Overview. Cardiovascular diseases (coronary heart disease, myocardial infarction, stroke) have emerged as leading sources of illness and death for persons with spinal cord injury (SCI). Cardiometabolic disease/syndrome (CMD) is a central risk factor for both cardiovascular disease and diabetes mellitus, and encompasses a cluster of risk factors including hypertension, dyslipidemia, elevated glucose profiles, and central adiposity. In comparison to the general populations, individuals with SCI are more likely to develop CVD and are more likely to have cardiovascular disease and diabetes mellitus. The prevalence of CMD in the SCI population ranges from 33%5 and 63%, and one study found that nearly 58% of Veterans with SCI presented with CMD. Physical inactivity is associated with multiple components of CMD, including obesity, insulin resistance, hypertension, and dyslipidemia. However, while moderate intensity exercise is supported as a powerful tool against CMD over half of individuals living with SCI report no regular physical activity or exercise. Individuals with SCI are nearly 1.5 times more likely to lead sedentary lives than the general population and demonstrate significantly lower physical activity levels compared to individuals with other chronic diseases.10 Critically, everyday activities are not enough to maintain cardiovascular fitness in people with SCI, necessitating targeted exercise interventions. This "physical activity participation gap" presents a significant health crisis for individuals living with SCI and can initiate and exacerbate secondary conditions while dampening psychological well-being and quality of life (QoL). Exercise is an effective non-pharmacologic intervention to improve cardiometabolic risk factors, reduce risk for chronic and secondary conditions, and enhance psychosocial well-being. However, various barriers, such as accessibility, transportation, costs, and motivation, hinder exercise participation for those with SCI, underscoring the urgent need to provide better access to exercise experiences for this population.

Virtual reality (VR) gaming has become increasingly integrated into interventions targeting physical, neurocognitive, and psychological conditions, concurrently addressing issues like access, cost, and motivation. VR-mediated exercise interventions report strong adherence, reduced perception of effort and fatigue, and increased enjoyment of exercise participation. A global survey by the American College of Sports Medicine concluded that remote, home-based exercise, including virtual exercise, is the top fitness trend following the COVID-19 pandemic. However, while the likely benefit of home-based virtual exercise platforms for mobility impaired users is acknowledged all interventions to date have employed systems designed for able-bodied individuals. Remarkably, there has yet to be a virtual exercise platform specifically informed by input from, and exercise needs of, individuals with SCI. Further, while laboratory studies have established the potency of virtual exercise for individuals with SCI, there has yet to be a prospective study of the feasibility or cardiometabolic efficacy of a home-based virtual exercise intervention in this population. The current study assembles expertise in SCI physical health, home-based virtual reality intervention, and Lived Experience to address the abovementioned gaps by examining the feasibility and prospective efficacy of the low-cost, immersive, interactive VR exercise platform - VR-Move, deployable for self-directed use within individual homes. The project team has substantial experience and strong preliminary data supporting development and deployment of home-based immersive VR physical activity interventions for individuals with SCI. Study design is supported by a user-centered development approach (community-based participatory research) preliminary data, and a home-based technology paradigm successfully implemented by the current research team in multiple ongoing longitudinal studies with persons with SCI. The proposed study represents an important, sustainable step in promoting cardiometabolic health among people with SCI.

This proposal has integrated design elements suggested during the previous review cycle; centrally, the investigators have modified our clinical trial design with direct input from our biostatistical team to be a crossover design with a 4-week baseline control phase followed by a longer intervention phase of 12-weeks. The investigators will obtain repeated measurements at baseline (0-week), pre-intervention (4-weeks), mid-intervention (10-weeks), and post-intervention (16-weeks) which are indeed critical to understanding the longer-term impact of the intervention. The investigators have also clarified VR refinement procedures and the place of the current intervention in the larger VR pain-intervention literature. The investigators believe that these and other changes, as well as our new exciting preliminary findings, further serve to demonstrate that this novel platform has potential to meaningfully impact the health and quality of life in individuals with SCI.