Virtual Reality Has Long-Term Benefits for Patients with Back Pain

By Pat Anson, PNN Editor

A novel treatment that combines virtual reality with cognitive behavioral therapy significantly reduced pain levels and other symptoms in patients with chronic back or neck pain, according to results of a new study presented at the annual meeting of the Congress of Neurological Surgeons.

Unlike other therapies using virtual reality (VR) – which temporarily distract people from their pain – patients in this study had long term reductions in their pain, anxiety and depression. This suggests that combining VR with cognitive behavioral therapy (CBT) induces neuroplasticity, a “rewiring” of the brain and nervous system that reduces the impact of physical and emotional trauma.    

“What we found is it actually creates new neural pathways to form, what's called neuroplastic reprogramming or neuroplastic change, and that actually creates a more resilient patient,” said co-author Gerry Stanley, MD, Chief Medical Officer of Harvard MedTech, a medical device company that offers VR therapy.

“The patient who may be thinking about their pain 22 hours a day, and their pain (level) has always been eight or nine, now thinks about their pain one or two hours a day and their pain (level) is a three or four, because the brain is no longer fixating on it. So it allows for, I don't want to say permanent distraction, it’s really neuroplastic reprogramming.”

Stanley and his colleagues enrolled 145 patients with non-operative degenerative neck or back pain in Harvard MedTech’s Vx Therapy program, which included daily virtual reality sessions for 14 weeks and weekly telephone calls with a therapist trained in CBT.  

Unlike other VR therapies, which encourage physical activity, participants sat stationary in a chair while watching and listening to prerecorded programs with a headset and earphones. The VR programs come in four categories that emphasize education, meditation, distraction or entertainment, depending on the patient’s needs and goals.

HARVARD MEDTECH IMAGE

After 14 weeks, results showed that Vx Therapy reduced pain and anxiety during sessions by an average of 33% and 46%, respectively. The duration of pain relief also increased over time, from 2.5 hours in the first weeks of treatment to 4.5 hours in the final weeks.

The study has not been peer-reviewed or published yet, but Stanley says the findings mirror what his company has learned after treating about 4,000 patients. The benefits of Vx Therapy continue long after the treatment ends, with many patients still reporting improvement after two years.  

“They're often reporting the same level of resiliency. I think a lot of it is they start getting into better sleep patterns,” he told PNN.  “And they really get good at meditation. Most people fail in meditation because of distractions. But when they're doing it in the virtual reality, they get very good at it. So they really develop some nice, I'm going to say muscle memory, even though I know it's cognitive. But they do develop a little bit of muscle memory around the meditation.”

Because Vx Therapy is done remotely, it’s available to any patient regardless of location, as long as they have a prescription. Some worker compensation insurers cover the treatment.   

Previous studies have also suggested that virtual reality therapy has long-term benefits for people with chronic back pain. A 2022 study showed that people with moderate lower back pain reported improvements in pain, function, mood and sleep six months after treatment ended.  

Low Dose Opioids Ineffective for Acute Lower Back and Neck Pain

By Pat Anson, PNN Editor

A low dose of prescription opioids works no better than a placebo in relieving acute lower back or neck pain, according to a new study in Australia.  

The blinded, placebo-controlled trial was relatively small – just 345 participants – but was unusual because patients were followed for up to a year, a rarity for a clinical trial that studies pain.  Half the participants received a combination of oxycodone and naloxone for six weeks at a low daily dose of 20mg or about 30 morphine milligram equivalents (MME). The other half received placebo tablets that looked similar to oxycodone.   

It's important to note that the study only included people with mild or moderate pain of less than 12 weeks duration -- not the severe, long-term back and neck pain caused by degenerative disc disease, spinal injuries, arthritis, and other chronic conditions. Participants were excluded if they had that type of pain.  

The study findings, published in The Lancet, showed no significant difference in pain severity between the opioid and placebo groups. On a scale of zero to 10, the average pain score was 2.8 in the opioid group after six weeks, compared to 2.3 in the placebo group. After a year, the average pain score was 2.4 in the opioid group, versus 1.8 in the placebo group. 

