Project idea: VRforLOWBACKPAIN

L.Beijer(1,3), Maikel Trommelen(2), Bart Kral(2), Niki Stolwijk(3), Wienand Remkes(3),Vincent Bastiaans(3), Marjo
Maas(3), Sebastiaan van Pinxteren(4), Eric Jutten(5), Marijn Huijbregts(6)

(1)Department of Innovation, Sint Maartenskliniek, Nijmegen, the Netherlands,
(2) RealHealth Institute, Berg en Dal, the
Netherlands,
(3)HAN University of Applied Sciences, Nijmegen, the Netherlands,
(4)BKC Media, Nijmegen, the Netherlands,
(5)The Simulation Crew, Nijmegen, the Netherlands,
(6)SpraakLab, Nijmegen, the Netherlands

Introduction
Globally, low back pain (LBP) is a common symptom across all age groups. Years lived with disability caused by LBP increased by 54% between 1990 and 2015, due to a growing and ageing population1,2.
Annually, 2000 patients with LBP are referred to the Sint Maartenskliniek near Nijmegen, a hospital specialized in care for posture and movement. About 65% of these patients is referred back to home or primary care since no indication for specialized medical care is established. Only 5% is subjected to surgery, 10 % receives invasive pain treatment and about 20% is referred to the pain management program provided by RealHealthNL and.
The RealHealth program entails an evidence-based combined physical and psychological program (CPP) in a two-weeks intensive residential setting for patients with invalidating LBP 3,4 This is built on the belief that LBP is a complex condition with multiple contributors to both the pain and associated disability, including psychological factors, social factors, biophysical factors, comorbidities, and painprocessing mechanisms.
The multidisciplinary expert team of the RealHealth program believes that the majority of LBP patients who are referred back from the SMK to primary care, would benefit from a shift towards self management rather than persistent dependence on healthcare. For this reason, in collaboration with BKC Media Inc., HAN University of Applied Sciences and primary care physiotherapists, they developed
the interactive Backing App, which supports health professionals in asynchronic blended coaching of patients towards self management of daily functioning with LBP. A personalized approach is warranted
by a cyclical procedure and motivational interviewing embedded in the app-design. Unfortunately, upscaling of this blended coaching of patients currently depends heavily on availability of health
professionals.

Project idea
The proposed VR-project aims for upscaled, improved blended personalized coaching and patients’ therapy adherence by the development of 1) a VR coach for a cognitive behavioral approach for low
back pain, built on motivational interviewing combined with VR technology5
, AI and Speech and Language Technology (SLT)6 , 2) an educational VR-tool for health professionals to train key therapeutical skills (e.g. motivational interviewing) underpinning the cognitive behavioral approach employed by RealHealth.

Methods
1) A VR coach will be developed by participatory action research, built on an iterative process between developers (VR, AI and SLT), LBP professionals and LBP patients
2) An educational VR tool will be developed by participatory action research, built on an iterative process between developers (VR, AI and SLT), health professionals and educational professionals ResultsFeasibility of the VR coach will be evaluated by outcome measures for both patients’ and professionals’ experience.
Feasibility for the educational VR tool will be evaluated by outcome measures for educational achievements.

References
[1] Buchbinder R et al. (2018). Low Back Pain. A call for action. The Lancet. Published online March
21, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30488-4
[2] Hartvigsen J et al. (2018). What low back pain is and why we need to pay attention. The Lancet.
Published online March 21, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30480-X
[3] van Hooff ML et al. (2012). A short, intensive cognitive behavioral pain management program
reduces health-care use in patients with chronic low back pain: two-year follow-up results of a
prospective cohort. Eur Spine J, 21(7): 1257-64.
[4] Groot D et al. (2019). Long-term results of an intensive cognitive behavioral pain management
program for patients with chronic low back pain: a concise report of an extended cohort
with a minimum of 5-year follow-up. European Spine Journal, 28:1579-1585
[5] Alemanno F et al. (2019). Efficacy of virtual reality to reduce chronic low back pain: Proof-ofconcept of a non-pharmacological approach on pain, quality of life, neuropsychological and functional
outcome. PLoS One, 14(5): e0216858. doi: 10.1371/journal.pone.0216858.
[6] Postma M et al. (2019). Hoe taal- en spraaktechnologie de zorg voor patiënten met lage rugpijn
verbetert. DIXIT tijdschrift voor taal- en spraaktechnologie, themanummer Gezondheid en Zorg: 5-7.