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, IrelandMaureen.simmonds@mcgill.ca

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!!