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Determining Physiological and Psychological Predictors of Time to Task Failure on a Virtual Reality Sørensen Test in Participants With and Without Recurrent Low Back Pain: Exploratory Study

Determining Physiological and Psychological Predictors of Time to Task Failure on a Virtual... Background: Sørensen trunk extension endurance test performance predicts the development of low back pain and is a strong discriminator of those with and without low back pain. Performance may greatly depend on psychological factors, such as kinesiophobia, self-efficacy, and motivation. Virtual reality video games have been used in people with low back pain to encourage physical activity that would otherwise be avoided out of fear of pain or harm. Accordingly, we developed a virtual reality video game to assess the influence of immersive gaming on the Sørensen test performance. Objective: The objective of our study was to determine the physiological and psychological predictors of time to task failure (TTF) on a virtual reality Sørensen test in participants with and without a history of recurrent low back pain. Methods: We recruited 24 individuals with a history of recurrent low back pain and 24 sex-, age-, and body mass index–matched individuals without a history of low back pain. Participants completed a series of psychological measures, including the Center for Epidemiological Studies-Depression Scale, Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and a self-efficacy measure. The maximal isometric strength of trunk and hip extensors and TTF on a virtual reality Sørensen test were measured. Electromyography of the erector spinae, gluteus maximus, and biceps femoris was recorded during the strength and endurance trials. Results: A two-way analysis of variance revealed no significant difference in TTF between groups (P=.99), but there was a trend for longer TTF in females on the virtual reality Sørensen test (P=.06). Linear regression analyses were performed to determine predictors of TTF in each group. In healthy participants, the normalized median power frequency slope of erector spinae (beta=.450, P=.01), biceps femoris (beta=.400, P=.01), and trunk mass (beta=−.32, P=.02) predicted TTF. In participants with recurrent low back pain, trunk mass (beta=−.67, P<.001), Tampa Scale for Kinesiophobia (beta=−.43, P=.01), and self-efficacy (beta=.35, P=.03) predicted TTF. Conclusions: Trunk mass appears to be a consistent predictor of performance. Kinesiophobia appears to negatively influence TTF for those with a history of recurrent low back pain, but does not influence healthy individuals. Self-efficacy is associated with better performance in individuals with a history of recurrent low back pain, whereas a less steep median power frequency slope of the trunk and hip extensors is associated with better performance in individuals without a history of low back pain. (JMIR Serious Games 2018;6(3):e10522) doi: 10.2196/10522 http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al KEYWORDS fatigue; low back pain; Sørensen test; trunk mass; virtual reality undergo traditional treatment for LBP may continue to Introduction experience pain and disability long after the symptoms are treated. A cognitive behavioral model of chronic LBP, termed Low back pain (LBP) represents a significant societal and the fear-avoidance model, explains the progression from acute economic burden [1] with direct medical costs approaching US pain to chronic pain and disability [18,19]. In addition, the model $100 billion annually in the United States alone [2]. These costs hypothesizes that an individual’s pain experience depends upon are driven primarily by the 10%-15% of individuals who develop their established levels of pain-related fear. Kinesiophobic chronic LBP [1,3]. Poor trunk extension endurance has been individuals, those who are prone to avoidance of movement for identified as a risk factor for the development of LBP [4]. fear of pain or harm, respond to pain with catastrophic thoughts Specifically, poor time to task failure (TTF) on the Sørensen (ie, “The pain will get worse if I attempt to overcome it”), back extension endurance test, which requires an individual to leading to inactivity and further progression of disability [18,20]. maintain the upper body in an unsupported horizontal position to the point of fatigue, predicts first-time episodes of LBP [5,6] Measures of kinesiophobia have been used to predict LBP [19]. and chronic LBP [7]. Although the Sørensen test has been used Pain-related fear predicts reduced maximal force production for the identification of LBP risk, the underlying mechanisms and increased pain-related interference in daily activities, driving poor performance on the test are not well understood. regardless of actual pain levels [21]. Moreover, kinesiophobia Research has demonstrated that in addition to physiological has been recognized as an integral factor in Sørensen test factors, such as median power frequency (MPF) slopes of the performance. Sørensen TTF “underperformance” in individuals trunk and hip extensors and anthropometrics, psychological with chronic LBP could be predicted, in part, by fear-avoidance factors must be considered in the assessment of performance beliefs, as well as self-efficacy [22]. on the Sørensen test. A variation of the Sørensen test that uses a virtual reality video Evidence suggests that individuals terminate the Sørensen test game could encourage maximal effort, counteract fear for reasons other than subjective fatigue; these reasons include cognitions, and allow for more accurate identification of both pain, discomfort, fear, and lack of motivation [8]. Studies of the physiological and psychological factors driving performance. rehabilitation motivation in clinical populations, such as those Accordingly, we have developed a variation of the Sørensen of individuals recovering from cardiac events, have test that uses a virtual reality video game to provide motivation demonstrated that although motivation is difficult to define and and distraction. This study aims to determine whether the use measure, it plays a crucial role in rehabilitation outcomes for of a virtual reality video game influences performance on the patients [9]. Motivation could be manipulated through the use Sørensen test and whether the predictors of TTF vary between of distracting, immersive virtual reality gaming. Virtual reality individuals with and without recurrent LBP on the virtual reality games have been implemented for pain distraction in individuals Sørensen test. receiving chemotherapy and during burn debridement, resulting in lower pain ratings and greater tolerance of treatments [10-12] Methods and encouraging greater lumbar spine flexion in individuals with kinesiophobia and LBP [13]. Thus, by providing a Participants distraction element to counteract fear cognitions during the A sample of 24 individuals (12/24, 50% male) with a history assessment, a virtual reality video game could enhance of recurrent LBP (LBP) and 24 individuals (12/24, 50% male) motivation during the Sørensen test, leading to maximal effort. with no history of LBP (Healthy) matched for age, sex, and body mass index (BMI) were recruited from the Ohio University However, psychological factors are likely still involved in student population and surrounding community for this performance on the Sørensen test. Self-efficacy contributes to comparative study. Table 1 summarizes the participants’ the performance of physical activities. Self-efficacy is the characteristics. Individuals with a history of hip arthroscopy or magnitude of belief in one’s ability to perform a certain task to spine surgery, known neurological, visual, or orthopedic achieve a specific outcome [14]. Self-efficacy is strongly impairments, depression, ongoing drug or alcohol problems, associated with sports performance [15]. Although the study of elevated resting blood pressure (>135/>90 mmHG), or BMI of self-efficacy regarding physical activity contributes to the >35 were excluded from the study. We defined LBP history as understanding of human behavior, application to the Sørensen having experienced more than one episode of LBP with test, specifically, is limited. symptoms occurring in the past 6 months and a previous The influence of fear of pain may vary as a function of prior consultation regarding their LBP symptoms with a health care LBP experience. Chronic pain is a biopsychosocial phenomenon; provider; participants reporting moderate to severe pain an individual’s