Pain Severity Over 52 Weeks

THE LANCET

Researchers say patients who received opioids had a slightly higher risk of opioid misuse at the end of the study, a finding based on a mental health survey that screens patients for drug related behavior.

“Our findings show that even judicious, short-term use of an opioid conferred no benefits in pain reduction and led to a small increase in pain at the medium-term and long-term compared with placebo. The opioid group had worse quality-of-life mental health scores than the placebo group,” researchers reported. “Although no difference was found in overall time to recovery, more people in the placebo group recovered in the first 14 days compared with those in the opioid group.”

Most medical guidelines recommend exercise and over-the-counter pain relievers for short-term back or neck pain, with opioids only used as a last resort. The authors of the Lancet study say even that limited use is inappropriate.

“Opioids should not be recommended for acute back and neck pain, full stop,” said lead investigator Christine Lin, PhD, a professor in the School of Public Health at University of Sydney. “Not even when other drug treatments are not able to be prescribed or have not been effective for a patient.”

The Lin study is somewhat similar to the 2018 Krebs study, which found that low doses of oxycodone were no more effective than over-the-counter pain relievers in treating chronic back and osteoarthritis pain. Critics say the Krebs study was biased from the start and this one is no better.

“They generalise enormously,” Michael Vagg, MD, Dean of Pain Medicine at the Australian and New Zealand College of Anaesthetists, told the Medical Republic. “They studied oxycodone and naloxone in a modified-release formulation. But modified-use opioids have never been on-label for use in acute pain and they are not recommended as such… to which I and everyone in pain medicine would say ‘We figured that out ages ago’. That’s not how you use opioids in acute pain.

“In layman’s terms, they’ve done a study where they tried to look at doing push-ups to help with back pain and then they’ve decided that all exercise is no good for the back pain.”

Lower back pain is the world’s leading cause of disability and neck pain is the fourth largest, but there is surprisingly little evidence about the best ways to treat them.

A previous study published in The Lancet by an international team of researchers found that lower back pain was often treated with bad advice, inappropriate tests, risky surgeries and painkillers. The authors said there was limited evidence to support the use of opioids for low back pain, and epidural steroid injections and acetaminophen (paracetamol) were not recommended at all. Most patients responded better to physical and psychological therapies that kept them active.

Guidelines Urge More Caution in Use of Invasive Neck Procedures

By Pat Anson, PNN Editor

Invasive procedures such as steroid injections, nerve blocks and radiofrequency ablation should be used more cautiously when treating chronic neck pain, according to new guidelines adopted by the American Academy of Pain Medicine and American Society of Regional Anesthesia and Pain Medicine.

The two medical societies formed a joint guidelines committee in 2020 to look into cervical spine joint procedures, which are increasingly used despite questions about their effectiveness and safety. The use of radiofrequency ablation -- heat from an electric current used to burn painful nerve endings — has increased by 112% in the U.S. over the past decade.

Spine pain in the neck or lower back is the leading cause of disability worldwide, with nearly half of adults likely to be affected at some point in their lives. The cervical facet joints, which allow the neck and back to tilt forwards, backwards and to rotate, are the primary source of pain in about 40% of patients with chronic neck pain and over half of those with neck pain after whiplash injury.

"It is precisely because neck pain and cervical spine procedures are so common, and there is so little high-quality evidence to guide care, that consensus guidelines are needed,” says lead author Steven Cohen, MD, a professor of anesthesiology at Johns Hopkins Hospital and co-chair of the guidelines committee.

The new guidelines, published online in the journal Regional Anesthesia & Pain Medicine, are based on over 400 publications and clinical studies of cervical spine procedures. Reviewers also looked at clinical signs and imaging used to select patients for particular procedures; the diagnostic and prognostic value of procedures; and several aspects of radiofrequency ablation (RFA), including how to reduce the risk of complications from the procedure and whether it should be repeated.

