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Research Report

Effect of a Virtual Reality–Enhanced


Exercise Protocol After Coronary
Artery Bypass Grafting
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

Background and Purpose. Virtual reality (VR) technology has gained impor-
tance in many areas of medicine. Knowledge concerning the application and
the influence of VR-enhanced exercise programs is limited for patients
receiving coronary artery bypass grafting. The purpose of this study was to
evaluate the effect of a virtual “country walk” on the number of sessions
necessary to reach cardiac rehabilitation goals in patients undergoing coro-
nary artery bypass grafting. Subjects. Twenty subjects who were seen for
cardiac rehabilitation between January and June 2004 comprised the study
sample. Methods. The protocol for this study included an initial maximum
graded exercise tolerance test, given to determine the subsequent training
goals for the subject, followed by biweekly submaximal endurance training
sessions. All subjects were assigned by lot to 1 of 2 submaximal endurance
training programs, one (group 2) with and the other (group 1) without the
added VR environment. In all other respects, the 2 programs were identical.
Each training session lasted for 30 minutes and was carried out twice per week
for about 3 months. The primary outcome measures were maximum load
during the work sessions, target oxygen consumption, target heart rate (beats
per minute), and number of training sessions required to reach rehabilitation
goals. Results. By the end of 20 training sessions, only 4 of the 10 control
subjects had reached the heart rate target goal of 85% their maximum heart
rate. In contrast, 9 of the 10 subjects in the VR program had attained this goal
by 9 or fewer training sessions. When target metabolic cost (75% peak oxygen
consumption) was used as the training goal, all 10 subjects in the VR program
had reached this target after 2 training sessions (or, in some cases, 1 training
session), but not until training session 15 did a cumulative number of 9
control subjects reach this goal. Discussion and Conclusion. These study
outcomes clearly support the notion that incorporating a VR environment
into cardiac rehabilitation programs will accelerate maximum recovery of
patients’ cardiovascular function. [Chuang TY, Sung WH, Chang HA, Wang
RY. Effect of a virtual reality– enhanced exercise protocol after coronary artery
bypass grafting. Phys Ther. 2006;86:1369 –1377.]

Key Words: Cardiopulmonary test, Endurance exercise, Rehabilitation, Revascularization, Simulation.

Tien-Yow Chuang, Wen-Hsu Sung, Hwa-Ann Chang, Ray-Yau Wang


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Physical Therapy . Volume 86 . Number 10 . October 2006 1369


R
esearch over the past decade has shown that term, simulation-based exercise training of people with
virtual reality (VR)– enhanced programs can cardiovascular disorders had not yet been investigated in
be effective in the treatment of patients recov- any systematic studies. Cardiac rehabilitation programs
ering from brain injury or with psychological are increasingly used by patients who have undergone
disorders.1– 4 Virtual reality technology also can be suc- coronary artery bypass grafting (CABG).8 Over succes-
cessfully incorporated into exercise programs. For sive sessions, the patients’ increasing physical endurance
instance, a patient on a stationary cycle ergometer and is matched by a similar increase in the training load used
provided with a VR display and 3-dimensional (3D) during these sessions. In an investigation of the effects of
stereo headphones can go for a virtual “ride in the hills” VR on patients who were receiving cardiac rehabilita-
during an exercise session. To ensure that the patient is tion, Chuang et al9 showed that the VR group achieved
carrying out the prescribed exercise properly, perfor- significantly higher values than the non-VR group for
mance can be monitored online.5 Virtual reality– peak oxygen consumption (V̇o2peak), peak metabolic
enhanced exercise programs have been shown to gener- equivalents, and V̇o2 level at which the anaerobic thresh-
ate feelings of positive involvement, revitalization, and old was reached when these values were measured in
calmness in participants.5 These feelings have enabled follow-up maximum exercise tests. The patients in that
the training periods to become more intense and to last investigation trained on a treadmill, either without the
longer.6 As our team previously reported, VR-based VR experience or with the treadmill linked by computer
rehabilitation can assist senior citizens who are healthy to a visual screen with a wide field of view, 3D auditory
in maintaining endurance, increasing their target exer- inputs and accelerator cards, and a graphic user inter-
cise intensity, and enhancing their total energy con- face allowing speeds and changes in the incline of the
sumption during exercise.7 In that experiment, elderly treadmill to be synchronized with changes in the scenery
subjects who were healthy exercised on friction-braked on the screen. Heart rate, blood pressure, and V̇o2 were
ergometers connected by computer to a flat screen monitored in both groups as in the previous experiment
depicting a country road with 2 cyclists riding on it. The with healthy subjects. After training twice weekly for 3
flow on the screen was matched to the speed of the months on the treadmill, the VR group achieved better
ergometer, and subjects were instructed to cycle at a cardiac performance (as shown by a higher V̇o2peak) on
pace equal to that of the riders on the screen as the the follow-up exercise tests than the control group. The
experimenter adjusted the load on the ergometer present study, therefore, was designed to examine the
according to the protocol and recorded the subject’s effect of VR-enhanced programs for patients with CABG
blood pressure, heart rate (HR), and oxygen consump- on the number of training sessions needed to reach
tion (V̇o2). target physiologic endpoints (which were, in this study,
85% maximum HR [HRmax] and 75% V̇o2peak).
Although better performance in subjects who were
healthy was shown by that experiment, the effect of the
VR environment on exercise capacity outcomes of long-

