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 In the VR arm, participants had 1 VR session of the 3 per week during the initial 12 weeks of the trial; this was withdrawn the subsequent 12 weeks.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in adherence at 12 weeks (baseline = 72.87%; 12 weeks = 82.80%), with significant reductions at 24 weeks when VR was withdrawn (65.48%); in the usual CR care arm, there were no changes over time.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

INTRODUCTIONCardiovascular rehabilitation (CR) programs are recommended in clinical guidelines, 1,2 because participation results in significantly lower mortality and morbidity, 3 including in low and middle-income countries (LMICs). 4 However, CR participation remains low, at around 20%-30% in high-income countries, [5][6][7] and 14% in LMICs such as Brazil. 8 The reasons for underuse of CR have been well-characterized in high-resource settings 7,9,10 and include factors at the healthcare system, provider and patient levels. However, barriers in lower-resource settings have not been well-studied. A recent review identified only 13 studies globally, 11 and there are also few studies in South America 12 or Brazil to date. [13][14][15][16] This is problematic, given the different contexts in these settings. Firstly, patients would be more socioeconomically disadvantaged, and hence face different barriers. Secondly, healthcare systems are more often two-tier. 17 So, for example, half of CR programs in Brazil are solely publicly-funded (53.3%), a third privately-funded, and the remainder a mixture. 18 It has been established that CR funding sources affect program characteristics, such as scale, healthcare providers on the team and component comprehensiveness. 17 However, to our knowledge, it has yet to be investigated how barriers might differ for patients accessing privately and publicly-funded programs in any country worldwide. 19 OBJECTIVESTherefore, the objectives of this study were to compare: (1) the sociodemographic and clinical characteristics of patients accessing publicly versus privately funded CR programs; and (2)

Introduction Participants in cardiac rehabilitation programs have low adherence to their sessions, which makes extremely important to recognize the barriers that cause non-adherence, identifying whether the type of service and level of adherence influence these barriers. Methods This is a cross-sectional observational study, in which 220 individuals (66.80±11.59 years) of both genders who are members of public and private exercise-based cardiac rehabilitation programs participated. The volunteers were divided according to the level of adherence, considering patients with low adherence (PLA) those with < 70% of attendance and high adherence (PHA) those with > 70%. Then, initial evaluation, Cardiac Rehabilitation Barriers Scale, analysis of socioeconomic level, Hospital Anxiety and Depression Scale, and Mini-Mental State Examination were applied. Results Higher total barriers were found in PLA in the public service compared to PHA in the private service (P=0.023). In the subscale “perceived need”, PHA in the public service showed higher values than PLA and PHA in the private service (P≤0.001). The “access” barrier was higher for PHA in the public service when compared to PHA in the private service (P=0.024). PHA in the public service exhibited a higher barrier regarding questions about distance, transportation problems, cost, and time constraints. Conclusion The public program presents higher barriers in the questions and categories compared to the private program, mainly the PHA. Furthermore, there are differences in the profile of the participants regarding socioeconomic and anxiety levels, treatment time, ethnicity, and city where they live.

OBJECTIVE: To assess the acute response of cardiac autonomic modulation (ACAM) during and after a session of virtual reality-based therapy (VRBT) compared to a session of conventional cardiovascular rehabilitation (CR) and to evaluate the effects of 12 weeks of training on this response. METHODS: We assessed 28 volunteers (63.39±12.48years). The ACAM was judged by linear indexes of heart rate variability (HRV) in VRBT and CR sessions. Later, patients completed 12 weeks of VRBT+CR and the assessment was repeated at the 12 th week. RESULTS: Throughout the 1 st VRBT session vagal withdrawal occurred (RMSSD/HFnu); sympathetic nervous system stimulation (LFnu) and progressive decrease of global HRV (SDNN). During the recovery, the SDNN, HFnu and LFnu improved from the 5 th minute on both therapies. After 12 weeks, the LFnu, HFnu and the LF/HF-ratio revealed no significant changes in Ex3-Ex4 equated to Rep during VRBT. In recovery, the HFnu and LFnu improved before the 5 th minute on both therapies. CONCLUSIONS: ACAM during and after the VRBT was comparable to CR, yet, the extents were greater in the VRBT. After 12 weeks of VRBT training, the subjects adapted to the exercises from the 15 th minute and exhibited faster recovery of HFnu and LFnu indexes compared to the 1 st week.