The increasing use of retroflexion proctoscopy to evaluate the distal rectum is not without complications. We report a series of three patients who experienced extraperitoneal rectal perforation secondary to retroflexion proctoscopy and discuss our success with conservative management. By evaluating each clinical situation individually and following certain principles, successful outcome can be achieved without surgical intervention. Success depends on several factors: 1) the injury must be below the peritoneal reflection; 2) the patient must have undergone a complete bowel preparation before endoscopy; 3) postinjury, the patient must continue to show no evidence of peritonitis or hemodynamic instability; and 4) the patient must be given nothing by mouth, started on intravenous antibiotics and possibly parenteral nutrition, and closely monitored with serial abdominal examinations. The presence of comorbid conditions does not necessarily diminish the chance that conservative therapy will succeed.
We describe two case studies that use embodiment in virtual reality as a treatment for chronic low back pain. The purpose of this case series was to determine the feasibility of a novel virtual reality-based digital therapeutic for the treatment of chronic pain.Two patients with chronic low back pain received seven sessions, two sessions per week, of a novel digital therapeutic that combines virtual embodiment with graded motor imagery to deliver functional rehabilitation exercises using an off-the-shelf virtual reality system. Pain intensity was measured using a visual analog scale before and after each session to get an indication whether individual sessions of virtual embodiment training decrease pain intensity. Pain catastrophizing scale was assessed before the first session and after the seventh session to determine the extent to which virtual embodiment training can improve psychological symptoms of chronic low back pain.In both patients, pain intensity was improved after individual sessions of virtual embodiment training as measured by a paired t-test: (Patient A: t = 2.890, P < 0.05) and (Patient B: t = 5.346, P < 0.005). This indicates that individual sessions of virtual embodiment training decrease pain intensity. In both patients, improvements were observed in three subscales of the pain catastrophizing scale (rumination, magnification, and helplessness). This indicates that virtual embodiment training may have benefits for chronic pain symptoms such as pain intensity, pain-related mobility impairment, and disability.This case series provides evidence that embodiment in virtual reality improves symptoms of persistent chronic low back pain. We propose a mechanism by which virtual embodiment may improve chronic pain symptoms by recontextualizing sensory feedback from the body as patients engage in functional rehabilitation exercises while in virtual reality.
BACKGROUND Chronic pain has long been a major health burden that has been addressed through numerous forms of pharmacological and nonpharmacological treatment. One of the tenets of modern medicine is to minimize risk while providing efficacy. Further, because of its noninvasive nature, virtual reality (VR) provides an attractive platform for potentially developing novel therapeutic modalities. OBJECTIVE The purpose of this study was to determine the feasibility of a novel VR-based digital therapy for the treatment of chronic pain. METHODS An open-label study assessed the feasibility of using virtual embodiment in VR to treat chronic pain. In total, 24 patients with chronic pain were recruited from local pain clinics and completed 8 sessions of a novel digital therapeutic that combines virtual embodiment with graded motor imagery to deliver functional rehabilitation exercises over the course of 4 weeks. Pain intensity as measured by a visual analog scale before and after each virtual embodiment training session was used as the primary outcome measure. Additionally, a battery of patient-reported pain questionnaires (Fear-Avoidance Beliefs Questionnaire, Oswestry Low Back Pain Disability Questionnaire, Pain Catastrophizing Scale, and Patient Health Questionnaire) were administered before and after 8 sessions of virtual embodiment training as exploratory outcome measures to assess if the measures are appropriate and warrant a larger randomized controlled trial. RESULTS A 2-way ANOVA on session × pre- versus postvirtual embodiment training revealed that individual virtual embodiment training sessions significantly reduced the intensity of pain as measured by the visual analog scale (<i>P</i><.001). Perceived disability due to lower back pain as measured by the Oswestry Low Back Pain Disability Questionnaire significantly improved (<i>P</i>=.003) over the 4-week course of virtual embodiment regimen. Improvement was also observed on the helplessness subscale of the Pain Catastrophizing Scale (<i>P</i>=.02). CONCLUSIONS This study provides evidence that functional rehabilitation exercises delivered in VR are safe and may have positive effects on alleviating the symptoms of chronic pain. Additionally, the virtual embodiment intervention may improve perceived disability and helplessness of patients with chronic pain after 8 sessions. The results support the justification for a larger randomized controlled trial to assess the extent to which virtual embodiment training can exert an effect on symptoms associated with chronic pain. CLINICALTRIAL ClinicalTrials.gov NCT04060875; https://clinicaltrials.gov/ct2/show/NCT04060875
Presentation of CaseA 69-year-old woman was admitted to the hospital because of recurrent pain in the right lower abdominal quadrant and radiographic evidence of a cecal abnormality.The patient had been well until 44 days earlier, when fever and pain in the right lower quadrant developed, without nausea, vomiting, or diarrhea. Two days later she was admitted to another hospital. The white-cell count was 16,600 per cubic millimeter; the bilirubin level was 2.4 mg per deciliter (41 μmol per liter); other tests of liver function were negative. A Gastrografin-enema examination showed that the colon was normal except for considerable . . .
