Immersive virtual reality in cycle ergometer exercise for hospitalised heart failure patients: a three-phase implementation study

Background

Heart failure (HF) affects millions globally, with exercise intolerance significantly impairing quality of life. Cardiac rehabilitation (CR) improves functional capacity and reduces hospitalisations, yet adherence remains critically low worldwide (< 20% globally1,2; 1–3% Brazil3,4). Barriers include perceived monotony, low motivation, and anxiety/depression symptoms. immersive virtual reality (IVR) offers an innovative approach via multisensory engagement and gamification, potentially enhancing adherence and clinical outcomes.

Purpose

To describe three implementation phases evaluating immersive virtual reality integrated with cycle ergometer exercise in hospitalised HF patients, assessing exercise performance, usability, and satisfaction.

Methods

A three-phase sequential implementation design:

• Phase 1 (Scoping Review, 2021)5: Researcher search across 7 databases (2000–2019) identified 51 articles; 3 met inclusion criteria. Analysed VR integration in CR programmes for cardiac patients.

• Phase 2 (Pilot Study, 2021–2023)6: Prospective cross-sectional study with 10 HF patients (LVEF ≤ 50%). Single-session, 20-minute cycle ergometer exercise with immersive VR and continuous haemodynamic monitoring. Primary outcomes: usability (System Usability Scale, SUS), exercise enjoyment (Physical Activity Enjoyment Scale, PACES), psychological symptoms (Hospital Anxiety and Depression Scale, HADS).

• Phase 3 (REVIVE-HF Trial, 2024–2027): Randomised controlled trial, parallel allocation (1:1), comparing IVR-augmented cycle ergometer exercise versus conventional exercise. Single 20-minute session comprising five 3-minute pedalling blocks with 1-minute rest intervals. Primary outcome: exercise performance. Secondary outcomes: perceived exertion, haemodynamic parameters, exercise enjoyment, usability. Continuous electrocardiographic monitoring ensured safety.

Results

• Phase 15: Prior literature (n=68 patients across 3 studies) demonstrated VR increased peak VO₂, reduced perceived exertion, prolonged exercise duration, and enhanced motivation. Proposed mechanisms: (1) multisensory distraction; (2) gamification; (3) autonomic modulation; (4) psychological modification.

• Phase 26: Mean SUS score 68.2 ± 17.8 (good usability); mean PACES score 79.6 ± 7.7 (high enjoyment). Severely affected HF patients (mean LVEF 27.8%) with anxiety/depression symptoms accepted IVR technology. Baseline psychological status showed no correlation with usability or enjoyment perception.

• Phase 3: Patient recruitment ongoing; final results anticipated Q2 2027.

Conclusions

Immersive virtual reality demonstrates potential effectiveness for CR in HF patients through psychological modification mechanisms, with broad applicability independent of baseline psychological status. Completion of Phase 3 data collection will provide definitive evidence regarding effectiveness, guiding clinical implementation pathways.