Can virtual reality be used as an adjunct to conventional pulmonary rehabilitation in cognitively intact adults with chronic respiratory diseases (e.g., chronic obstructive pulmonary disease, interstitial lung disease, post‑COVID‑19 lung injury) who have no severe vestibular disorders, uncontrolled seizures, or contraindications to moderate‑intensity exercise, and what are the recommended session duration, frequency, supervision, and safety monitoring?

Virtual Reality in Pulmonary Rehabilitation

Virtual reality can be used as an adjunct to conventional pulmonary rehabilitation for adults with stable chronic respiratory disease, but it should not replace comprehensive center-based or telerehabilitation programs that remain the evidence-based standard of care. 1

Primary Recommendation Framework

The American Thoracic Society (2023) provides a strong recommendation (moderate-quality evidence) that adults with stable chronic respiratory disease should be offered the choice between center-based pulmonary rehabilitation or telerehabilitation—virtual reality is not mentioned as an established modality in these guidelines, reflecting insufficient evidence for VR as a standalone intervention. 1, 2

Key Distinction: VR vs. Telerehabilitation

• Telerehabilitation (using video conferencing, remote monitoring, and digital platforms) has moderate-quality evidence showing equivalent outcomes to center-based programs for exercise capacity (6-minute walk distance), quality of life, and dyspnea. 1

• Virtual reality (immersive or semi-immersive gaming/simulation environments) has emerging evidence as an adjunctive tool within pulmonary rehabilitation but lacks the robust evidence base of telerehabilitation. 2, 3

Evidence for Virtual Reality as an Adjunct

Effectiveness Data

A 2024 meta-analysis (5 RCTs, 344 participants) demonstrated that VR-based therapy added to conventional pulmonary rehabilitation produced:

• Improved functional capacity: 6-minute walk test (SMD=0.4,95% CI 0.07-0.71, p=0.017) 4
• Enhanced pulmonary function: FEV1 (SMD=0.33,95% CI 0.01-0.65, p=0.048) 4
• Better functional mobility: Timed Up and Go test (SMD=0.77,95% CI 0.5-1.1, p<0.001) 4

Non-immersive VR (using screens and motion-sensing controllers like Nintendo Wii) is the most studied modality in pulmonary rehabilitation. 4

Safety Profile

A 2013 pilot study (32 patients with moderate-to-severe COPD) using virtual game systems showed:

• Adherence rate: 76% of patients attended ≥50% of VR sessions 5
• Physiologic response: Dyspnea increased from 1.5±1.1 to 3.2±1.2; oxygen saturation decreased from 94±3% to 91±5% (p<0.001); heart rate increased from 88±15 to 102±18 bpm (p<0.001) 5
• Adverse events: One patient required nitroglycerin for chest pain; five experienced transient desaturation below 85% 5
• Patient satisfaction: High enjoyment scores (8±2.6/10) 5

Recommended Implementation Algorithm

Patient Selection Criteria

Include patients who:

• Have stable chronic respiratory disease (COPD, interstitial lung disease, post-COVID lung injury) 1, 6
• Are cognitively intact and can follow VR instructions 6
• Have no severe vestibular disorders, uncontrolled seizures, or balance impairments that would be exacerbated by immersive environments 7
• Have no contraindications to moderate-intensity exercise 1
• Are already enrolled in or completing a comprehensive pulmonary rehabilitation program 2, 3

Exclude or use caution in patients with:

• Significant vision or hearing impairment that prevents VR interaction 7
• History of arrhythmias requiring close physiological monitoring 1
• WHO/NYHA class IV pulmonary hypertension or severe hemodynamic impairment 1

Session Structure and Monitoring

Duration and frequency:

• VR sessions should be 20-30 minutes, 3 times weekly as an adjunct to standard rehabilitation 5, 8
• Total program duration should be at least 6-12 weeks to achieve meaningful benefits 7

Supervision requirements:

• Continuous monitoring of oxygen saturation, heart rate, and dyspnea before, during, and after VR sessions 5
• Immediate access to supplemental oxygen and emergency medications (e.g., nitroglycerin) 5
• Healthcare professional supervision during initial sessions to establish safety parameters 3, 7

