Many adults are physically inactive. While the reasons are complex, inactivity is, in part, influenced by the presence of negative feelings and low enjoyment during exercise. While virtual reality (VR) has been proposed as a way to improve engagement with exercise (e.g., choosing to undertake exercise), how VR is currently used to influence experiences during exercise is largely unknown. Here we aimed to summarize the existing literature evaluating the use of VR to influence motivation, affect, enjoyment, and engagement during exercise. A Population (clinical, and healthy), Concept (the extent and nature of research about VR in exercise, including underpinning theories), and Context (any setting, demographic, social context) framework was used. A systematic search of Medline, Scopus, Embase, PsycINFO, and Google Scholar was completed by two independent reviewers. Of 970 studies identified, 25 unique studies were included (n = 994 participants), with most (68%) evaluating VR influences on motivation, affect, enjoyment, and engagement during exercise in healthy populations (n = 8 studies evaluating clinical populations). Two VR strategies were prominent – the use of immersion and the use of virtual avatars and agents/trainers. All studies but one used virtual agents/trainers, suggesting that we know little about the influence of virtual avatars on experiences during exercise. Generally, highly immersive VR had more beneficial effects than low immersive VR or exercise without VR. The interaction between VR strategy and the specific exercise outcome appeared important (e.g., virtual avatars/agents were more influential in positively changing motivation and engagement during exercise, whereas immersion more positively influenced enjoyment during exercise). Presently, the knowledge base is insufficient to provide definitive recommendations for use of specific VR strategies to target specific exercise outcomes, particularly given the numerous null findings. Regardless, these preliminary findings support the idea that VR may influence experiences during exercise via multiple mechanistic pathways. Understanding these underlying mechanisms may be important to heighten effects targeted to specific exercise outcomes during exercise. Future research requires purposeful integration of exercise-relevant theories into VR investigation, and careful consideration of VR definitions (including delineation between virtual avatars and virtual agents), software possibilities, and nuanced extension to clinical populations.

Background Despite well-established benefits of physical activity for knee osteoarthritis (OA), nine of ten people with knee OA are inactive. People with knee OA who are inactive often believe that physical activity is dangerous, fearing that it will further damage their joint(s). Such unhelpful beliefs can negatively influence physical activity levels. We aim to evaluate the clinical- and cost-effectiveness of integrating physiotherapist-delivered pain science education (PSE), an evidence-based conceptual change intervention targeting unhelpful pain beliefs by increasing pain knowledge, with an individualised walking, strengthening, and general education program. Methods Two-arm, parallel-design, multicentre randomised controlled trial involving 198 people aged ≥50 years with painful knee OA who do not meet physical activity guideline recommendations or walk regularly for exercise. Both groups receive an individualised physiotherapist-led walking, strengthening, and OA/activity education program via 4x weekly in-person treatment sessions, followed by 4 weeks of at-home activities (weekly check-in via telehealth), with follow-up sessions at 3 months (telehealth) and 5 and 9 months (in-person). The EPIPHA-KNEE group also receives contemporary PSE about OA/pain and activity, embedded into all aspects of the intervention. Outcomes are assessed at baseline, 12 weeks, 6 and 12 months. Primary outcomes are physical activity level (step count; wrist-based accelerometry) and self-reported knee symptoms (WOMAC Total score) at 12 months. Secondary outcomes are quality of life, pain intensity, global rating of change, self-efficacy, pain catastrophising, depression, anxiety, stress, fear of movement, knee awareness, OA/activity conceptualisation, and self-regulated learning ability. Additional measures include adherence, adverse events, blinding success, COVID-19 impact on activity, intention to exercise, treatment expectancy/perceived credibility, implicit movement/environmental bias, implicit motor imagery, two-point discrimination, and pain sensitivity to activity. Cost-utility analysis of the EPIPHA-KNEE intervention will be undertaken, in addition to evaluation of cost-effectiveness in the context of primary trial outcomes. Discussion We will determine whether the integration of PSE into an individualised OA education, walking, and strengthening program is more effective than receiving the individualised program alone. Findings will inform the development and implementation of future delivery of PSE as part of best practice for people with knee OA. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12620001041943 (13/10/2020).

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Background and Aims This cross‐sectional study evaluated the nature of pain curriculum being taught in accredited exercise physiology degrees across Australian universities and its perceived usefulness for preparing exercise physiologists to treat people with chronic pain. Materials & Methods Universities and graduates were asked about the nature and sufficiency of pain curriculum taught, with particular emphasis on competencies for physical therapists as outlined by the International Association for the Study of Pain. Results Ten universities and 101 graduates responded. Median (interquartile range) instruction time on pain curriculum was 12 (7.25–18.75) hours. Few universities (30%) were aware of the guidelines for physical therapy pain curricula, although most (70%) agreed their degrees contained adequate instruction on pain assessment and management. In contrast, 74% of graduates felt their degree did not adequately prepare them to treat people with chronic pain. Half the graduates (51%) were not aware of the guidelines for physical therapy pain curricula. Discussion & Conclusion There is a disconnect between perceptions of Australian universities and their graduates regarding the sufficiency of pain curriculum taught to student exercise physiologists. Benchmarking pain curriculum in Australian university programs against relevant international recommendations may enhance the suitability of pain curricula taught to exercise physiologists, thereby better preparing new graduates to treat people with pain.