We used the pain thresholds test because steady supra-threshold test stimuli could result in a floor effect due to its relatively low initial painfulness. Pain perception was measured using pressure pain thresholds (PPT) and heat pain thresholds (HPT). Thus, the present study aimed to investigate which method was more effective for pain management: VR combined with exercise imagery or VR distraction. In the present study, we hypothesized that VR combined with exercise imagery would have a greater effect on pain than VR distraction, regardless of exercise imagery ability. The video clip except for exercise is eligible for VR distraction, because exercise observation activates the same neural regions as those involved in the actual execution of the observed action. VR combined with exercise imagery could potentially have a superior effect on pain management compared with VR distraction however, this has yet to be demonstrated. Although the precise mechanisms of exercise imagery intervention for pain management are still unclear, it is believed to occur via both pain distraction and punctually activated brain regions involved in the pain matrix network. Participants imagine the same movement as seen just prior to the exercise imagery or while watching a video clip of the movements. Clinically, exercise imagery has been shown to attenuate pain in patients following total knee arthroplasty and in those with shoulder impingement syndrome, chronic shoulder pain, and nonspecific lower back pain. Based on this evidence, several studies have promoted exercise imagery as a therapeutic tool. The brain regions that are active during exercise imagery highly overlap with those responsible for actual movement, but exercise imagery results in low levels of activation. Although VR combined with a cognitive task demonstrated no superiority for pain management, the effects of other combinations on pain have not yet been investigated.Įxercise imagery intervention, which has been recently proposed as a treatment for pain, is the mental representation of an action without any concomitant body movement. reported that there was no significant difference in pain reduction between high and low cognitive load environment interventions. suggested that there is no significant difference in the effects on pain between VR combined with enhancement of pain control and VR distraction. It was previously reported that the passive behavior of watching video clips had effects on pain than interactive behavior, although both were effective. However, few experimental studies have investigated the different VR methodologies for pain management. Watching video clips in VR is often combined with enhancement of pain control, cognitive load, hypnosis, and exercise imagery. The VR methodologies commonly used for pain management include playing video games and watching video clips. The effects of VR on pain are influenced by the sense of presence in the VR environment and various psychological factors. VR is effective at reducing pain independent of the participant's imagery ability however, imagery without VR is effective with only participants with high imagery abilities. It has been reported that the primary mechanism through which pain perception is attenuated is via distraction, although other nondistraction mechanisms have been proposed. The effects of VR on pain have been revealed through a variety of mechanical and thermal modalities. According to several reviews conducted in the field of pain management, many studies have evaluated VR as a means to attenuate pain perception. VR presents the participant with a 360° illusion of being completely surrounded by a virtual environment via a head-mounted display that tracks the motion of the participant's head. Virtual Reality (VR) has been used in various medical applications during the past two decades.
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