Because acute neck pain often resolves by itself, the guidelines recommend 6 weeks of conservative management, such as non-opioid painkillers and physical therapy, before opting for RFA or nerve blocks.

The reviewers found that RFA may be helpful for easing chronic neck pain, but only in patients whose pain corresponds to the joints being treated; those whose symptoms don’t emanate from a nerve root; and those who obtain meaningful pain relief from diagnostic nerve blocks, which are typically performed before RFA. 

Many insurance carriers require two nerve blocks, but the evidence indicates that doubling up will result in a significant number of unnecessary procedures and higher costs. Reviewers say the evidence for performing only a single block is much stronger for the neck than for the lower back.

The guidelines also recommend against stringent patient selection criteria, such as requiring nearly total pain relief from diagnostic blocks, because it might exclude patients who might benefit from radiofrequency ablation. None of the clinical studies that were reviewed support using pain relief thresholds above 50 percent.

Physicians should warn patients about the common side effects of RFA, such as tingling and burning sensations, numbness, dizziness, and loss of balance and coordination, which can last from a few days to a few weeks after the procedure. Patients also need to be told that RFA won’t cure them, and that pain relief typically lasts between 6 and 14 months. 

While most patients who have the procedure repeated will get pain relief, the benefits may wane over several years. RFA shouldn’t be repeated more than twice a year, the guidelines recommend.

Other key recommendations include:

• Use only soluble, short-acting steroids when injecting into the upper neck joints

• Use fluoroscopy imaging before spinal injections to avoid inadvertent needle placement

• Use smaller needles and electrodes than those used for the lower back

• Use nerve and muscle stimulation to improve effectiveness and reduce the risk of complications

• Take steps to minimize interference with implanted electrical devices such as pacemakers

“Clinical trials evaluating cervical facet blocks and RFA are characterized by widely disparate outcomes, and there is enormous variation in selecting patients and performing procedures. These multi-society guidelines have been developed to serve as a roadmap to improve outcomes, enhance safety, and minimize unnecessary tests and procedures,” the reviewers concluded.

Bad Posture During Computer Use Leads to Back Pain

By Pat Anson, PNN Editor

It's no secret that staring into a computer screen for too long can lead to a stiff neck or back pain. Many of us instinctively lean forward to get a closer look at laptop or tablet, without being fully aware of how bad our posture is or what it’s doing to our spines.

Researchers at San Francisco State University say this “head-forward position” compresses the neck and can lead to fatigue, headaches, poor concentration and muscle tension. And it takes less than a minute for the symptoms to start.

"When your posture is tall and erect, the muscles of your back can easily support the weight of your head and neck -- as much as 12 pounds," says Erik Peper, PhD, a Professor of Holistic Health at San Francisco State University.

"But when your head juts forward at a 45-degree angle, your neck acts like a fulcrum, like a long lever lifting a heavy object. Now the muscle weight of your head and neck is the equivalent of about 45 pounds. It is not surprising people get stiff necks and shoulder and back pain."

Peper and his colleagues tested the effects of head and neck position in a recent study published in the journal Biofeedback.

SAN FRANCISCO STATE UNIVERSITY

First, they asked 87 students to sit upright with their heads properly aligned on their necks and asked them to turn their heads. Then the students were asked to "scrunch" their necks and jut their heads forward. Ninety-two percent reported being able to turn their heads much farther when they were not scrunching.

In a second test, 125 students scrunched their necks for 30 seconds. Afterwards, 98 percent reported some level of pain in their head, neck or eyes.

“Most participants were totally surprised that 30 seconds of neck scrunching would rapidly increase symptoms and induce discomfort. It provided motivation to identify situations that evoked neck scrunching and avoid those situations or change the ergonomics,” Peper said.  

What can you do to prevent yourself from scrunching? Two easy solutions would be to increase the font size on your computer screen or get a pair of computer reading glasses. You can also make sure your computer screen is at eye level, which will reduce the temptation to lean forward.

