Introduction and Overview of Thesis: Multiple sclerosis (MS) is a chronic neurodegenerative disease characterised by diverse physical and cognitive symptoms. This thesis investigates how virtual reality (VR)-exergaming as an innovative intervention can enhance the effectiveness of MS rehabilitation strategies, considering both scientific evidence and perceptions of people with MS (PwMS). This includes a comprehensive assessment of the intervention’s potential, its practical implementation, and its alignment with the needs and expectations of the end-users.

Methodology: Employing a framework for developing complex interventions, this research integrates a systematic review, qualitative insights, and a feasibility study. This approach, guided by the Medical Research Council (MRC) framework, allows for a comprehensive exploration of VR-exergaming’s potential in MS rehabilitation. A patient-centred approach was integral to the research, ensuring iterative feedback and development across the three phases. The mixed-methods design allowed for a thorough investigation of both quantitative and qualitative dimensions, with a focus on key feasibility domains such as usability, recruitment, and adherence. The methodology was based on principles from rehabilitation science, understanding how people adopt new technologies, and focusing on patient needs. This ensured a well-rounded approach to developing and evaluating the intervention.

Studies:

1. Systematic Review: This review examined the comparative impacts of VR-exergaming and conventional exercise on MS rehabilitation. Searching databases like EMBASE, PubMed, and Scopus, it identified 10 eligible studies with a total of 486 participants from an initial pool of 239 articles. Key findings indicated that VR-exergaming showed benefits in improving balance, upper limb function, and cognitive processing speed, though results varied across studies. While VR-exergaming often enhanced engagement and adherence, the impact on fatigue and psychological well-being was mixed. Some studies suggested VR-exergaming might be more effective for specific outcomes, such as balance and cognitive speed, but further research is needed to clarify these effects. This review provides a comprehensive synthesis of existing evidence on VR-exergaming for MS, offering valuable insights into its potential effectiveness compared to conventional exercise, while also highlighting the need for more standardised, large-scale trials.

2. Qualitative Study: This study explored the perceptions of PwMS regarding immersive VR-exergaming using Meta Quest 2. Through thematic analysis of interviews with six participants, key themes emerged around the enjoyment of physical activity, the desire for rehabilitation methods improving cognition and alleviating fatigue, and the positive yet mixed experiences with immersive VR-exergaming, considering concerns like cost and comfort. The study highlighted the importance of personalising VR experiences to enhance user engagement and promote long-term adherence. Participants consistently emphasised the value of rehabilitation methods that are both enjoyable and motivating. The study effectively captured the lived experiences of PwMS, offering rich insights into their attitudes, perceived barriers, and facilitators concerning VR-exergaming adoption, including concerns about cost and comfort.

3. Feasibility Study: Investigating the feasibility of an immersive VR-exergaming system, this study involved a single-arm trial with nine participants over 4 weeks. Results indicated high participants’ satisfaction, usability, and adherence (100%), with significant improvements in upper limb function and fatigue reduction, but no significant change in processing speed cognition tests. The study underlined the feasibility of conducting larger clinical trials to evaluate the efficacy of immersive VR-exergaming in MS rehabilitation, particularly in improving hand function, fatigue, and cognition. Adhering to the CONSORT extension for pilot and feasibility trials, the study ensured a rigorous evaluation of key outcomes, including recruitment and retention rates, intervention acceptability, and usability. Key practical aspects, such as adherence and participant safety, were effectively managed throughout the trial. Application of these results will prove beneficial to the design of more extensive trials targeting better understanding of the long-term benefits and broader applicability of VR-exergaming in MS rehabilitation.

Conclusion: The thesis demonstrates VR-exergaming’s significant potential in MS rehabilitation, offering substantial benefits over traditional methods. Two key strengths of this thesis were the iterative learning approach, where the outcomes of each study informed the next, and its patient-centred aspect, emphasising the importance of aligning rehabilitation strategies with PwMS’ needs and preferences. This approach ensures that the development of VR-exergaming interventions is grounded in real-world patient needs and preferences, paving the way for personalised, effective MS rehabilitation solutions. Future research should continue to optimise these interventions, focusing on patient-centred experiences and advanced technology integration. Long-term studies are also needed to assess the sustained benefits of VR-exergaming and its potential impact on disease progression and quality of life for PwMS.