emotions and appraisal of pain contributes to (numerical pain rating scale of >3) within the past 6 weeks or chronicity [16]. Cognitive appraisal of pain varies based on those who did not meet the classification of category 1 (LBP individuals’ beliefs about their ability to cope with pain. In that does not radiate) through category 3 (LBP that radiates many situations, pain can elicit negative emotional reactions beyond the knee but without neurological signs) on the that lead to the amplification of pain experiences [17]. Classification System of the Quebec Task Force on Spinal Individuals with maladaptive emotional responses to pain who Disorders were excluded from participation. The protocol was http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al approved by the Ohio University Institutional Review Board LBP. In addition, construct validity and predictive ability has for human subjects research, and all individuals provided written been established in LBP populations [30]. In the general consent prior to participation. population, TSK-G is also reliable and valid as a self-report measure of fear of movement and (re)injury [31]. Instruments Self-Efficacy Measure Center for Epidemiological Studies-Depression Scale The self-efficacy measure was developed for this study based The Center for Epidemiological Studies-Depression Scale on prior studies [32,33]. After practicing the task position for (CES-D) was used in the general population to measure a brief period, participants were asked to indicate their depressive symptomatology. Good predictive validity for the confidence in their ability to maintain the Sørensen test position identification of depression in individuals with chronic pain has for 1, 2, 3, and 4 minutes on a scale ranging from “Not at all been established [22] as well as good sensitivity (93.2%) using confident” (0) to “Highly confident” (100). a cutoff score of 19 (out of 60) for the identification of depression in individuals with chronic pain [23]. Data Collection Participants completed 2 separate testing sessions. Participants Pain Catastrophizing Scale in this study were first included in an assessment of performance The Pain Catastrophizing Scale (PCS) is a 13-item scale that on the classic Sørensen test [34] and were invited to participate measures pain catastrophizing by assessing the degree to which in the virtual reality Sørensen test 3-14 days later. During the the respondent experiences specific thoughts and feelings during first testing session, participants completed the psychological pain on a 5-point Likert-type scale with the endpoints “Not at surveys, maximal strength assessments, and the classic Sørensen all” (0) and “All the time” (4) with a score of 30 indicating test. During the second testing session, participants completed clinically relevant pain catastrophizing behavior. PCS has been the virtual reality Sørensen test. identified as a reliable and valid measure of pain catastrophizing (Cronbach alpha=.87; test-retest intraclass correlation Electromyography Data coefficient=.93). PCS is consistently associated with pain Electromyography (EMG) was performed as described sensitivity and pain-related distress in experimental pain studies previously [34]. In brief, EMG was collected using a 16-channel [24-26]. Furthermore, pain catastrophizing is a primary Delsys Bagnoli system (Delsys Inc, Boston, MA, USA; vulnerability construct [27,28]. bandwidth 20-450 Hz); the bar leads were modified with clip leads to allow attachment to Ag-Ag Cl surface electrodes over Pain Resilience Scale the erector spinae (ERS) at the L2 and L4 level aligned between The Pain Resilience Scale (PRS) asks participants how they the posterior superior iliac spine and the lateral border of the respond when faced with intense or prolonged pain by rating muscle at the 12th rib, gluteus maximus midway between the items on a 14-item Likert scale using a “Not at all” (0) to “All greater trochanter and the posterior superior iliac spine, and the time” (4) scale with higher scores indicating greater pain long head of the biceps femoris (BF) midway between the resilience. Strong internal consistency and acceptable levels of fibular head and the ischial tuberosity. The raw surface EMG stability have been established (alpha=.93, intraclass correlation data were amplified (1k) and A/D converted with 16-bit coefficient=.80) [29]. resolution, sampled at 1000 Hz, and averaged across sides for each muscle. Tampa Scale for Kinesiophobia and Tampa Scale for Kinesiophobia-General Population Median Power Frequency Two versions of the Tampa Scale for Kinesiophobia (TSK) MPF was calculated as described previously [35]. Using a fast were used in this study, each using 17 items on a 4-point Likert Fourier transformation with a 512-point Hamming window, the scale ranging from “Strongly disagree” (1) to “Strongly agree” EMG power spectrum for each muscle was calculated. MPF (4) with scores >36 indicating clinically relevant kinesiophobia. was determined using a 2-second moving window with 50% The LBP group completed the standard TSK, which assessed overlap. The normalized slope of MPF was determined as fear of movement at the risk of injury or (re)injury. The healthy follows: (MPF slope/initial MPF)x100 [35]. All processing of group completed the TSK-General Population (TSK-G), which EMG data were performed with custom software written in used items modified to ask how much the respondent would MATLAB (Version 2016b; The MathWorks). fear movement at the risk of injury or (re)injury if they had Table 1. Participant characteristics. Characteristics Healthy (n=24), mean (SE) Low back pain (n=24), mean (SE) Age (years) 29.2 (2.2) 24.3 (1.5) Height (m) 1.7 (0.0) 1.7 (0.0) Weight (kg) 73.3 (2.6) 71.4 (2.6) Body mass index (kg/m ) 24.8 (0.7) 24.2 (0.7) http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al hip height by a padded bar connected to the single DOF load Force Output and Torque Moment Data cell. Bracing of the feet was inhibited with a foam roll placed The maximal voluntary contraction data were measured as below the ankles. The trunk mass was measured in this position. described previously [34]. In brief, our custom articulated EMG was measured as previously described and the custom fatigue table integrated a 6 degree of freedom (DOF) load cell LABVIEW (Version 13; National Instruments) program (MC5-1250; AMTI, Watertown, MA, USA) into the trunk collected EMG and load cell measurements. platform connected to a signal conditioner (GEN 5; AMTI), and single DOF load cell (XTS4-500; Load Cell Central, Milan, For the trunk extension trials, participants were instructed to PA, USA) into the leg brace connected to an analog signal pull their torso up into the back restraint. Three submaximal conditioner (OM19; Load Cell Central). Force and torque data trunk extension attempts of increasing intensity were followed were A/D converted at 16-bit resolution and sampled at 1000 by 3 maximal trunk extension attempts. Then, participants were Hz. instructed to extend their legs up against the stationary leg restraint; 3 submaximal hip extension attempts of increasing Position Data intensity were followed by 3 maximal attempts. We provided The trunk position during the Sørensen test was measured as 2 minutes of rest between each attempt. Verbal encouragement described previously [34]. In brief, custom-made potentiometers and visual and audio feedback were provided via the custom were anchored over the participant’s sacrum at the level of LABVIEW (Version 13; National Instruments) program. L5-S1 and trunk at the level of T12-L1. An algorithm converted Virtual Reality Sørensen Procedure the potentiometers’ voltages into position (degrees of rotation) The participants performed the virtual reality Sørensen test on with excellent linearity of fit (R =0.9988). Our custom a standard table with belts across the pelvis and calves at 33% LABVIEW (Version 13; National Instruments, Austin, TX, of hip height, the anterior superior iliac spine aligned with the USA) program used the algorithm to track the position during edge of the table, and the upper body unsupported, as seen in the Sørensen tests. The horizontal position was individually Figure 2. Subjects wore an Oculus Rift head mounted display calibrated prior to each test. (Oculus Rift Developers Kit 2), as shown in Figure 2. During Maximal Voluntary Contraction Procedure the test, the Oculus Rift displayed a sky environment in which The maximal voluntary contraction procedure was completed the participant attempted to “fly” through