Examining the Feasibility, Acceptability, and Preliminary Efficacy of an Immersive Virtual Reality–Assisted Lower Limb Strength Training for Knee Osteoarthritis: Mixed Methods Pilot Randomized Controlled Trial

Abstract Background Knee osteoarthritis prevalently causes significant pain, activity limitations, psychological distress, and reduced quality of life. Despite lower limb strength training being a core treatment for knee osteoarthritis, adherence remains a challenge, prompting the exploration of virtual reality (VR) to improve exercise compliance. Recent research suggests the potential of VR in providing enhanced pain management and functional outcomes for knee osteoarthritis, necessitating further exploration of immersive VR technology. Objective We aimed to study the feasibility, acceptability, and preliminary efficacy of an immersive VR-assisted lower limb strength training for knee osteoarthritis (VRiKnee). Methods A convergent, parallel, mixed methods study was conducted in 30 participants with knee osteoarthritis. After 1:1 randomization, the VRiKnee group (n=15) was assigned to perform repetitive concentric quadriceps and isometric vastus medialis oblique exercise in an immersive environment using a head-mounted display for 12 weeks. The control group (n=15) completed the same exercises without VRiKnee. VRiKnee participants were interviewed at week 12 to study VRiKnee acceptability and user experience. Quantitative data included feasibility outcomes such as recruitment, dropout, and exercise adherence rates, and effectiveness outcomes such as the numeric rating scale, the Western Ontario and McMaster Universities Osteoarthritis Index (100 points) pain and function subscales, and objective physical activity measured by metabolic equivalents of task using an ActivPAL accelerometer. Qualitative data were analyzed by thematic analysis, followed by integration with quantitative data using joint displays. Results The recruitment rate was 100% (N=30), with enrollment of 30 participants in 7.57 weeks. The median age was 63.5 (IQR 61.8‐66.3) years, with 76% (n=23) being female. The response rates were 80% and 93% for the VRiKnee and control groups. Dropout rates were 13% for VRiKnee and 7% for the control group. Median exercise adherence was 77% (IQR 37-104%) for VRiKnee and 62% (IQR 40-166%) for the control group, respectively, with adherence reduction over this study’s period and no significant intergroup differences ( P =.82). No statistically significant differences were observed in primary and secondary outcomes, though positive trends were observed in pain and stiffness. Cybersickness was reported by 5 (33%) participants in the VRiKnee group. In the qualitative analysis, 4 themes, 11 subthemes, and 16 quotes were generated, identifying facilitators and barriers with practical suggestions to enhance the usability of VRiKnee. Conclusions VRiKnee demonstrated feasibility, acceptability, and potential efficacy in managing knee osteoarthritis. Future trials of larger sample sizes and better VR designs will confirm its role in clinical practice.