TY Chuang, MD, is Attending Physician and Associate Professor, Department of Physical Medicine and Rehabilitation, Taipei Veterans General
Hospital, No. 201, Shih-Pai Rd, Sec. 2, Taipei, 11217 Taiwan, and School of Medicine, National Yang-Ming University, Taipei, Taiwan. Address all
correspondence to Dr Chuang at: tychuang@vghtpe.gov.tw.

WH Sung, PhD, is Assistant Professor, Department of Biomedical Engineering, I-Shou University, Kaohsiung, Taiwan.

HA Chang, PT, MS, is Physical Therapist and Research Associate, Department of Physical Medicine and Rehabilitation, Taipei Veterans General
Hospital.

RY Wang, PT, PhD, is Professor and Acting Chairman, Institute and Faculty of Physical Therapy, National Yang-Ming University.

Dr Chuang and Dr Sung provided concept/idea/research design and facilities/equipment. Dr Chuang provided writing. Ms Chang provided data
collection and analysis. Dr Chuang and Ms Chang provided subjects. Dr Wang provided research consultation (including review of manuscript
before submission).

This study was approved by the Ethics Committee of the Institutional Board of Taipei Veterans General Hospital.

This study was supported by a grant from the National Science Council (NSC 92-2314-B-075-030).

This article was received October 19, 2005, and was accepted May 10, 2006.

DOI: 10.2522/ptj.20050335

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Figure 1.
Experimental setup.

Method The Microsoft* Windows series operating systems form


the principal operating environment for this model and
Participants include Windows 2000 Professional and XP. High-end
Each subject who participated in this study had received PCs process and display the 3D simulations in real time
CABG between January and June 2004. Subjects were through powerful PC engines, which are based on a
prospectively recruited from the cardiovascular surgery 2.4-GHz Pentium IV processor with 512 MB of SDRAM
department at the Veterans Affairs Medical Center Tai- and 3D accelerator cards. Within this protocol, the VR
pei, Taipei, Taiwan, and were included if they qualified scenes show a Microsoft Direct 3D-constructed “virtual
for the supervised outpatient cardiac rehabilitation pro- runner” model. For our program, the scenes were fused
grams (phase II). During this time, 24 subjects were into standard 2-dimensional background descriptions.
recruited after undergoing bypass surgery. The place- This process involved loading the virtual environment in
ment of each subject in a treatment arm was decided by stages, beginning with the basic scene description and
lottery. Two balls, designated A and B, were placed in a followed by the 3D graphics, which were the nested
box. If the A ball was drawn, then the subject was descriptions.
assigned to group 1; that is, no VR would be used. If the
B ball was drawn, the subject was assigned to group 2, The images were projected from behind the viewer
and a VR experience would be provided during the through 3 projectors connected with computers. Three
rehabilitation sessions. Informed consent was obtained computers communicated with each other via a trans-
after the nature of the study procedures had been fully mission control protocol or Internet transfer protocols,
explained and understood. which made up a local area network. A virtual environ-
ment was displayed on three ⬃239-cm (94-in)-wide con-
Instrumentation nected screens and fixed in place in front of the viewer.
The Veterans Affairs Medical Center Taipei operates the The total viewing range of a subject is called the field of
Telepresence Cardiac Rehabilitation Program, in which view and is about 154 degrees horizontally and about 37
users are physically active in and interactive with an degrees vertically. Within this field of view, the eyes can
imaginary 3D setting, as though they were physically in a register the objects surrounding the viewer (Fig. 1). The
real-life scenario. The system’s graphic user interface virtual terrain in our study consisted of a 5-km-long
permits speed alteration and treadmill incline adjust- straight (or curved) stretch of road, grass, and trees with
ments in conjunction with scenery changes. The system
also comprises a visual screen with a wide field of view,
3D auditory outputs, and 3D accelerator cards. * Microsoft Corp, One Microsoft Way, Redmond, WA 98052-6399.

