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Visual Field Immersion: The
Holodeck Comes Alive
Professor Maureen J. Simmonds PT,PhD
Director, School of Physical andOccupational Therapy,
Research Director, Pain, Mind andMovement Research Lab
Associate Dean (Rehabilitation),
Faculty of Medicine,
McGill University, Montreal, Canada
Satellite Conference IASP
Pain, Mind and Movement II
August 13th -15th, 2008
Dublin, [email protected]
www.painandmovement.org.uk
Introduction
! The problem –
" Pain
" Impact of Pain - Movement difficulties
! Or the motor expression of pain?
! Novel rehabilitation approaches
! Virtual reality
" Understand mechanisms
" Means of Intervention
Introduction
! The problem –" Pain
" Impact of Pain - Movement difficulties
! Or the motor expression of pain?
! Assessment and outcome measures (activity based)
" Expanded conceptual framework of what is important and to whom
! Exercise is good for the mind and the body
! How do you get people to exercise?
! Just do it!
! Virtual Exercise?
The Measurement Enigma
Examine movements & function but …..
Timed Sit-Stand & Distance Walk
Assessment and Outcome Measures
Expanded Conceptual Framework
! 50 foot fast walk
! 5 minute distance walk
! Loaded forward reach
! Sit-to-stand (5 reps)
! Timed repeated
flexion (5 reps)
! 360o rollover
!"#$%&'(&$)*+,-'.-/#$0,1*2&/,*%#3,$*.-4&5%#$0,*/.6,7*89#:3*.-*-,#0;<
=&//.$75*,%*#:>*=?&$,*@AAB
Physical Performance Tests (General:
including Spine, HIV & Cancers) Simmonds et al,
Spine, 1998; J Pain and Symp Manag, 2003;Clin J Pain, 2005)
! Timed tests
" Putting on a sock
" Tying a belt
" Reach behind neck x3
" Placing coins in a cup
" Sit-to-stand x2
" Reach up x3
" Picking up a pen
" 50-foot walk-preferred speed
" 50-foot walk- fastest speed
" Repeated Flexion
! Distance tests
" Functional reach
" Loaded reach
" 5 & 6 minute walk
Discriminative and Construct Validity of
Performance Tasks (Simmonds et al, 1999; Lee et al, 2000
&2002; Novy et al, 2002; Lee et al, 2003; Simmonds et al, 2003)
! Discriminant function analysis
! Correct classification
" 82.7% LBP 85.4% controls
" Overall correct classification 84.3%
" Predict survival (lymphoma, aged)
! Performance differences based on
" Gender,
" Pain intensity
" Pain distribution
" Disease
.0001146.941,1826 minute Walk
.000142.591,18250-foot Fast Walk
.0001129.181,182Sit-to-Stand
.000162.771,182Forward Reach
.000194.971,182Reach up
.0235.281,182Coin
.000123.501,182Belt Tie
.000118.311,182Sock
P ValueF valuedfTask
Control (n=105)subjects outperform those with cancer (n=108)
by a factor of 2 or 3 and outperform patients with HIV/AIDS
(n=100) by up to a factor of 4
Biomechanical Task Analysis:
Loaded Forward Reach (n=60)
2
2.5
3
3.5
4
4.5
5
Control LBP Fusion
Time
(sec)
*
Groups
0
10
20
30
40
50
60
Control LBP Fusion
Dis
pla
cem
en
t
(cm
)
Lateral
Fore/aft
Sit To StandQuantity of Muscle Activity
0
5
10
15
20
25
30
35
40
45
50
LES LGM LMH LRF RES RGM RMH RRF
Muscle
No
rma
lize
d E
MG
(m
V/s
)
NorMat
LBP
Loaded Reach TestQuantity of Muscle Activity
50
100
150
200
250
300
350
400
450
LES RES LGM RGM LMH RMH LRF RRF
Muscle
No
rma
lize
d E
MG
(u
V)
Control
LBP
Fusion
Perceived Effort and Walk DistanceMoving slowly is relatively energy inefficient(Lee & Simmonds 2002)
0
1
2
3
4
5
6
7
8
9
10
RPE
AIDS
HIV
LBP
NORMAL
0
500
1000
1500
2000
2500
Distance Wlk
AIDS
HIV
LBP
NORMAL
Ft.
RP
E
0-1
0
* p<.05
**
*
42 50 44 48N
1515 1515 1515N =
Repeated Sit-to-Stand
n= 30 LPB & age and gender matched controls
GROUP
back painnormal
95%
CI
40
30
20
10
0
Speed Condition
SLOW
PREFERRED
FASTEST
Slower at all speeds?
Expected vs.actual PainPreliminary studysit-to-stand task across three speed conditions(slow,preferred, fastest)
actual pain intensit
expected pain intens
actual pain intensit
expected pain intens
actual pain intensit
expected pain intens
Mea
n
6.4
6.2
6.0
5.8
5.6
p<.05
p<.05
ns
Pai
n
5-minute Distance Walk
Case Number
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Valu
e
900
800
700
600
500
400
5 Mins Distance Pre-
Int
5 Mins Distance Post
-Int
Speed Targeted Intervention
Wingate “sprint” protocol
3 minute walk at preferred speed
30 second walk as fast as possible
3 minute walk at preferred speed
Repeat number of reps # training challenge
Brisk walk Elderly (Modified Wingate)
0
5
10
sit-std
pre
post
0
500
1000
1500
2000
2500
pre
post
0
5
10
stroop
pre
post
0
5
10
15
borg
pre
post
6 min walk
*p<.05* p<.05
* p<.05
Management:
Specific Exercise or lifestyle?
! Speed targeted Rx
! Tai Chi
! Dance
! Yoga
! Walking
What will the individual do?
Exercise is better than rest BUT
no difference between exercise regimens!!