If you suffer from headaches or neck and backaches from computer work, check your posture and make sure you are sitting upright, with your head aligned on top of your neck.

"You can do something about this poor posture very quickly," says Peper, who recommends people test themselves by scrunching forward and try rotating their head. Until they do that, many have no idea how bad posture contributes to back and neck pain.

"You can exaggerate the position and experience the symptoms. Then when you find yourself doing it, you can become aware and stop," he said.

A recent study by researchers at the University of Nevada Las Vegas found that 60 percent of students have persistent pain in their neck and shoulders -- often caused by slouching or bending to watch their iPads or tablets. Women were twice as likely as men to experience neck and shoulder pain during tablet use.

Lyrica and Neurontin Ineffective for Low Back Pain

By Pat Anson, Editor

Lyrica, Neurontin and other anti-convulsant drugs are ineffective for treating low back pain and may even be harmful to patients, according to a new study published in the Canadian Medical Association Journal.

Prescriptions for anti-convulsant drugs have soared in recent years, as doctors seek “safer” alternatives to opioid pain medication.  Lyrica (pregabalin) and Neurontin (gabapentin) belong to a class of anti-convulsant nerve medications known as gabapentinoids. They are primarily used for treating nerve pain and fibromyalgia, but are increasingly being prescribed off-label to treat lower back and neck pain.

Australian researchers reviewed 9 placebo-controlled randomized trials and found high quality evidence that gabapentinoids did not reduce back pain or disability and often had side effects such as drowsiness, dizziness and nausea.

“The take-home message is that anti-convulsants are not effective and can lead to adverse effects in people with low back pain and radiating leg pain (eg, sciatica), so they should not be recommended to this patient population,” lead author Oliver Enke, MD, a researcher at the University of Sydney Medical School, told Helio Family Medicine.

Low back pain is the world’s leading cause of disability. Guidelines for treating low back pain usually recommend physical therapy, exercise and non-opioid pain relievers rather than stronger analgesics such as opioids or anti-convulsants.

A 2017 study published in PLOS Medicine also warned that pregabalin and gabapentin were ineffective for low back pain and have a “significant risk of adverse effects.” 

PNN readers often complain about side effects from Lyrica and Neurontin.

“I have used both medicines and neither help with lower back pain for me,” said Sheri. “I will say the mental confusion and memory loss on Lyrica is very real, but it takes a slight edge of pain away in my body as a whole from the fibromyalgia.”

“I can vouch that Lyrica does not help with back pain,” said Debra. “It helped with the nerve pain but I thought I was literally losing my mind. I couldn't remember simple words or synonyms for words.”

“I've been taking gabapentin for almost six months; it has helped my peripheral neuropathy, but I still suffer every day from arthritis in every joint of my body, including my lower back,” another reader wrote.

Lyrica and Neurontin are both made by Pfizer and are two of the company’s top selling drugs, generating billions of dollars in sales annually. Lyrica is approved by the FDA to treat diabetic nerve pain, fibromyalgia, post-herpetic neuralgia caused by shingles, and spinal cord injuries.

Neurontin is approved by the FDA to treat epilepsy and neuropathic pain caused by shingles, but is also widely prescribed off-label to treat depression, ADHD, migraine, fibromyalgia and bipolar disorder. According to one estimate, over 90% of Neurontin sales are for off-label uses. About 68 million prescriptions were written for gabapentin in the U.S. last year, compared to 44 million in in 2013.

There have been increasing reports of gabapentinoids being abused by drug addicts, who have learned they can use the medications to heighten the high from heroin, marijuana, cocaine and other substances. Gabapentin is not currently scheduled as a controlled substance by the DEA, while pregabalin is classified as a Schedule V controlled substance, meaning it has a low potential for addiction and abuse.  

Women Most at Risk for ‘iPad Neck’

By Pat Anson, Editor

If you have neck and shoulder pain and regularly use an iPad or tablet device, there’s a good chance the two are connected. Especially if you’re a young woman.

