A Randomized, Controlled, Crossover Trial of Virtual Reality in Maintenance Cardiovascular Rehabilitation in a Low-Resource Setting: Impact on Adherence, Motivation, and Engagement

Abstract

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 In the VR arm, participants had 1 VR session of the 3 per week during the initial 12 weeks of the trial; this was withdrawn the subsequent 12 weeks.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in adherence at 12 weeks (baseline = 72.87%; 12 weeks = 82.80%), with significant reductions at 24 weeks when VR was withdrawn (65.48%); in the usual CR care arm, there were no changes over time.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.

Effects of Exergaming in Patients with Cardiovascular Disease Compared to Conventional Cardiac Rehabilitation: A Systematic Review and Meta-Analysis

“…Regarding motivation, Jaarsma, Klompstra, Ben Gal, Ben Avraham, and Boyne [ 29 ] measured it directly through a validated motivation questionnaire and showed no differences between the two groups for improving motivation. In the same line, the study of da Cruz, Ricci-Vitor, Borges, da Silva, and Turri-Silva [ 51 ], which was excluded from our systematic review due to the inclusion of patients with cardiovascular risk factors, found that adding one session of exergaming to a conventional CR program (i.e., two weeks) significantly diminished motivation in patients with CVD or cardiovascular risk factors. Conversely, Garcia-Bravo, Cano-de-la-Cuerda, Dominguez-Paniagua, Campuzano-Ruiz, and Barrenada-Copete [ 42 ], who used a nonvalidated client satisfaction questionnaire, reported that patients found exergaming to be more motivating than conventional CR programs.…”

“…In brief, from a total of 1524 studies after deleting duplicates, 20 studies were eligible for full-text analysis after reviewing titles and abstracts. After reviewing the full texts, eight studies were included [ 24 , 28 , 29 , 38 , 39 , 40 , 41 , 42 ], and 12 were excluded for the following reasons: no exercise-based CR intervention ( n = 9) [ 22 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ], patients with other pathologies were also included ( n = 1) [ 51 ], the patients included were the same as another publication and study design did not fulfill our inclusion criteria ( n = 1) [ 52 ], and lack of information/abstract ( n = 1) [ 53 ]. Although efforts were made to localize unpublished studies, all included studies had been published in peer-reviewed journals.…”

An sEMG-Controlled Forearm Bracelet for Assessing and Training Manual Dexterity in Rehabilitation: A Systematic Review

“…Another advantage of VR observed in the studies included in this review is that it can improve user’s motivation, interest, adherence, and satisfaction towards therapy [ 7 , 9 , 10 ], and this is common to other studies that examine semi-immersive VR-based therapy in different disorders, such as cardiovascular diseases [ 33 , 34 ], brain damage [ 35 , 36 ], children and adults with CP [ 37 , 38 , 39 ], neurodegenerative diseases [ 40 , 41 ] or chronic pain [ 42 ].…”

Analysis of Barriers to Public and Private Cardiac Rehabilitation Programs in Patients with Low and High Adherence

“…In this context, some strategies have been proposed to improve adherence to CR, such as home rehabilitation [ 2 ] , unsupervised modalities, like using apps on mobile [ 23 ] , use of virtual reality in CR [ 24 ] , use of cognitive and behavioral elements, training for changes in lifestyle, presence of a doctor in the program area, and adequate space and equipment [ 25 ] . Besides, programs must be broad, simple, and low cost, these strategies being able to minimize the barriers found in this study.…”