hoops, as seen in as described previously [34]. As illustrated in Figure 1, subjects Figure 3. Extending and flexing the trunk appeared to make the were situated on the custom fatigue table with the anterior subject fly higher and lower, respectively. The hoops were superior iliac spine aligned with the edge of the table and the positioned such that the participants were encouraged to torso supported by the platform positioned such that the trunk maintain a horizontal position for as long as possible. center of mass was centered over the 6 DOF load cell. In Immediately following a brief practice attempt of <5 seconds, addition, the torso was secured to the platform, the pelvis was participants completed the self-efficacy questionnaire. secured to the table, and the lower legs were secured at 33% of Figure 1. Experimental setup on the fatigue table for maximal voluntary contraction of the trunk and hip. http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al Figure 2. Experimental setup on the standard table for the virtual reality Sørensen test. Figure 3. Participant’s perspective during gameplay, displayed through the Oculus Rift headset. Participants then attempted to maintain the task position until Statistical Analysis failure while receiving audio and visual feedback through the In this study, independent-sample t tests were used to evaluate virtual reality video game; a tone played when the participant’s differences in participant demographics. A two-way analysis position was >2° beyond the target position in either direction, of variance was used to determine group and sex differences in which was visually represented by flying above or below the TTF on the virtual reality Sørensen test. In addition, stepwise hoops. The trial was terminated when participants fell out of linear regression analyses were performed to determine which the range (±2°) for >3 consecutive seconds. physiological factors were related to TTF on the virtual reality Sørensen test in each group. The second set of linear regression analyses was performed with the significant physiological http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al factors entered into the first block and psychological factors the linear regression analyses. Table 4 displays the Pearson entered stepwise in the second block to determine which correlations. psychological factors were related to TTF on the virtual reality Healthy Sørensen test in each group. All analyses were performed in A stepwise linear regression analysis identified the normalized SPSS (IBM Corp.), and results are reported as mean (SE) unless MPF slope of ERS (beta=.45, P=.01), normalized MPF slope otherwise stated. of BF (beta=.40, P=.01), and trunk mass (beta=−.32, P=.03) as significant predictors of TTF. A separate linear regression Results analysis was then run with the MPF slopes of ERS and BF; Demographics trunk mass was entered into the first block and all psychological measures (ie, CES-D, TSK, self-efficacy, PCS, and PRS) were The independent-sample t test revealed no significant differences offered stepwise into the second block. Only trunk mass and between Healthy and LBP groups with one exception; the the normalized MPF slopes of ERS and BF were retained as depression scores were significantly higher in the LBP group significant predictors of TTF on the virtual reality Sørensen test than in those the healthy group (Table 2). in the healthy group (Table 5). Time to Task Failure Low Back Pain A 2 Group (Healthy, LBP) x 2 Sex (Male, Female) two-way A stepwise linear regression analysis identified the trunk mass analysis of variance revealed no significant differences in group (beta=−.53, P=.01) as a significant predictor of TTF. A separate (F =0.00, P=.99) or group by sex (F =0.33, P=.57; Table 1,44 1,44 linear regression analysis was then run with trunk mass entered 3); however, there was a marginal effect of sex (F =3.89, 1,44 into the first block, and all psychological measures (ie, CES-D, P=.06), which reflected a tendency toward the longer TTF in TSK, self-efficacy, PCS, and PRS) were offered stepwise into female versus male participants. the second block. In the final model, the trunk mass (beta=−.67, P=.001), TSK (beta=−.43, P=.01), and self-efficacy (beta=.35, Predictors of Virtual Reality Sørensen Time to Task P=.03) were retained as significant predictors of TTF on the Failure virtual reality Sørensen test in the LBP group (Table 5). Simple correlations were run between TTF and each of the physiological and psychological factors that were entered into Table 2. Anthropometric, strength, and psychological survey measures. Survey measures Healthy (n=24), mean (SE) Low back pain (n=24), mean (SE) P value Trunk mass (kg) 36.7 (1.5) 35.4 (1.6) .54 Trunk length (m) 0.5 (0.0) 0.4 (0.0) .15 Vertical trunk force (N) 476.7 (52.8) 511.7 (35.4) .65 Trunk moment (Nm) 42.3 (4.1) 45.4 (5.4) .66 Hip force (N) 131.0 (8.2) 138.4 (8.6) .50 −0.1 (0.0) −0.1 (0.0) .32 Erector spinae MPF slope (%/s) Gluteus maximus MPF slope (%/s) −0.3 (0.0) −0.2 (0.0) .16 Biceps femoris MPF slope (%/s) 3.8 (0.8) 7.6 (1.2) .38 39.3 (2.1) 37.7 (2.1) .01 Depression (0-60) 7.6 (1.3) 6.8 (0.9) .61 Pain resilience (0-56) 30.9 (1.2) 32.0 (1.3) .59 Pain catastrophizing (0-52) 38.7 (4.1) 44.5 (3.2) .54 Kinesiophobia (17-68) MPF: median power frequency. Ranges for the scales. Table 3. Time to task failure on the virtual reality Sørensen test. Participants Healthy, mean (SE) Low back pain, mean (SE) Total, mean (SE) Male 107.2 (9.6) 98.1 (9.7) 102.7 (6.7) Female 128.7 (21.1) 137.3 (17.8) 133.0 (13.5) Total 118.0 (11.6) 117.7 (10.7) 117.8 (7.8) http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al Table 4. Simple correlations between time to task failure and factors entered into the linear regression analyses. Measures Healthy Low back pain r P value r P value Trunk mass −0.467 .02 −0.532 .01 Trunk length 0.180 .40 0.016 .94 Vertical trunk force 0.065 .76 −0.061 .78 Trunk moment −0.248 .24 −0.200 .35 Hip force −0.056 .80 −0.299 .16 Erector spinae MPF slope 0.616 .001 0.314 .14 Gluteus maximus MPF slope 0.440 .03 −0.174 .42 Biceps femoris MPF slope 0.513 .01 0.418 .04 Self-efficacy 0.525 .01 0.235 .27 Depression 0.128 .55 −0.194 .36 Pain catastrophizing −0.158 .46 −0.091 .67 Pain resilience −0.030 .89 −0.362 .08 Kinesiophobia −0.106 .62 −0.276 .19 MPF: median power frequency. Table 5. Significant factors identified by the linear regression analyses. Factor Unstandardized beta SE Standardized beta t P value Healthy (Constant) 301.32 10.20 — 7.50 <.001   Erector spinae MPF 140.21 45.17 .45 3.10 .01   Biceps femoris MPF 130.24 44.74 .40 2.91 .01   Trunk mass −1.12 0.49 −.32 −2.30 .03 Low back pain (Constant) 342.21 61.68 — 5.55 <.001   Trunk mass −2.08 0.48 −.67 −4.34 <.001   Kinesiophobia −3.56 1.27 −.43 −2.81 .01   Self-efficacy 1.15 0.49 .35 2.34 .03 MPF: median power frequency. exhibited a markedly longer TTF than those with any LBP Discussion experience [37]. Many studies have reported consistent findings; however, others have failed to find a difference in performance Principal Findings between those with and without LBP. Many physiological This study aimed to examine the performance on a variation of factors, including the BMI, trunk mass, MPF slopes of the trunk the Sørensen test using a virtual reality video game in and hip extensors, and maximal trunk and hip strength, have individuals with and without a history of recurrent LBP. To the been found to influence the performance on the task; these best of our knowledge, this is the first study to use a virtual factors have been discussed previously [34]. reality video game in conjunction with the Sørensen test. Although our sample of individuals with recurrent LBP Contrary to much of the published literature, we did not find a performed just as well on the virtual reality Sørensen test as significant difference in TTF between the groups. In the first those without LBP, several interesting findings regarding the longitudinal study, males with a short TTF on the Sørensen test factors associated with TTF emerged. In the healthy group, it were most likely to experience LBP in the following year, appears that TTF was driven primarily by trunk mass and the identifying the test as a predictor of first-time LBP [36]. The MPF slopes of the trunk and hip extensors, and this is consistent test was later recognized as a discriminator of those with and with our previous work [34]. In addition, trunk mass was a without LBP; individuals who had no prior LBP experience http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al