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

OBJECTIVE

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.

METHODS

This study was a randomized, 1:1 concealed-allocation, single-blinded, 2 parallel-arm, crossover trial. Blinded assessments were undertaken at baseline (midprogram), 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 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 In the VR arm, participants had 1 VR session of the 3 per week during the initial 12 weeks of the trial; this was withdrawn the subsequent 12 weeks.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 randomly assigned (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in adherence at 12 weeks (baseline = 72.87%; 12 weeks = 82.80%), with significant reductions at 24 weeks when VR was withdrawn (65.48%); in the usual CR care arm, there were no changes over time.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 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.

Psychometric validation of the short version of the Information Needs in Cardiac Rehabilitation scale through a first global assessment

AIMS

Tailored education is recommended for cardiac patients, yet little is known about information needs in areas of the world where it is most needed. This study aims to assess (i) the measurement properties of the Information Needs in Cardiac Rehabilitation short version (INCR-S) scale and (ii) patient's information needs globally.

METHODS AND RESULTS

In this cross-sectional study, English, simplified Chinese, Portuguese, or Korean versions of the INCR-S were administered to in- or out-patients via Qualtrics (January 2022-November 2023). Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated recruitment. Importance and knowledge sufficiency of 36 items were rated. Links to evidence-based lay education were provided where warranted. A total of 1601 patients from 19 middle- and high-income countries across the world participated. Structural validity was supported upon factor analysis, with five subscales extracted: symptom response/medication, heart diseases/diagnostic tests/treatments, exercise and return-to-life roles/programmes to support, risk factors, and healthy eating/psychosocial management. Cronbach's alpha was 0.97. Construct validity was supported through significantly higher knowledge sufficiency ratings for all items and information importance ratings for all subscales in cardiac rehabilitation (CR) enrolees vs. non-enrolees (all P < 0.001). All items were rated as very important-particularly regarding cardiac events, nutrition, exercise benefits, medications, symptom response, risk factor control, and CR-but more so in high-income countries in the Americas and Western Pacific. Knowledge sufficiency ranged from 30.0 to 67.4%, varying by region and income class. Ratings were highest for medications and lowest for support groups, resistance training, and alternative medicine.

CONCLUSION

Identification of information needs using the valid and reliable INCR-S can inform educational approaches to optimize patients' health outcomes across the globe.

Publicly versus privately funded cardiac rehabilitation: access and adherence barriers. A cross-sectional study

BACKGROUND

Cardiac rehabilitation (CR) barriers are well-understood in high-resource settings. However, they are under-studied in low-resource settings, where access is even poorer and the context is significantly different, including two-tiered healthcare systems and greater socioeconomic challenges.

OBJECTIVE

To investigate differences in characteristics of patients attending publicly versus privately funded CR and their barriers to adherence.

DESIGN AND SETTING

Observational, cross-sectional study in public and private CR programs offered in Brazil.

METHODS

Patients who had been attending CR for ≥ 3 months were recruited from one publicly and one privately funded CR program. They completed assessments regarding sociodemographic and clinical characteristics and the CR Barriers Scale.

RESULTS

From the public program, 74 patients were recruited, and from the private, 100. Participants in the public program had significantly lower educational attainment (P < 0.001) and lower socioeconomic status (P < 0.001). Participants in the private program had more cognitive impairment (P = 0.015), and in the public program more anxiety (P = 0.001) and depressive symptoms (P = 0.008) than their counterparts. Total barriers among public CR participants were significantly higher than those among private CR participants (1.34 ± 0.26 versus 1.23 ± 0.15/5]; P = 0.003), as were scores on 3 out of 5 subscales, namely: comorbidities/functional status (P = 0.027), perceived need (P < 0.001) and access (P = 0.012).

CONCLUSION

Publicly funded programs need to be tailored to meet their patients' requirements, through consideration of educational and psychosocial matters, and be amenable to mitigation of patient barriers relating to presence of comorbidities and poorer health status.

Perfil do desenvolvimento motor em escolares com excesso de peso

Introdução: Diferenças relacionadas ao peso e as habilidades motoras em crianças em idade escolar ainda apresentam controversias. 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. Métodos: Foram avaliados 85 escolares de ambos os sexos, de 6 a 10 anos, de Presidente Prudente, São Paulo, Brasil. Os instrumentos utilizados foram a classificação do IMC/idade, a Escala de Desenvolvimento Motor e o Questionário do Nível de Atividade Física Modificado e Adaptado. A amostra foi dividida em dois grupos: grupo com excesso de peso (GEP), com 50 escolares com diagnostico nutricional de sobrepeso e obesidade; e grupo com normopeso (GNP), com 35 escolares eutroficos. Para analise dos dados obtidos foram utilizados: Shapiro Wilk (normalidade), teste t de Student não pareado ou Mann Whitney (amostras independentes), teste de Spearman (correlação) e teste do χ2 (proporção), com nível de significância p<0,05. Resultados: O GEP apresentou resultados inferiores significantes no desenvolvimento motor geral (91,32±10,68 versus 97,14±9,06; p=0,010), nas áreas de motricidade fina – QM1 (93,21±21,59 versus 103,1±13,12; p=0,0138) e motricidade global – QM2 (90,31±23,54 versus 112,6±16,07; p<0,0001). Observou-se correlação positiva significativa entre o nível de atividade física e o desenvolvimento motor no GEP, nas áreas de equilibrio – QM3 (0,35080; p=0,0125) e organização espacial – QM5 (0,41820; p=0,0025). Conclusão: O GEP, quando comparado com o GNP, demonstrou resultados inferiores no quociente motor geral (QMG), QM1 e QM2.

