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\nThe 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.\n\n\nMETHODS\nThis study was a randomized, 1:1 concealed-allocation, single-blinded, 2 parallel-arm crossover trial. Blinded assessments were undertaken at baseline (mid-program), 12\xa0weeks, and 24\xa0weeks 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\xa0months. 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 In the VR arm, participants had 1 VR session of the 3 per week during the initial 12\xa0weeks of the trial; this was withdrawn the subsequent 12\xa0weeks. Measures were: program adherence (% of 3 sessions/week over 12\xa0weeks; 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.\n\n\nRESULTS\nSixty-one (83.6%) patients were randomized (n\xa0=\xa030 to CR\xa0+\xa0VR); 54 (88.5%) were retained at 12 and 24\xa0weeks. At baseline, participants had been in CR on average 7\xa0years and had high engagement and motivation. CR\xa0+\xa0VR resulted in a significant increase in adherence at 12\xa0weeks (baseline\xa0=\xa072.87%; 12\xa0weeks\xa0=\xa082.80%), with significant reductions at 24\xa0weeks when VR was withdrawn (65.48%); in the usual CR care arm, there were no changes over time.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\xa0+\xa0VR arm than usual CR at 12\xa0weeks (73.51%). Motivation decreased significantly from baseline to 12\xa0weeks (4.32 [SD\xa0=\xa00.37] vs 4.02 [SD\xa0=\xa00.76]) and significantly increased from 12 to 24\xa0weeks in the CR\xa0+\xa0VR arm (4.37 [SD\xa0=\xa00.36]). Absorption was significantly lower at 12\xa0weeks in the CR\xa0+\xa0VR arm (6.79 [SD\xa0=\xa00.37] vs 6.20 [SD\xa0=\xa01.01]).\n\n\nCONCLUSION\nAlthough VR increased program adherence, interspersing it with usual CR sessions actually decreased patient motivation and absorption.\n\n\nIMPACT\nSupplementing 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.