Physical Therapy . Volume 86 . Number 10 . October 2006 Chuang et al . 1371


Table 1. was identical for each subject. The
Treadmill Grade and Speed Levels Used in Exercise Testing and Training Protocols grades and speeds of the periods are
shown in Table 1. The subjects exer-
Testing Protocola Training Protocolb cised in accordance with the protocol
Speed, km/h Speed, km/h until they reached a level at which they
Grade (%) (mph) Grade (%) (mph) experienced subjective exhaustion or a
1 1.6 (1)c 0 0.48 (0.3)c plateauing of their oxygen intake or
0 1.6 (1) 0 0.96 (0.6) until some clinical contraindication set
0 2.4 (1.5) 1 1.76 (1.1) in.
3.5 3.2 (2) 2 2.56 (1.6)
7 4.8 (3) 3 3.36 (2.1)
5 4.8 (3) 4 4.16 (2.6)
Training Protocol
7.5 4.8 (3) All subjects were asked to perform sub-
10 4.8 (3) maximal endurance training exercises
12 4.8 (3) twice per week for about 3 months in
15 4.8 (3) the hospital until they were able to
a
Each level was used for 3 minutes. achieve a level that corresponded to
b

c
Each level was used for 5 minutes. 85% HRmax, 75% V̇o2peak, or both, as
There was a 3-minute warm-up period.
recorded during the exercise testing
session. These target intensities were
chosen on the basis of guidelines from
a mountain background.10 Once the treadmill was the American College of Sports Medicine11,12 and, being
attached to the PC system, the rate of the subject’s 15% to 25% lower than those used for subjects who are
movement matched the environmental flow on the healthy, were thought to be safe for the compromised
screen at a rate of 30 frames per second. The VR group in our study. Heart rate, V̇o2 , and treadmill
programs also offered immediate biofeedback on the grades and speeds were recorded for each subject during
subject’s condition with free-run (ie, continuously dis- each session. Blood pressure was measured in these
played without recording) HR, respiratory rate, and sessions every 5 minutes, before an increase in the
electromyography waveforms (I-330-C2†) of both thighs treadmill grade or speed. The subject was connected to
on an additional window at the right upper corner of the an electrocardiography machine for recording of HR.
screen. To estimate 75% V̇o2peak during the endurance train-
ing session, we recorded the speed and incline of the
In some VR experiments, the users wear head-mounted treadmill at 75% V̇o2peak during the exercise testing
displays and thus experience “total immersion” in VR. session and used attainment of this speed and incline as
We chose to use large “wraparound” screens instead of evidence that 75% V̇o2peak had been achieved.13 This
head-mounted displays because head-mounted displays procedure has been used for years in exercise training,
produce “simulation sickness” in some users. In addi- because it is impossible to use the precise procedure
tion, head-mounted displays prevent users from being (use of a mask) to record oxygen and carbon dioxide
able to see their own bodies, and this situation, for some, levels. Oxygen consumption was chosen as a second
can be a highly unpleasant experience.4 exercise endpoint because many of the subjects were
taking beta-adrenergic blockers, which affect HRmax. In
Cardiorespiratory Testing the training protocol, the subject exercises on a tread-
Cardiorespiratory testing was done initially to find each mill, starting with 3 minutes of very low-level exercise
subject’s HRmax and V̇o2peak. These data were used to (warm-up), after which the work rate is increased every 5
determine the specific goals for the subject to reach minutes, as shown in Table 1. In this way, the work rate
during the subsequent exercise training sessions. We adds 1% and 0.8 km/h (0.5 mph) during each 5-minute
described cardiorespiratory testing in previous period until the subject reaches a score of 16 for
reports.7,9 The anaerobic threshold, which is the point at perceived level of exertion on the Borg 6- to 20-point
which the steepness of the slope of the curve for V̇o2 rating scale (that is, an effort somewhere between “hard”
versus work output lessens as anaerobic glycolysis begins, and “very hard”) or until the subject reaches the target
also was measured. HR and V̇o2.