A recent study of over 400 university students, alumni and staff found that 60 percent have persistent pain in the neck and upper shoulders – often caused by slouching or bending to watch their iPads or tablet computers. Over two-thirds (68%) said they experienced symptoms while using their tablets.

"Such high prevalence of neck and shoulder symptoms, especially among the younger populations, presents a substantial burden to society," said lead author Szu-Ping Lee, PhD, a physical therapy professor at the University of Nevada Las Vegas. His study was published last week in the Journal of Physical Therapy Science.

The top risk factor for “iPad neck” was surprising. Women were twice as likely as men to experience neck and shoulder pain during tablet use.

“Our study revealed that females and individuals with current musculoskeletal symptoms were more likely to be at risk for neck and shoulder symptoms,” Lee wrote.

“Certain postures during use were also identified as important risk factors, specifically sitting without back support and with the tablet in lap were significantly associated with symptoms during use.”

UNLV IMAGE

The most frequently reported symptoms were stiffness, soreness or aching pain in the neck, upper back, shoulder, arms, hands or head. Most of those surveyed (55%) reported moderate discomfort, but 10 percent said their symptoms were severe and 15 percent said it affected their sleep. Less than half (46%) said they stopped using the devices when they felt discomfort.

Lee says the findings concern him, especially given the growing popularity of tablets, e-book readers, and other devices for personal, school and business purposes. At PNN, we know that about 10 percent of our readers use iPads or tablets.

Almost half of the tablet users surveyed use their devices for three or more hours each day. Flexing the neck forward for long periods of time puts pressure on your spine, causing neck and shoulder pain. Sedentary behavior and bad posture while reading are also contributing factors.

Researchers say many students sit cross-legged on the floor when studying on their tablets. Interestingly, women were far more likely (77%) to use their tablets while sitting on the floor than men (23%).

Lee offered these tips to avoid iPad neck:

• Sit in a chair with back support.
• Use a posture reminder device -- small, wearable devices that beep to alert you when you're slouching.
• Place your iPad on a stand (rather than a flat surface) and attach a keyboard to achieve a more upright posture.
• Exercise to strengthen your neck and shoulder muscles.

"Using these electronic devices is becoming a part of our modern lives," Lee said. "In order to reduce the risk of developing long-term neck and shoulder problems, we need to think about how technology like tablet computer affects human ergonomics and posture."

Why Smoking is a Pain in the Neck

By Pat Anson, Editor

Need another reason to stop smoking? What if you knew it was causing that pain in your neck?

That’s the conclusion of a new study being presented this week at the annual meeting of the Association of Academic Physiatrists. In a study of 182 patients who were given CT scans,  researchers found that smokers were more likely to have cervical degenerative disc disease.

“This is another example of the detrimental effects of smoking. Tobacco abuse is associated with a variety of diseases and death, and there are lifestyle factors associated with chronic neck pain,” says lead investigator Mitchel Leavitt, MD, resident physician at Emory University’s Department of Physical Medicine and Rehabilitation.

“Pain and spine clinics are filled with patients who suffer chronic neck and back pain, and this study provides the physician with more ammunition to use when educating them about their need to quit smoking.”

The cervical spine is located in the neck and is made up of bones called vertebrae. Between these bones are cervical discs that absorb shock to the spine. Through the normal aging process, these discs slowly degenerate, which means they become dehydrated and shrink.

In some cases, the drying of the disc may cause cracks and tears, through which some of the jelly-like central portion of the disc may spill out and irritate local nerves. That can result in pain in the shoulders, arms, hands and fingers.

It isn’t only wear and tear that can damage these discs. Some unhealthy habits, such as smoking, can add to cervical disc degeneration.

“Smoking is not healthy for a person’s intervertebral discs given the risk of developing microvascular disease – a disease of the small blood vessels – due to nicotine abuse,” says Leavitt. “Intervertebral discs receive their nourishment from the microvasculature that line the endplates on either side of each disc; when these blood vessels are damaged, the discs do not receive nourishment and this may speed up the degenerative process.”

