Comparison of Focus of Attention in Virtual Reality-Based Exercise Training in Older Adults With Low Back Pain

Comparison of External and Internal Focus of Attention in Virtual Reality-Based Exercise Training in Older Adults With Chronic Low Back Pain: A Randomized Controlled Trial

Chronic low back pain is highly prevalent among older adults and is associated with impaired balance, increased fall risk, frailty, depressive symptoms, and reduced functional capacity. Exercise-based rehabilitation is a cornerstone of management in this population, and emerging evidence suggests that attentional focus strategies may influence motor learning and functional outcomes. Virtual reality-based exercise interventions provide an interactive and engaging environment that may further enhance rehabilitation outcomes in older individuals.

The purpose of this randomized controlled trial is to compare the effects of external and internal focus of attention strategies applied during a virtual reality-based core stabilization exercise program on frailty, balance, fall risk, lower extremity functional strength, sarcopenia risk, and depression in older adults with chronic low back pain.

Participants will be randomly allocated to either an external focus or internal focus group. Both groups will receive the same virtual reality-based core stabilization exercise program, administered three times per week for six weeks under physiotherapist supervision in a safe clinical setting. The exercise content, session duration, exercise volume, and progression will be identical between groups; the only difference will be the verbal and visual instructions provided to direct participants' attentional focus.

Outcomes will be assessed at baseline and after the intervention period. Frailty will be evaluated using the Frailty Assessment Scale (FAS-TR), sarcopenia risk using the SARC-T questionnaire, balance and fall risk using the Biodex Balance System, functional lower extremity strength using the Five Times Sit-to-Stand Test, and depressive symptoms using the Beck Depression Inventory. This study aims to determine whether attentional focus strategies differentially influence clinical and functional outcomes in older adults with chronic low back pain undergoing virtual reality-based exercise training.

This randomized controlled trial will be conducted to investigate the comparative effects of external and internal focus of attention strategies applied during virtual reality-based exercise training in older adults with chronic low back pain.

Study Population and Setting The study population will consist of older adults aged 65 years and above who present to the Physical Therapy and Rehabilitation Clinic of Kırşehir Ahi Evran University Hospital, Kırşehir, Türkiye, with a diagnosis of chronic low back pain lasting at least three months. Individuals included in the target population will be community-dwelling older adults who are able to walk independently, perform most activities of daily living without assistance, and have no acute medical conditions that would contraindicate participation in a virtual reality-based exercise program.

Chronic low back pain in older adults is closely associated with balance impairments, increased fall risk, reduced physical activity, frailty, and psychological consequences. Therefore, this population has been selected to examine the potential benefits of attentional focus strategies integrated into virtual reality-based rehabilitation.

Eligibility will be determined through an initial screening interview and baseline assessment conducted by a physiotherapist in accordance with the inclusion and exclusion criteria.

Randomization and Study Groups

After completion of all baseline assessments, eligible participants will be randomly allocated into one of two intervention groups using a randomization procedure:

Group 1: External Focus of Attention Virtual Reality Exercise Group Participants in this group will receive a structured virtual reality-based core stabilization exercise program accompanied by verbal and visual instructions designed to direct attention toward the effects of movement on the environment, task outcomes, and externally defined targets within the virtual environment.

Group 2: Internal Focus of Attention Virtual Reality Exercise Group Participants in this group will receive the same structured virtual reality-based core stabilization exercise program, accompanied by verbal and visual instructions aimed at directing attention toward body segment positioning, trunk control, muscle activation, and internal components of movement.

The exercise content, session duration, number of exercises, and progression principles will be identical between the two groups. The only difference between groups will be the attentional focus instructions provided during exercise performance.

Intervention Protocol The intervention will be conducted over a total period of six weeks, with sessions administered three times per week. Each exercise session will last approximately 45-60 minutes. All sessions will be supervised by a physiotherapist and performed in a safe clinical environment.

All participants will engage in a virtual reality-supported core stabilization exercise program targeting trunk control, postural stability, balance, and functional movement performance. Exercise intensity and difficulty will be progressively adjusted according to participants' performance and tolerance throughout the intervention period.

The only difference between groups will be the type of attentional focus instructions delivered during exercise performance:

External Focus Group: Participants will receive verbal and visual cues directing attention toward movement outcomes, environmental interaction, and task-related effects within the virtual environment. Instructions will emphasize the impact of movement on virtual targets or external objects.

Internal Focus Group: Participants will receive verbal and visual cues directing attention toward body segment positioning, trunk muscle activation, and movement mechanics. Instructions will emphasize awareness of internal bodily movements and muscular control.

Depressive symptoms will be assessed using the Beck Depression Inventory. This study aims to determine whether different attentional focus strategies applied during virtual reality-based exercise training result in differential effects on physical, functional, and psychological outcomes in older adults with chronic low back pain.

Inclusion Criteria:

• Aged 65 years and older
• Diagnosis of non-specific chronic low back pain lasting at least 3 months
• Ability to stand and walk independently (use of assistive devices such as a cane or walker is permitted)
• Ability to perform most activities of daily living independently
• No severe visual, auditory, or vestibular impairments that would prevent participation in a virtual reality-based exercise program
• Adequate cognitive function to understand and follow instructions (Mini-Mental -State Examination score ≥ 24 or clinical judgment)
• Willingness to participate in the study and provision of written informed consent

Exclusion Criteria:

• Presence of specific causes of low back pain (e.g., vertebral fracture, tumor, infection, inflammatory rheumatic diseases, advanced spinal stenosis, spondylolisthesis)
• History of lumbar spine or lower extremity surgery within the past 6 months
• Presence of severe neurological disorders (e.g., stroke, Parkinson's disease, multiple sclerosis) or severe peripheral neuropathy
• Uncontrolled cardiovascular, respiratory, or metabolic diseases that may pose a risk during exercise participation
• Any acute medical condition or musculoskeletal disorder that contraindicates participation in exercise training