world: visit Rio de Janeiro, take a walk on the beaches of California, dive into the Red Sea with scuba diving, ski down a mountain at an alpine resort, jump with a parachute, and more. Patients say that after the program, it is as if they went on vacation abroad. The doctors also decided to test a VR tour of Kyiv filmed specifically for military personnel. One of the patients was delighted because, as he says, for all nine years in the army, he saw nothing but military service.
Barabash recalls a case when a soldier, after amputation at the level of the lower leg due to a mine-explosive injury, voluntarily took the opioid analgesic Nalbuphine to reduce his phantom pain. Uncontrolled use of this drug can lead to addiction and irreversible changes. However, after several sessions of VR therapy, mirror gymnastics, and the use of a percussion massager, the patient began to consciously reduce the use of analgesics.
Doctors say that VR is an optional tool, but it works well at improving patients' psycho-emotional state. Over time, it will likely be used more and more widely in rehabilitating wounded soldiers.
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