Virtual reality and cardiac rehabilitation: a new middle-range theory to outline its mechanism of effectiveness

Background To reduce symptoms and improve outcomes in patients with cardiovascular diseases, international guidelines recommend cardiac rehabilitation. However, patients’ adherence to rehabilitation programs remains suboptimal, compromising its beneficial effects. Virtual reality has proven to be effective in enhancing adherence to rehabilitation in different fields (e.g., neurological and post-trauma). In the cardiological field, it has been proven effective in improving functional capacity and several psychological parameters (e.g., anxiety, depression, and emotional stress). Despite the increasing use of this digital technology, there is still a lack of information regarding its underlying mechanism of effectiveness. Purpose This middle-range theory aims to explain the mechanism of effectiveness of virtual reality in cardiac rehabilitation. Methods An inductive-deductive approach was used to develop this middle-range theory. Three steps were conducted including synthesis of key concepts, definition of the relationship between these concepts, and setting up of a hypothetical model. Results This middle-range theory proposes both proximal and distal outcomes of virtual reality. Proximal outcomes are classified as responses at the psychological (i.e., emotional stress, depression, and anxiety) and physical (i.e., exercise capacity) level, which, in turn, influence adherence to rehabilitation (i.e., distal outcome). Mediators of the relationship between virtual reality and outcomes are both at a proximal and distal level. The proximal mediators are activated at the neurological level to generate a multisensory experience of sight, hearing, and touch. This alters perception, by inducing an immersive altered state of consciousness and activating the distal mediators of attention, enjoyment, and sense of presence. The activation of the distal mediators promotes distraction from negative external stimuli related to the disease and healthcare setting and perception of positive emotions by interacting with the virtual world. Consequently, these mediators influence physical and psychological responses that enhance overall adherence to cardiac rehabilitation. Moderators of the relationship between virtual reality and rehabilitation adherence include age, gender, trust in technology, and cognitive status (Figure 1). Conclusions This middle-range theory aims to clarify the mechanism by which virtual reality enhances adherence to cardiac rehabilitation. Further qualitative and quantitative studies are warranted to test its hypothetical model.