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

Abstract

The purpose of this study was to investigate the effects of adding virtual reality (VR) to maintenance cardiac rehabilitation (CR); it was hypothesized VR would increase adherence, motivation, and engagement. This study was a randomized, 1:1 concealed-allocation, single-blinded, 2parallel-arm, crossover trial. Blinded assessments were undertaken at baseline (midprogram), 12weeks, and 24weeks 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 3months or longer. 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 In the VR arm, participants had 1 VR session of the 3 per week during the initial 12weeks of the trial; this was withdrawn the subsequent 12weeks. Measures were program adherence (% of 3 sessions/week over 12weeks, 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. Sixty-one (83.6%) patients were randomly assigned (n=30 to CR+VR); 54 (88.5%) were retained at 12 and 24weeks. At baseline, participants had been in CR on average 7years and had high engagement and motivation. CR+VR resulted in a significant increase in adherence at 12weeks (baseline=72.87%; 12weeks=82.80%), with significant reductions at 24weeks when VR was withdrawn (65.48%); in the usual CR care arm, there were no changes over time.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 12weeks (73.51%). Motivation decreased significantly from baseline to 12weeks (4.32 [SD=0.37] vs 4.02 [SD=0.76]) and significantly increased from 12 to 24weeks in the CR+VR arm (4.37 [SD=0.36]). Absorption was significantly lower at 12weeks in the CR+VR arm (6.79 [SD=0.37] vs 6.20 [SD=1.01]). Although VR increased program adherence, interspersing it with usual CR sessions actually decreased patient motivation and absorption. Supplementing a maintenance CR program with VR using "exergames" resulted in significantly greater adherence (8% increase or 3 of 36 sessions), and this was quite a robust effect given it was extinguished with the removal of VR. However, contrary to the 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.