Using embodied illusions and therapeutic touch to modulate chronic pain:
An Active Inference approach to chronic pain management.
Overview
Chronic pain affects around 30% of the global population and imposes significant personal and economic burdens [1]. In the UK, musculoskeletal (MSK) conditions account for 84% of chronic pain cases [2], with back pain alone costing the economy £1.6 billion in direct costs and £10 billion in indirect costs [3]. Many sufferers experience persistent pain, with 34% reporting no improvement over six years.
Traditionally, chronic pain was linked to physical damage, but 90% of chronic low back pain cases are classified as nonspecific [5], shifting the focus to brain-based pain processing [6]. Pain perception involves exteroception (external sensory input) and interoception (internal bodily states) [7]. Emerging research suggests pain is shaped by predictive brain models, where expected pain can persist despite no nociceptive input [6]. These expectations are influenced by contextual cues [8, 9,10], including therapeutic relationships and touch, which can be modulated, as explained by an Active Inference mechanism, to reshape pain models [11].
Virtual Reality (VR) has shown promise in pain modulation by altering sensory prediction errors [12,13]. A novel intervention combining VR with Manual Therapy (MTVR) could enhance expectation-based pain relief by leveraging embodiment and sensory illusions [14]. MTVR is an embodied virtual reality environment where both external therapeutic touch is combined with body illusions (e.g. colour change in virtual body part in pain) that leverage shifts in brain prior beliefs about pain that then reduce pain through active inference mechanisms.
Project Contact:
Professor Dave Newell
Email: dnewell@aecc.ac.uk
Details
This study will explore the feasibility and acceptability of MTVR in modulating chronic pain perception by:
- Review of existing evidence of pain modulation through body illusions
- Testing a proof-of-concept intervention combining manual therapy with VR.
- Assessing feasibility, usability, and patient engagement.
- Measuring pain perception changes using self-reported pain levels before, during, and after sessions.
MTVR is being developed through a Research Innovation Funding grant in collaboration with AUB, with proof-of-concept expected before the PhD starts. The project will consist of 3-4 linked studies within the proposed Pain Active Inference Lab (PAIn Lab) at HSU:
- Systematic Review – Evaluating literature on pain modulation through Active Inference, therapeutic touch, and VR.
- Experimental Testing – HSU students will assess MTVR usability and its impact on pain modulation using experimental pain methodologies, refining the intervention iteratively.
- Clinical Feasibility Study – Recruiting a large cohort of chronic pain patients through HSU clinics to assess patient usability and feasibility. A subgroup will test haptic vests to enable home-based MTVR use.
The study anticipates that MTVR will:
- Be a feasible and acceptable intervention for chronic pain.
- Significantly reduce pain during treatment sessions by reinforcing predictive coding mechanisms.
- Establish groundwork for clinical trials assessing MTVR as a chronic pain intervention.
If successful, this study could:
- Offer an innovative, non-pharmacological chronic pain intervention.
- Reduce healthcare burdens through scalable, home-based VR solutions.
- Contribute to digital therapeutics by integrating manual therapy, sensory feedback, and immersive VR for optimized pain relief.
Funding 
We have funding available via fee-waiver support for up to three UK home students. Applicants are asked to make it clear as part of their application that they are applying for this opportunity. Decisions will be made based on the excellence of the candidate.
Self-funded students are also welcome to apply for this project. Self-funded students can be UK home students or international students.
Availability
Available to both UK and International students.
Potential Supervisors
- Professor Dave Newell, Professor of Integrated Musculoskeletal Care
- Dr Alister Du Rose, Senior Lecturer (Clinical Sciences)
Advisors:
- Jorge Esteves, Professor Coordinator, Escola Superiror de Saude Atlantica, Portugal
- Mick Thacker, Professor of Pain, Royal College of Surgeons in Ireland
- Dr Keith Walker, School of Health Professions, Plymouth University
References
Steven P Cohen, Lene Vase, William M Hooten. Chronic pain: an update on burden, best practices, and new advances. The Lancet. Volume 397, Issue 10289, 2021, Pages 2082-2097,
The State of MSK Health 2021 (https://www.versusarthritis.org/media/24653/state-of-msk-health2-2021.pdf ).
Maniadakis, N. & Gray, A. (2000). The economic burden of back pain in the UK. Pain. 84(1), 95-103. DOI: 10.1016/S0304-3959(99)00187-6
Chronic pain in adults 2017: Health Survey for England (Chronic pain in adults 2017: Health Survey for England)
Low back pain World Health Organisation
Ongaro G, Kaptchuk TJ. Symptom perception, placebo effects, and the Bayesian brain. Pain. 2019 Jan;160(1):1-4. doi: 10.1097/j.pain.0000000000001367. PMID: 30086114; PMCID: PMC6319577.
Di Lernia D, Lacerenza M, Ainley V, Riva G. Altered Interoceptive Perception and the Effects of Interoceptive Analgesia in Musculoskeletal, Primary, and Neuropathic Chronic Pain Conditions. Journal of Personalized Medicine. 2020; 10(4):201. https://doi.org/10.3390/jpm10040201
Cook CE, Bailliard A, Bent JA, Bialosky JE, Carlino E, Colloca L, Esteves JE, Newell D, Palese A, Reed WR, Vilardaga JP, Rossettini G (2023). An international consensus definition for contextual factors: findings from a nominal group technique. Front Psychol. 2023 Jul 3;14:1178560. doi: 10.3389/fpsyg.2023.1178560. PMID: 37465492; PMCID: PMC10351924.
Sherriff B, Clark C, Killingback C, Newell D (2022). Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review. Chiropr Man Therap. 2022 Apr 21;30(1):20. doi: 10.1186/s12998-022-00430-8. PMID: 35449074; PMCID: PMC9028033.
Rossettini G, Camerone EM, Carlino E, Benedetti F, Testa M (2020). Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy. Arch Physiother. 2020 Jun 11;10:11. doi: 10.1186/s40945-020-00082-y. PMID: 32537245; PMCID: PMC7288522.
McParlin, Zoe & Cerritelli, Francesco & Manzotti, Andrea & Friston, Karl & Esteves, Jorge. (2023). Therapeutic touch and therapeutic alliance in pediatric care and neonatology: An active inference framework. Frontiers in Pediatrics. 11. 10.3389/fped.2023.961075.
Riva G, Wiederhold BK, Mantovani F. Neuroscience of Virtual Reality: From Virtual Exposure to Embodied Medicine. Cyberpsychol Behav Soc Netw. 2019 Jan;22(1):82-96.
Cerritelli F, Chiera M, Abbro M, Megale V, Esteves J, Gallace A, Manzotti A. The Challenges and Perspectives of the Integration Between Virtual and Augmented Reality and Manual Therapies. Front Neurol. 2021 Jun 30;12:700211.
Hadjiat Y and Marchand S (2022). Virtual Reality and the Mediation of Acute and Chronic Pain in Adult and Pediatric Populations: Research Developments. Front. Pain Res. 3:840921. doi: 10.3389/fpain.2022.840921
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