predictor of TTF in the LBP group. Other studies also games are not effective in any form to counteract pain-related demonstrated the marked effects of anthropometrics on fear. performance. The workload of the task is governed by the weight Previous research has demonstrated an effect of sex on of the body above the hips. It is obvious that an individual with performance on the Sørensen test. Females tend to maintain the a heavier trunk mass will not be able to maintain the test position test position for longer than males [43,44]; however, several for as long as another individual with the same strength capacity studies have found no sex differences [45,46], and others have but lighter trunk mass. The effects of anthropometrics tend to found that males maintain the test position for longer than be consistent in both individuals with and without LBP. females [47-49]. We did identify a trend toward a sex difference Previously, marked associations have been identified between on TTF with females maintaining the position slightly longer body mass, BMI, and the MPF slope of ERS in males and than males (P=.06). Others have reported that healthy females females with and without LBP [38]. Moreover, a marked maintained an isometric trunk extension task markedly longer association between TTF and torso mass in females with and than healthy males [50]. The authors attributed their results to without LBP has been demonstrated [39]. Trunk mass is an the muscle mass and strength hypothesis, which describes the important factor in Sørensen test TTF, especially in those with relationship among the total muscle mass, vascular compression, a history of LBP, and should be considered when assessing and the demand for oxygen. According to this hypothesis, performance. A variation in the Sørensen test that normalizes because females typically have lower muscle mass, the the workload to a consistent percentage of maximal strength vasculature is less compressed during isometric exercise, and would account for differences in trunk mass and strength to the demand for oxygen to the active muscles is lower [51,52]. allow for a more objective assessment of endurance. There is some evidence that females have a greater ratio of type In this study, self-efficacy emerged as an important factor in I oxidative muscle fibers in the trunk extensors [53], which Sørensen test performance. Motivation has long been recognized would have a greater concentration of beta-2 adrenergic as a consequential factor in Sørensen test performance receptors, enhancing vasodilation [54]; there is also evidence [22,36,40-43]; however, to the best of our knowledge, we are that females have a greater degree of capillarization in some the first to attempt to manipulate it through the use of a virtual muscles [55], enhancing perfusion. However, others have reality video game. The self-efficacy measure was created demonstrated that intramuscular pressure may not be associated specifically for the Sørensen test task, which likely explains its with a shift in MPF during isometric trunk extension exercises strong association with TTF in the LBP group. Interestingly, [56,57]. Although muscle mass was not measured in this sample, self-efficacy was not predictive of performance in the healthy it is possible that TTF was influenced by perfusion. group. Thus, in this sample of individuals without a history of Limitations LBP, it appears that self-efficacy did not drive performance. As with any study of human subjects, this study is not without Alternatively, our sample of individuals with a history of its limitations. Our LBP group consisted of individuals with recurrent LBP performed better on the virtual reality Sørensen mild, recurrent LBP, which may have also restricted the sample test if they reported higher ratings of confidence in their capacity to individuals with low levels of disability and pain-related fear. to perform the task; this is consistent with our previous findings Individuals with higher disability and pain-related fear have on the standard Sørensen test [34] as well as those obtained by poorer rehabilitation outcomes and typically perform more others who found that performance was predicted, in part, by poorly on the Sørensen test. Thus, significant pain-related fear self-efficacy [22]. This would suggest that self-efficacy may be associations may have emerged in a sample of individuals with a worthwhile target for cognitive behavioral interventions for more severe kinesiophobia and disability symptoms. In addition, LBP. this group was primarily young, fit, college-aged students; future In addition, there was a significant effect of kinesiophobia in studies will benefit from measuring physical activity levels our LBP group; those who had lower TSK scores maintained a because cardiorespiratory fitness is likely associated with longer TTF on the virtual reality Sørensen test; this would performance on any endurance task, such as the Sørensen test. suggest that TSK is predictive of performance in individuals Conclusions with recurrent LBP when provided with a distraction element. On the classic version of the Sørensen test [34], TSK was not This study demonstrates that individuals with and without mild, predictive of performance in this same group of individuals recurrent LBP perform similarly on a variation of the Sørensen with recurrent LBP. The virtual reality video game may have test using a virtual reality video game, but the underlying actually exacerbated fear cognitions by blocking the participant’s mechanisms driving performance vary between the groups. view of the real world, reducing their sense of control, and Performance on this variation of the Sørensen test in healthy instead redirecting focus toward their pain-related fear. individuals is driven primarily by physiological factors, Moreover, it is possible that attentional resources were reduced including trunk mass and the MPF slopes of ERS and BF. In in response to the game. Future research could benefit from addition, trunk mass is an important factor of performance in investigating the response to different types of games to individuals with a history of recurrent LBP; however, levels of determine whether certain games are more effective or whether self-efficacy and kinesiophobia also appear to be important predictors of TTF on this virtual reality Sørensen test. http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al Conflicts of Interest None declared. References 1. Vlaeyen J, Morley S, Linton S, Boersma K, Jong J. Pain-Related Fear: Exposure-Based Treatment for Chronic Pain. Washington: IASP Press; 2012. 2. Simon LS. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Mil Med 2016 Dec;181(5):397-399. [doi: 10.7205/MILMED-D-16-00012] [Medline: 27136641] 3. 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Higher skeletal muscle alpha2AMPK activation and lower energy charge and fat oxidation in men than in women during submaximal exercise. J Physiol 2006 Jul 01;574(Pt 1):125-138 [FREE Full text] [doi: 10.1113/jphysiol.2006.108720] [Medline: 16600998] 56. Kramer M, Dehner C, Hartwig E, Völker HU, Sterk J, Elbel M, et al. Intramuscular pressure, tissue oxygenation and EMG fatigue measured during isometric fatigue-inducing contraction of the multifidus muscle. Eur Spine J 2005 Aug;14(6):578-585 [FREE Full text] [doi: 10.1007/s00586-004-0857-3] [Medline: 15700188] 57. Dehner C, Schmelz A, Völker H, Pressmar J, Elbel M, Kramer M. Intramuscular pressure, tissue oxygenation, and muscle fatigue of the multifidus during isometric extension in elite rowers with low back pain. J Sport Rehabil 2009 Nov;18(4):572-581. [Medline: 20108857] Abbreviations BF: biceps femoris BMI: body mass index CES-D: Center for Epidemiological Studies-Depression DOF: degree of freedom EMG: electromyography ERS: erector spinae LBP: low back pain MPF: median power frequency PCS: Pain Catastrophizing Scale PRS: Pain Resilience Scale TSK: Tampa Scale for Kinesiophobia TSK-G: Tampa Scale for Kinesiophobia-General Population TTF: time to task failure Edited by G Eysenbach; submitted 28.03.18; peer-reviewed by B Atzori, M Alshehri; comments to author 26.04.18; revised version received 20.06.18; accepted 21.06.18; published 10.09.18 Please cite as: Applegate ME, France CR, Russ DW, Leitkam ST, Thomas JS Determining Physiological and Psychological Predictors of Time to Task Failure on a Virtual Reality Sørensen Test in Participants With and Without Recurrent Low Back Pain: Exploratory Study JMIR Serious Games 2018;6(3):e10522 URL: http://games.jmir.org/2018/3/e10522/ doi: 10.2196/10522 PMID: 30201604 ©Megan E Applegate, Christopher R France, David W Russ, Samuel T Leitkam, James S Thomas. Originally published in JMIR Serious Games (http://games.jmir.org), 10.09.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 12 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Determining Physiological and Psychological Predictors of Time to Task Failure on a Virtual Reality Sørensen Test in Participants With and Without Recurrent Low Back Pain: Exploratory Study