Perceptions and preferences of patients with cardiac conditions to the inclusion of virtual reality-based therapy with conventional cardiovascular rehabilitation: A qualitative study

BACKGROUND

Virtual reality-based therapy (VRBT) has been recently used in rehabilitation programs, as it can improve patient's adherence to treatment. However, patients' acceptance of VRBT has been scarcely investigated.

OBJECTIVE

To qualitatively analyze the perceptions and preferences of patients about the inclusion of VRBT to a conventional cardiovascular rehabilitation program (CRP).

METHODS

Fifteen patients from a randomized clinical trial participated in focus groups for qualitative assessment.

RESULTS

Patients demonstrated good acceptance and satisfaction of VRBT. Physical and psychosocial benefits were highlighted, and patients reported the perception of higher exercise intensity in VRBT then when doing conventional training. In addition, the frequency of VRBT (once a week), associated with conventional treatment was reported as satisfactory. Cognitive aspects that influenced participation to the new approach were also raised by study participants.

CONCLUSION

Patients with cardiac conditions demonstrated satisfaction with the inclusion of VRBT in a conventional CRP, demonstrating that VRBT has the potential to be a new approach for this patient population, allowing training diversification. Benefits perceived by patients include physical, mental, and social aspects.

TRIAL REGISTERED

NCT04336306 (https://clinicaltrials.gov/ct2/show/NCT04336306).

Translation, Cultural Adaptation of the Portuguese Provider Attitudes toward Cardiac Rehabilitation and Referral (PACRR-P) Scale and Assessment of Its' Measurement Properties

BACKGROUND/OBJECTIVES

Access to cardiac rehabilitation (CR) is contingent upon physician referrals, yet these are often inadequate, particularly in low-resource settings. This multi-method study aimed to translate, culturally adapt, and validate the Portuguese version of the Provider Attitudes toward CR and Referral (PACRR-P) scale, as well as to identify key factors influencing CR referral in a Latin American context for the first time.

METHODS

The PACRR was translated into Brazilian Portuguese through a rigorous process involving independent translation, back-translation, and expert panel review to ensure face, content, and cross-cultural validity. A total of 44 Brazilian physicians completed the questionnaire, allowing for an assessment of internal consistency, criterion validity, and convergent validity.

RESULTS

The findings confirmed the face, content, and cultural validity of the 20 translated items, with a mean item clarity rating of 4.8/5. The final version included 17 of the original 19 PACRR-P items, with a Cronbach's alpha of 0.73. Referral rates were significantly associated with over one-third of the PACRR-P items, preliminarily supporting the scale's criterion validity, while correlations with the ReCaRe scores further supported its convergent validity. The most prominent barriers to referral were a lack of familiarity with CR site locations, absence of a standard referral form, and lack of automatic referral processes.

CONCLUSIONS

The PACRR's validity and reliability among Portuguese-speaking providers are preliminarily supported.

Psychometric validation of the Cardiac Rehabilitation Barriers Scale Revised (CRBS-R) for hybrid delivery

OBJECTIVE

To test the measurement properties of the revised version of the English Cardiac Rehabilitation Barriers Scale (CRBS-R), suitable for hybrid delivery, structural validity, internal reliability, as well as face, cross-cultural, construct and criterion validity were assessed.

DESIGN

Cross-sectional study, where participants completed an online survey via Qualtrics (2023-2024).

SETTING

Multicentre, with cardiac rehabilitation (CR) programmes recruiting patients globally; most patients stemmed from a hybrid programme in Iran and supervised programme in Brazil.

PARTICIPANTS

Participants include inpatients or outpatients with a cardiovascular diagnosis or procedure that is indicated for participation in CR.

MEASURES

In addition to sociodemographic and CR use items, the 21-item CRBS-R was administered. It assesses multilevel barriers and was revised based on a literature review. Responses range from 1 to 5, with higher scores indicating greater barriers.

RESULTS

235 patients participated from all 6 WHO regions. Items were rated as highly applicable, and open-ended responses revealing no key barriers were omitted, supporting face and cross-cultural validity. Cronbach's α for the total CRBS-R was 0.82. Principal components analysis resulted in the extraction of 4 components, which collectively accounted for 60.5% of the variance and were all internally consistent. Construct validity was supported by associations of total CRBS scores with work status (p=0.04), exercise history (p=0.01) and social support (p=0.03). Total CRBS-R scores were significantly lower in patients who were referred and enrolled versus those who were not (both p≤0.01), confirming criterion validity.

CONCLUSIONS

The CRBS-R is a reliable and valid scale comprising four subscales, applicable to hybrid CR across diverse settings. It can serve as a valuable tool to support identification of patient's CR barriers, to optimise secondary prevention utilisation globally.