Safety thresholds for stopping exercise:

• Oxygen saturation drops below 85% 5
• Chest pain, severe dyspnea, or dizziness develops 1
• Heart rate exceeds individualized target or shows arrhythmia 1

Essential Program Components

VR must be integrated within comprehensive pulmonary rehabilitation that includes:

• Structured, progressive exercise training (not just VR gaming) 2, 3
• COPD self-management education 3, 7
• Patient-tailored behavioral support and behavior change strategies 3
• Multidisciplinary coordination with healthcare professionals from multiple disciplines 3
• Nutritional assessment and intervention 7

VR should NOT be used as:

• A standalone intervention replacing comprehensive pulmonary rehabilitation 2, 3
• A simple mobility aid without the full rehabilitation framework 2

Critical Implementation Barriers

Technology Access Issues

• 31% of COPD patients in the UK have never accessed the internet 7
• Factors associated with lower technology use include older age, lower household income, Black race, Latinx ethnicity, and female sex 7
• Patients require smartphones/tablets/computers, reliable internet access, and technical skills to operate equipment 7

Quality Assurance Requirements

• Programs using lower-intensity remote supervision require robust service audit and benchmarking processes to ensure efficacy 1, 7
• Only program models tested in clinical trials should be implemented 7
• Characteristics of patients most likely to succeed with VR-enhanced rehabilitation are not yet established 7

Common Pitfalls to Avoid

Do not substitute VR for comprehensive pulmonary rehabilitation—technology should deliver all core components (exercise training, education, behavioral support, nutritional assessment), not just exercise monitoring or gaming. 3

Do not deploy VR without proper physiologic monitoring—transient desaturation and cardiovascular responses require real-time assessment, especially in patients with severe disease. 5

Do not assume all patients can access or use VR technology—screen for digital literacy, equipment availability, and sensory/cognitive limitations before prescribing VR-enhanced programs. 7

Do not use VR as first-line therapy—refer all eligible patients to traditional center-based pulmonary rehabilitation first, which has the strongest evidence for reducing mortality (OR 0.28; 95% CI 0.10-0.84) and hospitalizations (OR 0.22; 95% CI 0.08-0.58). 7

Practical Clinical Pathway

1. Assess eligibility for pulmonary rehabilitation in all symptomatic patients with chronic respiratory disease 7

2. Offer center-based pulmonary rehabilitation as first-line (strongest evidence for mortality/morbidity reduction) 1, 7

3. If center-based PR is inaccessible (transportation barriers, rural location, mobility limitations), offer telerehabilitation as an equivalent alternative 1, 2

4. Consider adding VR as an adjunct for patients who:

   • Are already enrolled in comprehensive PR 4
   • Have adequate technology access and digital literacy 7
   • Express interest in gamified exercise to improve adherence 5
   • Have no vestibular, visual, or balance contraindications 7, 6

5. Verify before VR deployment:

   • Patient has necessary equipment and reliable internet 7
   • No significant vision, hearing, or balance impairments 7
   • Baseline oxygen saturation, heart rate, and dyspnea documented 5
   • Emergency protocols established for chest pain or desaturation 5

6. Monitor during VR sessions:

   • Oxygen saturation continuously (stop if <85%) 5
   • Heart rate and rhythm 5
   • Dyspnea scores before and after exercise 5

7. Ensure program includes all core PR components beyond VR exercise (education, behavioral support, multidisciplinary care) 2, 3

Evidence Gaps and Future Directions

The American Thoracic Society identifies "new exercise training strategies" and "which PR model for which patient" as priority research needs, acknowledging that VR and other technologies are "currently being adapted and tested" but lack the robust evidence base of traditional programs. 1, 3

Until VR demonstrates outcomes equivalent to standard programs in rigorous trials with mortality and hospitalization endpoints, it should remain an adjunctive tool within comprehensive pulmonary rehabilitation rather than a standalone intervention. 2, 7