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Abstract

Background: Sørensen trunk extension endurance test performance predicts the development of low back pain and is a strong discriminator of those with and without low back pain. Performance may greatly depend on psychological factors, such as kinesiophobia, self-efficacy, and motivation. Virtual reality video games have been used in people with low back pain to encourage physical activity that would otherwise be avoided out of fear of pain or harm. Accordingly, we developed a virtual reality video game to assess the influence of immersive gaming on the Sørensen test performance. Objective: The objective of our study was to determine the physiological and psychological predictors of time to task failure (TTF) on a virtual reality Sørensen test in participants with and without a history of recurrent low back pain. Methods: We recruited 24 individuals with a history of recurrent low back pain and 24 sex-, age-, and body mass index–matched individuals without a history of low back pain. Participants completed a series of psychological measures, including the Center for Epidemiological Studies-Depression Scale, Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and a self-efficacy measure. The maximal isometric strength of trunk and hip extensors and TTF on a virtual reality Sørensen test were measured. Electromyography of the erector spinae, gluteus maximus, and biceps femoris was recorded during the strength and endurance trials. Results: A two-way analysis of variance revealed no significant difference in TTF between groups (P=.99), but there was a trend for longer TTF in females on the virtual reality Sørensen test (P=.06). Linear regression analyses were performed to determine predictors of TTF in each group. In healthy participants, the normalized median power frequency slope of erector spinae (beta=.450, P=.01), biceps femoris (beta=.400, P=.01), and trunk mass (beta=−.32, P=.02) predicted TTF. In participants with recurrent low back pain, trunk mass (beta=−.67, P<.001), Tampa Scale for Kinesiophobia (beta=−.43, P=.01), and self-efficacy (beta=.35, P=.03) predicted TTF. Conclusions: Trunk mass appears to be a consistent predictor of performance. Kinesiophobia appears to negatively influence TTF for those with a history of recurrent low back pain, but does not influence healthy individuals. Self-efficacy is associated with better performance in individuals with a history of recurrent low back pain, whereas a less steep median power frequency slope of the trunk and hip extensors is associated with better performance in individuals without a history of low back pain. (JMIR Serious Games 2018;6(3):e10522) doi: 10.2196/10522 http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al KEYWORDS fatigue; low back pain; Sørensen test; trunk mass; virtual reality undergo traditional treatment for LBP may continue to Introduction experience pain and disability long after the symptoms are treated. A cognitive behavioral model of chronic LBP, termed Low back pain (LBP) represents a significant societal and the fear-avoidance model, explains the progression from acute economic burden [1] with direct medical costs approaching US pain to chronic pain and disability [18,19]. In addition, the model $100 billion annually in the United States alone [2]. These costs hypothesizes that an individual’s pain experience depends upon are driven primarily by the 10%-15% of individuals who develop their established levels of pain-related fear. Kinesiophobic chronic LBP [1,3]. Poor trunk extension endurance has been individuals, those who are prone to avoidance of movement for identified as a risk factor for the development of LBP [4]. fear of pain or harm, respond to pain with catastrophic thoughts Specifically, poor time to task failure (TTF) on the Sørensen (ie, “The pain will get worse if I attempt to overcome it”), back extension endurance test, which requires an individual to leading to inactivity and further progression of disability [18,20]. maintain the upper body in an unsupported horizontal position to the point of fatigue, predicts first-time episodes of LBP [5,6] Measures of kinesiophobia have been used to predict LBP [19]. and chronic LBP [7]. Although the Sørensen test has been used Pain-related fear predicts reduced maximal force production for the identification of LBP risk, the underlying mechanisms and increased pain-related interference in daily activities, driving poor performance on the test are not well understood. regardless of actual pain levels [21]. Moreover, kinesiophobia Research has demonstrated that in addition to physiological has been recognized as an integral factor in Sørensen test factors, such as median power frequency (MPF) slopes of the performance. Sørensen TTF “underperformance” in individuals trunk and hip extensors and anthropometrics, psychological with chronic LBP could be predicted, in part, by fear-avoidance factors must be considered in the assessment of performance beliefs, as well as self-efficacy [22]. on the Sørensen test. A variation of the Sørensen test that uses a virtual reality video Evidence suggests that individuals terminate the Sørensen test game could encourage maximal effort, counteract fear for reasons other than subjective fatigue; these reasons include cognitions, and allow for more accurate identification of both pain, discomfort, fear, and lack of motivation [8]. Studies of the physiological and psychological factors driving performance. rehabilitation motivation in clinical populations, such as those Accordingly, we have developed a variation of the Sørensen of individuals recovering from cardiac events, have test that uses a virtual reality video game to provide motivation demonstrated that although motivation is difficult to define and and distraction. This study aims to determine whether the use measure, it plays a crucial role in rehabilitation outcomes for of a virtual reality video game influences performance on the patients [9]. Motivation could be manipulated through the use Sørensen test and whether the predictors of TTF vary between of distracting, immersive virtual reality gaming. Virtual reality individuals with and without recurrent LBP on the virtual reality games have been implemented for pain distraction in individuals Sørensen test. receiving chemotherapy and during burn debridement, resulting in lower pain ratings and greater tolerance of treatments [10-12] Methods and encouraging greater lumbar spine flexion in individuals with kinesiophobia and LBP [13]. Thus, by providing a Participants distraction element to counteract fear cognitions during the A sample of 24 individuals (12/24, 50% male) with a history assessment, a virtual reality video game could enhance of recurrent LBP (LBP) and 24 individuals (12/24, 50% male) motivation during the Sørensen test, leading to maximal effort. with no history of LBP (Healthy) matched for age, sex, and body mass index (BMI) were recruited from the Ohio University However, psychological factors are likely still involved in student population and surrounding community for this performance on the Sørensen test. Self-efficacy contributes to comparative study. Table 1 summarizes the participants’ the performance of physical activities. Self-efficacy is the characteristics. Individuals with a history of hip arthroscopy or magnitude of belief in one’s ability to perform a certain task to spine surgery, known neurological, visual, or orthopedic achieve a specific outcome [14]. Self-efficacy is strongly impairments, depression, ongoing drug or alcohol problems, associated with sports performance [15]. Although the study of elevated resting blood pressure (>135/>90 mmHG), or BMI of self-efficacy regarding physical activity contributes to the >35 were excluded from the study. We defined LBP history as understanding of human behavior, application to the Sørensen having experienced more than one episode of LBP with test, specifically, is limited. symptoms occurring in the past 6 months and a previous The influence of fear of pain