Enhancing Exercise and Education in Cardiac Rehabilitation
Cardiac rehabilitation is a vital part of recovery following a cardiac event, such as a heart attack or heart failure. This necessary treatment decreases morbidity and mortality rates and improves overall patient outcomes. Yet, according to the CDC and the AHA, only about one-third of all eligible patients participate in cardiac rehab treatment, and even fewer complete their recommended number of rehabilitation sessions. We introduced a virtual walking trail system, Bionautica Trails from Plas.md, to provide patients with a novel way to engage with their treatment and to reinforce the education they receive during cardiac rehab.
Opportunity
Social, economic, and cultural factors play a part in the lack of participation in cardiac rehabilitation. Even after accounting for these factors, many patients exhibit a lack of understanding as to why cardiac rehab is essential — or they lack the motivation to attend treatment sessions. With so much room for growth, we identified the opportunity to address patient understanding and motivation through a randomized controlled trial focused on patient adherence, attendance, satisfaction, and retention.
Education is a fundamental part of cardiac rehab sessions. At many centers, including the Jefferson Health Methodist Cardiac Rehabilitation facility where this study took place, the volume and scheduling of patients limits staff from providing one-on-one education on a regular basis. Most educational materials are distributed in paper format — either on a bulletin board or as a handout. To address this, we created audio versions of these cardiac education facts and included them as part of the virtual walking trails. While patients walked on the treadmill, tokens would appear on the trail in front of them. When a patient “walked through” the token, this would trigger a random fact to play. This was inspired by research that shows patients are more likely to participate in treatment when given both auditory and visual cardiac education. By inserting educational materials into a more dynamic format, we also hoped to improve patient motivation to attend sessions and improve their retention of heart health knowledge.
Challenges
With technology like Bionautica Trails, it is difficult to double-blind study patients or staff when they can, quite literally, see the treatment. As blinding was not possible in this case, we decided to instead reduce bias by blinding patients to the study hypothesis. Essentially, patients were randomly selected for each group and not told what the different groups were. This meant we could not include the terms “virtual reality” or “virtual walking trails” in the consent process. To account for this, at the end of the study patients were debriefed — and if they were part of the control group, they were given the chance to try the virtual intervention.
Another challenge we faced was how best to include virtual reality technology into cardiac rehab. We chose to use a vertically oriented television screen and wireless headphones to create a sense of immersion for patients without increasing their risk of falling. With any project, it is important to fit the solution to the needs of the patient population, as well as to the needs of their healthcare providers.
Finally, when introducing a new tool to existing treatment, it is crucial to pick outcome measures that reflect the way patients will engage with the tool. For this project, we chose to use the six-minute-walk-test (6MWT) as a measurement of patient outcome. This is a standardized measure for assessing patients’ progression during treatment by comparing how far they can walk for a six-minute duration at their first and last treatment sessions.
Vision and Value
This study helped shape how we design research for patients. By working directly with healthcare providers, we set a precedent that all our research would be collaborative and feasible for integration into everyday care. We also learned the importance of adapting technology to fit patient care — rather than the other way around.
This project was completed in 2019, and while our results did not show the statistically significant improvements we had hoped, the program proved to be quite popular with patients. This was true regardless of all recorded patient demographics, including age. It is still in use at the Jefferson Health Methodist Cardiac Rehabilitation Center.
This initiative was to be presented as part of the 2020 Virtual Medicine Conference poster presentation (prior to COVID-19 related cancellation), and the results of the study are being submitted for publication in the Journal of Medical Internet Research (JMIR).
About the XR Lab
The XR Lab at The DICE Group is a multidisciplinary team passionate about transforming healthcare and education through immersive technology. They believe that XR should be easily accessible to everyone and that it has the potential to transform the healthcare experience.
Interested in how VR affects cardiac rehab and patient experience? Want to support projects like this? Contact us anytime at ARVR@jefferson.edu. Subject: CR.