While smoking has been associated with degeneration in the lumbar spine, this was one of the first studies to make the association with the cervical spine.  The patients evaluated by Leavitt and his colleagues were mostly female (57 percent), and about a third were smokers. A radiologist and a physiatrist – a physician who specializes in physical medicine and rehabilitation – reviewed their CT scans for signs of cervical degenerative disc disease. The amount of damage was rated on a scale of zero to 15.

Current smokers were found to have more cervical degenerative disc disease and were given a "damage score" that was about one point higher, on average. Not surprisingly, researchers also found that aging was associated with worsening cervical degenerative disc disease, but diabetes, hypertension, high cholesterol and high BMI were not.

Leavitt believes more research is needed on other lifestyle factors, such as high fat diets, alcohol use and obesity to see how they relate to chronic back and neck pain.

“Virtually everyone knows that moderate exercise somewhere around four to five times per week is beneficial, plus other lifestyle factors like avoidance of smoking and a proper diet are equally important. However, these topics are usually geared towards heart health, lowering blood pressure, managing diabetes, or controlling other medical conditions, and not specific to the spine,” Leavitt said. “It is one thing to live to the age of 95, and it is another to live to 95 while retaining one's mobility and being free of pain. Lifestyle medicine will likely play a large role in the future of healthcare, and having plenty of data to support lifestyle management is critical.”

Previous studies have found that smoking increases your chances of having several types of chronic pain conditions.

A study of over 6,000 Kentucky women found that those who smoked had a greater chance of having fibromyalgia, sciatica, chronic neck pain, chronic back pain and joint pain than non-smokers. Women in the study who smoked daily more than doubled their odds of having chronic pain.

A large study in Norway found that smokers and former smokers were more sensitive to pain than non-smokers. Smokers had the lowest tolerance to pain, while men and women who had never smoked had the highest pain tolerance.

In a recent study published in JAMA Neurology, Swedish researchers reported that continuing to smoke after a diagnosis of multiple sclerosis significantly accelerates progression of the disease.

A Pained Life: When Habits Hurt

By Carol Levy, Columnist

I am a creature of habits, some of them bad. Not the “I can't stop eating chocolate”  kind of bad,  but bad in that I don’t always follow my own advice.

For example, I have a bad neck and as a result lifting something heavy often leaves me with worse neck pain. Every time I lift something heavy, I hesitate and think, “You need to put on the neck brace first. You really need to do that.”

Then I get annoyed and tell myself putting on the neck brace would be too much trouble.

The fact that I leave the brace out on the dresser and it is easily accessible makes no difference. My neck is held together with clamps and screws. How can a neck held together with a bunch of metal not be able to pick up anything, no matter what it is?

The fallacy of that thought is proven each time I move something heavy. But I don't heed myself and I pick it up anyway. Bad habit #1.

Then comes bad habit #2. The neck brace is supposed to help hold up my neck. But even when I wear it, I fight it. A good example is what happens when I take out the trash

The containers are a little ways away from my apartment. I do not want to have to make a number of trips (there is always a minimum of 2 large bags and more often 3). At least one is filled with cat box litter and is always heavy. The extra weight turns me into a turtle. I automatically scrunch up my shoulders and lower my neck as I lift the bags, feeling that somehow makes me stronger.

It doesn't, of course. And once I am finished my neck hurts horribly and the pain exhausts me.

So why don't I learn my lesson? Why do I fight doing a really simple thing that will help me?

One reason is denial and the other is looking at the short term rather than the long. I have to make the decision to accept what I can and cannot do -- sometimes just out of sheer stubbornness -- if I want help myself and reduce the pain when and where I can.

It is a lesson so hard to learn because it comes out of an acceptance of our limitations. At the end of the day, it is not the physical things that I do or refuse to do that cause the pain. It is my refusal to accept. Then I’m not a turtle but an ostrich, keeping my head in the sand.

I wish they had a neck brace for that.

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.” 

Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.