In brief, for the exercise testing protocol used in the Depending on the subject’s condition, the training may
current investigation, subjects took part in up to 10 be stopped before 30 minutes or may last a little longer
exercise periods of 3 minutes’ duration. This protocol than 30 minutes. In addition, the work rate increment is
adjusted downward if required by the subject’s cardio-
respiratory status; that is, if, during a given work rate

J&J Engineering, 22797 Holgan Ct NE, Poulsbo, WA 98370.

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Only the group 2 subjects were pro-
vided with the VR environment and
asked to focus on a virtual scene. The
group 1 subjects performed treadmill
walking at measured speeds and grades
without VR. In all other respects, the 2
programs were identical.

Data Analysis
Data entry and statistical analyses were
performed with SPSS version 10.0.‡
The 2-sample t test for independent
samples was used to compare the base-
line characteristics of the 2 groups.
With the Kaplan-Meier method, the
number of training sessions that the
subjects in each training group under-
went before the target event occurred
was analyzed to evaluate the effect of
VR on the time required to achieve the
target goals. This method is used to
analyze discontinuous “yes/no” events
and takes into account the phenome-
non that some subjects may exit a study
before the target event has been
reached. We defined the event to be
evaluated as the achievement of target
exercise capacity (ie, 85% HRmax, 75%
V̇o2peak, or both). That is, the value of
the response variable was equal to 1 if
the target aerobic power was reached
and equal to 0 if the subject failed to
achieve the specified target. Compari-
sons of the resulting exercise goal
achievement graphs (VR versus non-
VR) were based on the log-rank and
Breslow tests. The acceptable level for
statistical significance was set at P⬍.05.

Figure 2. Results
Consort flow chart diagram outlining the progress of participants through the various phases of Of the 24 subjects selected, 4 were
the randomization. Subjects who completed the trial were included in the statistical analyses. found to be unable to tolerate the
Some subjects (see Figs. 3 and 4) left the trial when only one target goal had been achieved.
endurance training sessions because of
their medical conditions, which were as
follows: unstable angina (n⫽1), uncon-
increment, a subject’s blood pressure increased to more trolled symptomatic heart failure (n⫽2), and uncon-
than 220 mm Hg systolic or 120 mm Hg diastolic or a trolled cardiac arrhythmias causing symptoms or hemo-
subject’s HR increased more than 10 beats per minute,11 dynamic compromise (n⫽1) (Fig. 2). These subjects
the therapist decreased the next slope or speed incre- therefore were excluded from the analyses, leaving 20
ment somewhat from the preset protocol. We did not outpatients (20 men) in the study. The clinical charac-
always insist on the preset protocol for ethical reasons. teristics of this final sample are shown in Tables 2 and 3.
Previous research also showed that changing the size or Five subjects (4 in the control group and 1 in the VR
length of the increments in an exercise protocol does group) left the study before their second target goal had
not change the maximum load that a subject is able to been achieved. One subject in the control group did not
tolerate.14

SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

Physical Therapy . Volume 86 . Number 10 . October 2006 Chuang et al . 1373


Table 2. risk factors of smoking, hypertension,
Descriptive Data for Subjects Who Underwent Coronary Artery Bypass Grafting (CABG) and and diabetes mellitus are shown in
Who Took Symptom-Limited Exercise Tests With or Without Virtual Reality (VR)
Table 3.
Non-VR Groupa VR Groupa
(nⴝ10) (nⴝ10)
Figures 3 and 4 show the percentage of
subjects in each group who attained the
Parameter X SD X SD Pb
target goals versus time during consec-
Age (y) 63.70 10.03 65.70 14.48 NS
utive rehabilitation sessions under the
VR and non-VR protocols. Cross marks
Increase in body mass index (%)c 1.28 3.42 0.65 0.96 NS
on the graphs indicate sessions in
Months from date of CABG to 3.21 3.18 2.81 3.38 NS which a subject dropped out without
first evaluation
attaining the particular goal being mea-
Months from date of CABG to 4.19 4.37 4.47 3.47 NS sured on the graph and after which he
first intervention
was not included in the calculations for
V̇O2peak (mL/kg/min)d 19.50 3.75 18.06 3.47 NS that goal. There was a significant differ-
V̇O2 (mL/kg/min) at anaerobic 10.78 2.72 8.56 1.74 NS ence between the VR and non-VR
thresholdd groups in the number of sessions
a
All subjects in each group were men. required to achieve each target goal.
b
NS⫽not significant; no significant differences were noted between non-VR and VR groups, as To reach the target 85% HRmax, 9 of
determined by a 2-sample independent t test (P⬎.05).
c
Value recorded at the initial exercise test minus the value recorded before surgery.
10 subjects in the VR group needed no
d
Oxygen consumption (V̇o2) was determined from the initial maximum exercise test. V̇o2peak⫽peak more than 9 training sessions, whereas
oxygen consumption. by session 20, only 4 subjects in the
non-VR group had achieved this target
goal (Breslow test, P⫽.0006; log-rank
Table 3. test, P⫽.0005) (Fig. 3). With regard to the target V̇o2
Clinical Details for Subjectsa (75% V̇o2peak), all 10 subjects in the VR group had
achieved this target goal by the second round of train-
No. of Subjects ing, but 15 training sessions were needed for a compa-
Non-VR Group VR Group rable number of subjects in the non-VR group to achieve
Parameter (nⴝ10) (nⴝ10) this goal (Breslow test, P⫽.0013; log-rank test, P⫽.0003)
(Fig. 4).
Smoking 3 6
Diabetes mellitus 2 3 The treadmill speeds and grades were recorded during
Hypertension 4 6 the endurance training sessions to evaluate whether the
Hyperlipidemia 4 3 VR experience affected the maximum work rate
Medications achieved in these sessions. Our findings showed that the
ACE inhibitors 1 1 subjects in the VR group achieved a significantly greater
Vasodilators 2 3 highest speed than the subjects in the non-VR group
Diuretics 2 1 achieved (X⫾SD⫽4.64⫾1.40 versus 3.70⫾0.81 mph;
Beta-blockers 4 4
Calcium channel blockers 8 5
P⫽.037) as they completed the submaximal endurance
Antithrombotic agents 9 5 training exercise session.
Type of CABG
Cardiopulmonary bypass pump 9 10 Discussion
Minimally invasive 1 0 In this study, we investigated whether the incorporation
a
of a VR experience into a cardiac rehabilitation exercise
VR⫽virtual reality, ACE⫽angiotensin-converting enzyme, CABG⫽coronary
artery bypass grafting. program would enable subjects to reach performance
goals in fewer exercise sessions. The subjects in the VR
group showed an increase in the maximum workload
attain either target goal even after a maximum number achieved during these sessions, a decrease in the num-
(32) of training sessions. ber of sessions required to reach the target HR, and an
extreme reduction in the number of sessions required to
There were no significant differences between the 2 reach the target V̇o2. How might these results be
subject groups in age, changes in body mass index from explained?
before surgery to after surgery, time lag between surgery
and exercise testing, or time lag between surgery and
intervention (Tab. 2). Subjects’ clinical details regarding
medications taken, the type of CABG, and the cardiac

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Figure 3.
Comparison of number of sessions required to reach the target heart rate (85% maximum heart rate) for subjects in the virtual reality (VR) group and
subjects in the non-VR group, as determined by the Kaplan-Meier method. However, achievement is expressed here as the percentage of subjects
achieving the goal instead of as a rate of achievement. Cross marks indicate sessions in which a subject dropped out before attaining the goal and
therefore was not included in the later calculations.