may vary as a function of prior consultation regarding their LBP symptoms with a health care LBP experience. Chronic pain is a biopsychosocial phenomenon; provider; participants reporting moderate to severe pain an individual’s emotions and appraisal of pain contributes to (numerical pain rating scale of >3) within the past 6 weeks or chronicity [16]. Cognitive appraisal of pain varies based on those who did not meet the classification of category 1 (LBP individuals’ beliefs about their ability to cope with pain. In that does not radiate) through category 3 (LBP that radiates many situations, pain can elicit negative emotional reactions beyond the knee but without neurological signs) on the that lead to the amplification of pain experiences [17]. Classification System of the Quebec Task Force on Spinal Individuals with maladaptive emotional responses to pain who Disorders were excluded from participation. The protocol was http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al approved by the Ohio University Institutional Review Board LBP. In addition, construct validity and predictive ability has for human subjects research, and all individuals provided written been established in LBP populations [30]. In the general consent prior to participation. population, TSK-G is also reliable and valid as a self-report measure of fear of movement and (re)injury [31]. Instruments Self-Efficacy Measure Center for Epidemiological Studies-Depression Scale The self-efficacy measure was developed for this study based The Center for Epidemiological Studies-Depression Scale on prior studies [32,33]. After practicing the task position for (CES-D) was used in the general population to measure a brief period, participants were asked to indicate their depressive symptomatology. Good predictive validity for the confidence in their ability to maintain the Sørensen test position identification of depression in individuals with chronic pain has for 1, 2, 3, and 4 minutes on a scale ranging from “Not at all been established [22] as well as good sensitivity (93.2%) using confident” (0) to “Highly confident” (100). a cutoff score of 19 (out of 60) for the identification of depression in individuals with chronic pain [23]. Data Collection Participants completed 2 separate testing sessions. Participants Pain Catastrophizing Scale in this study were first included in an assessment of performance The Pain Catastrophizing Scale (PCS) is a 13-item scale that on the classic Sørensen test [34] and were invited to participate measures pain catastrophizing by assessing the degree to which in the virtual reality Sørensen test 3-14 days later. During the the respondent experiences specific thoughts and feelings during first testing session, participants completed the psychological pain on a 5-point Likert-type scale with the endpoints “Not at surveys, maximal strength assessments, and the classic Sørensen all” (0) and “All the time” (4) with a score of 30 indicating test. During the second testing session, participants completed clinically relevant pain catastrophizing behavior. PCS has been the virtual reality Sørensen test. identified as a reliable and valid measure of pain catastrophizing (Cronbach alpha=.87; test-retest intraclass correlation Electromyography Data coefficient=.93). PCS is consistently associated with pain Electromyography (EMG) was performed as described sensitivity and pain-related distress in experimental pain studies previously [34]. In brief, EMG was collected using a 16-channel [24-26]. Furthermore, pain catastrophizing is a primary Delsys Bagnoli system (Delsys Inc, Boston, MA, USA; vulnerability construct [27,28]. bandwidth 20-450 Hz); the bar leads were modified with clip leads to allow attachment to Ag-Ag Cl surface electrodes over Pain Resilience Scale the erector spinae (ERS) at the L2 and L4 level aligned between The Pain Resilience Scale (PRS) asks participants how they the posterior superior iliac spine and the lateral border of the respond when faced with intense or prolonged pain by rating muscle at the 12th rib, gluteus maximus midway between the items on a 14-item Likert scale using a “Not at all” (0) to “All greater trochanter and the posterior superior iliac spine, and the time” (4) scale with higher scores indicating greater pain long head of the biceps femoris (BF) midway between the resilience. Strong internal consistency and acceptable levels of fibular head and the ischial tuberosity. The raw surface EMG stability have been established (alpha=.93, intraclass correlation data were amplified (1k) and A/D converted with 16-bit coefficient=.80) [29]. resolution, sampled at 1000 Hz, and averaged across sides for each muscle. Tampa Scale for Kinesiophobia and Tampa Scale for Kinesiophobia-General Population Median Power Frequency Two versions of the Tampa Scale for Kinesiophobia (TSK) MPF was calculated as described previously [35]. Using a fast were used in this study, each using 17 items on a 4-point Likert Fourier transformation with a 512-point Hamming window, the scale ranging from “Strongly disagree” (1) to “Strongly agree” EMG power spectrum for each muscle was calculated. MPF (4) with scores >36 indicating clinically relevant kinesiophobia. was determined using a 2-second moving window with 50% The LBP group completed the standard TSK, which assessed overlap. The normalized slope of MPF was determined as fear of movement at the risk of injury or (re)injury. The healthy follows: (MPF slope/initial MPF)x100 [35]. All processing of group completed the TSK-General Population (TSK-G), which EMG data were performed with custom software written in used items modified to ask how much the respondent would MATLAB (Version 2016b; The MathWorks). fear movement at the risk of injury or (re)injury if they had Table 1. Participant characteristics. Characteristics Healthy (n=24), mean (SE) Low back pain (n=24), mean (SE) Age (years) 29.2 (2.2) 24.3 (1.5) Height (m) 1.7 (0.0) 1.7 (0.0) Weight (kg) 73.3 (2.6) 71.4 (2.6) Body mass index (kg/m ) 24.8 (0.7) 24.2 (0.7) http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al hip height by a padded bar connected to the single DOF load Force Output and Torque Moment Data cell. Bracing of the feet was inhibited with a foam roll placed The maximal voluntary contraction data were measured as below the ankles. The trunk mass was measured in this position. described previously [34]. In brief, our custom articulated EMG was measured as previously described and the custom fatigue table integrated a 6 degree of freedom (DOF) load cell LABVIEW (Version 13; National Instruments) program (MC5-1250; AMTI, Watertown, MA, USA) into the trunk collected EMG and load cell measurements. platform connected to a signal conditioner (GEN 5; AMTI), and single DOF load cell (XTS4-500; Load Cell Central, Milan, For the trunk extension trials, participants were instructed to PA, USA) into the leg brace connected to an analog signal pull their torso up into the back restraint. Three submaximal conditioner (OM19; Load Cell Central). Force and torque data trunk extension attempts of increasing intensity were followed were A/D converted at 16-bit resolution and sampled at 1000 by 3 maximal trunk extension attempts. Then, participants were Hz. instructed to extend their legs up against the stationary leg restraint; 3 submaximal hip extension attempts of increasing Position Data intensity were followed by 3 maximal attempts. We provided The trunk position during the Sørensen test was measured as 2 minutes of rest between each attempt. Verbal encouragement described previously [34]. In brief, custom-made potentiometers and visual and audio feedback were provided via the custom were anchored over the participant’s sacrum at the level of LABVIEW (Version 13; National Instruments) program. L5-S1 and trunk at the level of T12-L1. An algorithm converted Virtual Reality Sørensen Procedure the potentiometers’ voltages into position (degrees of rotation) The participants performed the virtual reality Sørensen test on with excellent linearity of fit (R =0.9988). Our custom a standard table with belts across the pelvis and calves at 33% LABVIEW (Version 13; National Instruments, Austin, TX, of hip height, the anterior superior iliac spine aligned with the USA) program used the algorithm to track the position during edge of the table, and the upper body unsupported, as seen in the Sørensen tests. The horizontal position was individually Figure 2. Subjects wore an Oculus Rift head mounted display calibrated prior to each test. (Oculus Rift Developers Kit 2), as shown