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Objective The purpose of this study was to investigate the effects of adding virtual reality (VR) to maintenance cardiac rehabilitation (CR); it was hypothesized to increase adherence, motivation, and engagement. Methods This study was a randomized, 1:1 concealed-allocation, single-blinded, 2 parallel-arm crossover trial. Blinded assessments were undertaken at baseline (mid-program), 12 weeks, and 24 weeks after baseline. The setting was a single CR program of unlimited duration in Brazil. Participants were patients with cardiovascular diseases or risk factors who had been in the program for ≥3 months. The CR program consisted of 3 supervised exercise sessions per week. In the VR arm, participants had 1 VR session of the 3 per week during the initial 12 weeks of the trial; this was withdrawn the subsequent 12 weeks. Measures were: program adherence (% of 3 sessions/week over 12 weeks; ascertained in all participants), motivation (Behavioral Regulation in Exercise Questionnaire 3), and engagement (User Engagement Scale, adapted; vigor, dedication, and absorption subscales); all 3 were primary outcomes. Results Sixty-one (83.6%) patients were randomized (n = 30 to CR + VR); 54 (88.5%) were retained at 12 and 24 weeks. At baseline, participants had been in CR on average 7 years and had high engagement and motivation. CR + VR resulted in a significant increase in adherence at 12 weeks (baseline = 72.87%; 12 weeks = 82.80%), with significant reductions at 24 weeks when VR was withdrawn (65.48%); in the usual CR care arm, there were no changes over time. There was a significant effect for arm, with significantly higher adherence in the CR + VR arm than usual CR at 12 weeks (73.51%). Motivation decreased significantly from baseline to 12 weeks (4.32 [SD = 0.37] vs 4.02 [SD = 0.76]) and significantly increased from 12 to 24 weeks in the CR + VR arm (4.37 [SD = 0.36]). Absorption was significantly lower at 12 weeks in the CR + VR arm (6.79 [SD = 0.37] vs 6.20 [SD = 1.01]). Conclusion Although VR increased program adherence, interspersing it with usual CR sessions actually decreased patient motivation and absorption. Impact Supplementing a maintenance CR program with VR using “exergames” resulted in significantly greater adherence (8% increase or 3/36 sessions), and this was quite a robust effect given it was extinguished with the removal of VR. However, contrary to hypotheses, offering 1 session of VR per week and 2 of usual CR exercise was related to lower motivation and absorption, which has implications for how clinicians design programs for this patient population.

Introdução: Diferenças relacionadas ao peso e às habilidades motoras em crianças em idade escolar ainda apresentam controvérsias. Objetivo: Analisar a relação entre desenvolvimento motor e nível de atividade física com o índice de massa corporal (IMC) de escolares com excesso de peso. ABSTRACT Introduction:In school-age children, differences in weight and motor skills are still controversial. Objective: To analyze the relation between motor development, level of physical activity, and body mass index (BMI) in children with overweight. Methods: 85 students of both genders, aged 6 to 10 years, living in Presidente Prudente, São Paulo, Brazil, were evaluated. The instruments used were: the classification of BMI/age, the Motor Development Scale and the Modified and Adapted Questionnaire of Level of Physical Activity. The sample was divided into two groups: the overweight group (OWG) was composed of 50 students with nutritional diagnosis of overweight and obesity; the normal weight group (NWG) was composed of 35 eutrophic students. The following tests were used for statistical analysis: Shapiro Wilk (data normality), Student's t test or Mann-Whitney (independent samples), Spearman's test (correlation) and χ 2 test (proportion), with significance level set at p<0.05. Results: The OWG had significantly lower results for general motor development (91.32±10.68 versus 97.14±9.06; p=0.010), fine motricity (93.21±21.59 versus 103.1±13.12; p=0.0138) and gross motricity (90.31±23.54 versus 112.6±16.07; p=0.0001). A significant positive correlation was found between level of physical activity and motor development in OWG subjects in the domains balance (0.35080; p=0.0125) and spatial organization (0.41820; p=0.0025). Conclusion: When OWG is compared to NWG, results are inferior for general motricity, fine motricity, and gross motricity.

INTRODUCTIONCardiovascular rehabilitation (CR) programs are recommended in clinical guidelines, 1,2 because participation results in significantly lower mortality and morbidity, 3 including in low and middle-income countries (LMICs). 4 However, CR participation remains low, at around 20%-30% in high-income countries, [5][6][7] and 14% in LMICs such as Brazil. 8 The reasons for underuse of CR have been well-characterized in high-resource settings 7,9,10 and include factors at the healthcare system, provider and patient levels. However, barriers in lower-resource settings have not been well-studied. A recent review identified only 13 studies globally, 11 and there are also few studies in South America 12 or Brazil to date. [13][14][15][16] This is problematic, given the different contexts in these settings. Firstly, patients would be more socioeconomically disadvantaged, and hence face different barriers. Secondly, healthcare systems are more often two-tier. 17 So, for example, half of CR programs in Brazil are solely publicly-funded (53.3%), a third privately-funded, and the remainder a mixture. 18 It has been established that CR funding sources affect program characteristics, such as scale, healthcare providers on the team and component comprehensiveness. 17 However, to our knowledge, it has yet to be investigated how barriers might differ for patients accessing privately and publicly-funded programs in any country worldwide. 19 OBJECTIVESTherefore, the objectives of this study were to compare: (1) the sociodemographic and clinical characteristics of patients accessing publicly versus privately funded CR programs; and (2)

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