Differences Between the Groups in the Slope and Speed “off the cliff,” but also his HR will go up as in fear, even
Adjustments in the Training Protocol though he knows at the same time that the cliff is not
Except for the incorporation of the VR experience, the real.4 The most likely explanation for our results is that
exercise protocols were the same for both groups of it was this feeling of presence and involvement in an
subjects. However, it is worth noting that even if the alternate experience that allowed the subjects in the VR
incremental steps used had been different, the results group to tolerate higher maximum exercise levels and
would not have been affected, because previous experi- reach their individual exercise goals in a shorter time
ments by others showed that variations in these steps do period. Whether more common distractions, such as
not change the exercise level at which a subject’s maxi- listening to music, also would accelerate attainment of
mum exercise tolerance occurs.14,15 these goals we do not know, because our protocol was
not designed to address this question.
Effect of the VR Experience Itself
The VR experience is a powerful one, quite different in Encouragement From Biofeedback
intensity and quality from ordinary attention diversions, One difference between the subjects in the VR group
such as listening to music or watching television. and the control subjects was that the former subjects
Although participants know that the VR experience is could see their HR, respiratory rates, and electromyogra-
not real, they describe the experience as feeling phy results in the right upper corner of the VR screen.
immersed in the VR scene, as if they are actually there, However, they were not told what their target HR was. It
and they behave as if the virtual is real.4 This immersion is possible that this opportunity for biofeedback was a
is physiological as well as psychological. For example, if factor in their superior performance. The possible expla-
VR shows the participant that his next step will cause him nations are not known at this time but will be investi-
to fall off a cliff, not only will he refuse to step forward gated in a future study.

Physical Therapy . Volume 86 . Number 10 . October 2006 Chuang et al . 1375


Figure 4.
Comparison of number of sessions required to achieve the target oxygen consumption for subjects in the virtual reality (VR) group and subjects in the
non-VR group, as determined by the Kaplan-Meier method. However, achievement is expressed here as the percentage of subjects achieving the goal
instead of as a rate of achievement. The cross mark indicates a subject who, although completing the study, did not achieve the target goal.

Heart Rate Versus V̇O2 Goals reason for these results was that the VR experience
Two target goals were used in this study: 85% HRmax lessened the subjects’ awareness of actual physical dis-
and 75% V̇o2peak. Both study groups reached the V̇o2 comfort, and so they exercised to a higher level than
goal in fewer training sessions than were needed to they otherwise would have chosen to do.
reach the HR goal. We used standard nomograms in this
study to calculate the degree of V̇o2 considered to be the Possible Long-Term Benefit
equivalent of the HR goal.16 However, despite this We do not yet know the long-term clinical benefit of
strategy, the V̇o2 goal seems to have been set at a lower early achievement of exercise goals. However, at the
level than the HR goal. Factors unrelated to HR, such as moment, early achievement of these goals would not
ambient temperature or physical fitness, can alter V̇o2 affect insurance reimbursement, because currently the
and the caloric cost of exercise.17 For this reason, HR number of training sessions reimbursed is based on the
and perceived exertion rating are the parameters most patient’s risk level, as determined by the American
frequently used for assessing exercise intensity levels. Association of Cardiovascular and Pulmonary Rehabili-
However, because we were concerned about the effect of tation classification rules, as follows: low risk level, up to
the beta-adrenergic blockers that some of the subjects 6 supervised training sessions; middle risk level, up to 18
were taking on the HR results, we wanted to use another such sessions; and high risk level, more than 36 such
independent, objective estimate of exercise intensity; sessions.18,19
therefore, we included V̇o2 as a second goal.
Conclusion
Effect of VR on V̇O2 Results We cannot explain exactly how VR influences exercise
The subjects in the VR group reached their V̇o2 goal by performance. However, our study showed a powerful
the end of the second training period, a time that seems effect of a VR environment on the progress of cardiac
too short for any substantial physiologic change to have rehabilitation and the results suggest that incorporating
occurred. They also reached greater highest treadmill VR into rehabilitation programs will accelerate the max-
speeds than the control subjects. Presumably part of the imum recovery of a patient’s cardiovascular fitness.

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