in Figure 2. During Maximal Voluntary Contraction Procedure the test, the Oculus Rift displayed a sky environment in which The maximal voluntary contraction procedure was completed the participant attempted to “fly” through hoops, as seen in as described previously [34]. As illustrated in Figure 1, subjects Figure 3. Extending and flexing the trunk appeared to make the were situated on the custom fatigue table with the anterior subject fly higher and lower, respectively. The hoops were superior iliac spine aligned with the edge of the table and the positioned such that the participants were encouraged to torso supported by the platform positioned such that the trunk maintain a horizontal position for as long as possible. center of mass was centered over the 6 DOF load cell. In Immediately following a brief practice attempt of <5 seconds, addition, the torso was secured to the platform, the pelvis was participants completed the self-efficacy questionnaire. secured to the table, and the lower legs were secured at 33% of Figure 1. Experimental setup on the fatigue table for maximal voluntary contraction of the trunk and hip. http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al Figure 2. Experimental setup on the standard table for the virtual reality Sørensen test. Figure 3. Participant’s perspective during gameplay, displayed through the Oculus Rift headset. Participants then attempted to maintain the task position until Statistical Analysis failure while receiving audio and visual feedback through the In this study, independent-sample t tests were used to evaluate virtual reality video game; a tone played when the participant’s differences in participant demographics. A two-way analysis position was >2° beyond the target position in either direction, of variance was used to determine group and sex differences in which was visually represented by flying above or below the TTF on the virtual reality Sørensen test. In addition, stepwise hoops. The trial was terminated when participants fell out of linear regression analyses were performed to determine which the range (±2°) for >3 consecutive seconds. physiological factors were related to TTF on the virtual reality Sørensen test in each group. The second set of linear regression analyses was performed with the significant physiological http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al factors entered into the first block and psychological factors the linear regression analyses. Table 4 displays the Pearson entered stepwise in the second block to determine which correlations. psychological factors were related to TTF on the virtual reality Healthy Sørensen test in each group. All analyses were performed in A stepwise linear regression analysis identified the normalized SPSS (IBM Corp.), and results are reported as mean (SE) unless MPF slope of ERS (beta=.45, P=.01), normalized MPF slope otherwise stated. of BF (beta=.40, P=.01), and trunk mass (beta=−.32, P=.03) as significant predictors of TTF. A separate linear regression Results analysis was then run with the MPF slopes of ERS and BF; Demographics trunk mass was entered into the first block and all psychological measures (ie, CES-D, TSK, self-efficacy, PCS, and PRS) were The independent-sample t test revealed no significant differences offered stepwise into the second block. Only trunk mass and between Healthy and LBP groups with one exception; the the normalized MPF slopes of ERS and BF were retained as depression scores were significantly higher in the LBP group significant predictors of TTF on the virtual reality Sørensen test than in those the healthy group (Table 2). in the healthy group (Table 5). Time to Task Failure Low Back Pain A 2 Group (Healthy, LBP) x 2 Sex (Male, Female) two-way A stepwise linear regression analysis identified the trunk mass analysis of variance revealed no significant differences in group (beta=−.53, P=.01) as a significant predictor of TTF. A separate (F =0.00, P=.99) or group by sex (F =0.33, P=.57; Table 1,44 1,44 linear regression analysis was then run with trunk mass entered 3); however, there was a marginal effect of sex (F =3.89, 1,44 into the first block, and all psychological measures (ie, CES-D, P=.06), which reflected a tendency toward the longer TTF in TSK, self-efficacy, PCS, and PRS) were offered stepwise into female versus male participants. the second block. In the final model, the trunk mass (beta=−.67, P=.001), TSK (beta=−.43, P=.01), and self-efficacy (beta=.35, Predictors of Virtual Reality Sørensen Time to Task P=.03) were retained as significant predictors of TTF on the Failure virtual reality Sørensen test in the LBP group (Table 5). Simple correlations were run between TTF and each of the physiological and psychological factors that were entered into Table 2. Anthropometric, strength, and psychological survey measures. Survey measures Healthy (n=24), mean (SE) Low back pain (n=24), mean (SE) P value Trunk mass (kg) 36.7 (1.5) 35.4 (1.6) .54 Trunk length (m) 0.5 (0.0) 0.4 (0.0) .15 Vertical trunk force (N) 476.7 (52.8) 511.7 (35.4) .65 Trunk moment (Nm) 42.3 (4.1) 45.4 (5.4) .66 Hip force (N) 131.0 (8.2) 138.4 (8.6) .50 −0.1 (0.0) −0.1 (0.0) .32 Erector spinae MPF slope (%/s) Gluteus maximus MPF slope (%/s) −0.3 (0.0) −0.2 (0.0) .16 Biceps femoris MPF slope (%/s) 3.8 (0.8) 7.6 (1.2) .38 39.3 (2.1) 37.7 (2.1) .01 Depression (0-60) 7.6 (1.3) 6.8 (0.9) .61 Pain resilience (0-56) 30.9 (1.2) 32.0 (1.3) .59 Pain catastrophizing (0-52) 38.7 (4.1) 44.5 (3.2) .54 Kinesiophobia (17-68) MPF: median power frequency. Ranges for the scales. Table 3. Time to task failure on the virtual reality Sørensen test. Participants Healthy, mean (SE) Low back pain, mean (SE) Total, mean (SE) Male 107.2 (9.6) 98.1 (9.7) 102.7 (6.7) Female 128.7 (21.1) 137.3 (17.8) 133.0 (13.5) Total 118.0 (11.6) 117.7 (10.7) 117.8 (7.8) http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al Table 4. Simple correlations between time to task failure and factors entered into the linear regression analyses. Measures Healthy Low back pain r P value r P value Trunk mass −0.467 .02 −0.532 .01 Trunk length 0.180 .40 0.016 .94 Vertical trunk force 0.065 .76 −0.061 .78 Trunk moment −0.248 .24 −0.200 .35 Hip force −0.056 .80 −0.299 .16 Erector spinae MPF slope 0.616 .001 0.314 .14 Gluteus maximus MPF slope 0.440 .03 −0.174 .42 Biceps femoris MPF slope 0.513 .01 0.418 .04 Self-efficacy 0.525 .01 0.235 .27 Depression 0.128 .55 −0.194 .36 Pain catastrophizing −0.158 .46 −0.091 .67 Pain resilience −0.030 .89 −0.362 .08 Kinesiophobia −0.106 .62 −0.276 .19 MPF: median power frequency. Table 5. Significant factors identified by the linear regression analyses. Factor Unstandardized beta SE Standardized beta t P value Healthy (Constant) 301.32 10.20 — 7.50 <.001   Erector spinae MPF 140.21 45.17 .45 3.10 .01   Biceps femoris MPF 130.24 44.74 .40 2.91 .01   Trunk mass −1.12 0.49 −.32 −2.30 .03 Low back pain (Constant) 342.21 61.68 — 5.55 <.001   Trunk mass −2.08 0.48 −.67 −4.34 <.001   Kinesiophobia −3.56 1.27 −.43 −2.81 .01   Self-efficacy 1.15 0.49 .35 2.34 .03 MPF: median power frequency. exhibited a markedly longer TTF than those with any LBP Discussion experience [37]. Many studies have reported consistent findings; however, others have failed to find a difference in performance Principal Findings between those with and without LBP. Many physiological This study aimed to examine the performance on a variation of factors, including the BMI, trunk mass, MPF slopes of the trunk the Sørensen test using a virtual reality video game in and hip extensors, and maximal trunk and hip strength, have individuals with and without a history of recurrent LBP. To the been found to influence the performance on the task; these best of our knowledge, this is the first study to use a virtual factors have been discussed previously [34]. reality video game in conjunction with the Sørensen test. Although our sample of individuals with recurrent LBP Contrary to much of the published literature, we did not find a performed just as well on the virtual reality Sørensen test as significant difference in TTF between the groups. In the first those without LBP, several interesting findings regarding the longitudinal study, males with a short TTF on the Sørensen test factors associated with TTF emerged. In the healthy group, it were most likely to experience LBP in the following year, appears that TTF was driven primarily by trunk mass and the identifying the test as a predictor of first-time LBP [36]. The MPF slopes of the trunk and hip extensors, and this is consistent test was later recognized as a discriminator of those with and with our previous work [34]. In addition, trunk mass was a without LBP; individuals who had no prior LBP experience http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al predictor of TTF in the LBP group. Other studies also games are not effective in any form to counteract pain-related demonstrated the marked effects of anthropometrics on fear. performance. The workload of the task is governed by the weight Previous research has demonstrated an effect of sex on of the body above the hips. It is obvious that an individual with performance on the Sørensen test. Females tend to maintain the a heavier trunk mass will not be able to maintain the test position test position for longer than males [43,44]; however, several for as long as another individual with the same strength capacity studies have found no sex differences [45,46], and others have but lighter trunk mass. The effects of anthropometrics tend to found that males maintain the test position for longer than be consistent in both individuals with and without LBP. females [47-49]. We did identify a trend toward a sex difference Previously, marked associations have been identified between on TTF with females maintaining the position slightly longer body mass, BMI, and the MPF slope of ERS in males and than males (P=.06). Others have reported that healthy females females with and without LBP [38]. Moreover, a marked maintained an isometric trunk extension task markedly longer association between TTF and torso mass in females with and than healthy males [50]. The authors attributed their results to without LBP has been demonstrated [39]. Trunk mass is an the muscle mass and strength hypothesis, which describes the important factor in Sørensen test TTF, especially in those with relationship among the total muscle mass, vascular compression, a history of LBP, and should be considered when assessing and the demand for oxygen. According to this hypothesis, performance. A variation in the Sørensen test that normalizes because females typically have lower muscle mass, the the workload to a consistent percentage of maximal strength vasculature is less compressed during isometric exercise, and would account for differences in trunk mass and strength to the demand for oxygen to the active muscles is lower [51,52]. allow for a more objective assessment of endurance. There is some evidence that females have a greater ratio of type In this study, self-efficacy emerged as an important factor in I oxidative muscle fibers in the trunk extensors [53], which Sørensen test performance. Motivation has long been recognized would have a greater concentration of beta-2 adrenergic as a consequential factor in Sørensen test performance receptors, enhancing vasodilation [54]; there is also evidence [22,36,40-43]; however, to the best of our knowledge, we are that females have a greater degree of capillarization in some the first to attempt to manipulate it through the use of a virtual muscles [55], enhancing perfusion. However, others have reality video game. The self-efficacy measure was created demonstrated that intramuscular pressure may not be associated specifically for the Sørensen test task, which likely explains its with a shift in MPF during isometric trunk extension exercises strong association with TTF in the LBP group. Interestingly, [56,57]. Although muscle mass was not measured in this sample, self-efficacy was not predictive of performance in the healthy it is possible that TTF was influenced by perfusion. group. Thus, in this sample of individuals without a history of Limitations LBP, it appears that self-efficacy did not drive performance. As with any study of human subjects, this study is not without Alternatively, our sample of individuals with a history of its limitations. Our LBP group consisted of individuals with recurrent LBP performed better on the virtual reality Sørensen mild, recurrent LBP, which may have also restricted the sample test if they reported higher ratings of confidence in their capacity to individuals with low levels of disability and pain-related fear. to perform the task; this is consistent with our previous findings Individuals with higher disability and pain-related fear have on the standard Sørensen test [34] as well as those obtained by poorer rehabilitation outcomes and typically perform more others who found that performance was predicted, in part, by poorly on the Sørensen test. Thus, significant pain-related fear self-efficacy [22]. This would suggest that self-efficacy may be associations may have emerged in a sample of individuals with a worthwhile target for cognitive behavioral interventions for more severe kinesiophobia and disability symptoms. In addition, LBP. this group was primarily young, fit, college-aged students; future In addition, there was a significant effect of kinesiophobia in studies will benefit from measuring physical activity levels our LBP group; those who had lower TSK scores maintained a because cardiorespiratory fitness is likely associated with longer TTF on the virtual reality Sørensen test; this would performance on any endurance task, such as the Sørensen test. suggest that TSK is predictive of performance in individuals Conclusions with recurrent LBP when provided with a distraction element. On the classic version of the Sørensen test [34], TSK was not This study demonstrates that individuals with and without mild, predictive of performance in this same group of individuals recurrent LBP perform similarly on a variation of the Sørensen with recurrent LBP. The virtual reality video game may have test using a virtual reality video game, but the underlying actually exacerbated fear cognitions by blocking the participant’s mechanisms driving performance vary between the groups. view of the real world, reducing their sense of control, and Performance on this variation of the Sørensen test in healthy instead redirecting focus toward their pain-related fear. individuals is driven primarily by physiological factors, Moreover, it is possible that attentional resources were reduced including trunk mass and the MPF slopes of ERS and BF. In in response to the game. Future research could benefit from addition, trunk mass is an important factor of performance in investigating the response to different types of games to individuals with a history of recurrent LBP; however, levels of determine whether certain games are more effective or whether self-efficacy and kinesiophobia also appear to be important predictors of TTF on this virtual reality Sørensen test. http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al Conflicts of Interest None declared. References 1. Vlaeyen J, Morley S, Linton S, Boersma K, Jong J. Pain-Related Fear: Exposure-Based Treatment for Chronic Pain. Washington: IASP Press; 2012. 2. Simon LS. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Mil Med 2016 Dec;181(5):397-399. [doi: 10.7205/MILMED-D-16-00012] [Medline: 27136641] 3. 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[Medline: 20108857] Abbreviations BF: biceps femoris BMI: body mass index CES-D: Center for Epidemiological Studies-Depression DOF: degree of freedom EMG: electromyography ERS: erector spinae LBP: low back pain MPF: median power frequency PCS: Pain Catastrophizing Scale PRS: Pain Resilience Scale TSK: Tampa Scale for Kinesiophobia TSK-G: Tampa Scale for Kinesiophobia-General Population TTF: time to task failure Edited by G Eysenbach; submitted 28.03.18; peer-reviewed by B Atzori, M Alshehri; comments to author 26.04.18; revised version received 20.06.18; accepted 21.06.18; published 10.09.18 Please cite as: Applegate ME, France CR, Russ DW, Leitkam ST, Thomas JS Determining Physiological and Psychological Predictors of Time to Task Failure on a Virtual Reality Sørensen Test in Participants With and Without Recurrent Low Back Pain: Exploratory Study JMIR Serious Games 2018;6(3):e10522 URL: http://games.jmir.org/2018/3/e10522/ doi: 10.2196/10522 PMID: 30201604 ©Megan E Applegate, Christopher R France, David W Russ, Samuel T Leitkam, James S Thomas. Originally published in JMIR Serious Games (http://games.jmir.org), 10.09.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Applegate et al bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/3/e10522/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e10522 | p. 12 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Sep 10, 2018

Keywords: fatigue; low back pain; Sørensen test; trunk mass; virtual reality

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