Virtual Reality in Intensive Care Unit: Patient Satisfaction, Clinical and Functional Outcomes, Feasibility

To assess patient satisfaction, the investigators will use the Net Promoter Score (NPS) method, it is a methodology that indicates the likelihood of a consumer recommending products or services to others. The results are interpreted using the following parameters: 75-100% is considered "excellent," 50-74% is classified as "very good" and below 49% as "poor."

To evaluate patient experience, the Raw Task Load Index (RTLX) will be used to assess perceived workload during or immediately after rehabilitation sessions. It is a multidimensional scale scored from 0 to 100, with higher scores indicating greater cognitive load.

Perceived motivation will be assessed using the Intrinsic Motivation Inventory (IMI), a 7-point Likert scale evaluating the individual's subjective experience during an activity (1 = strongly disagree; 7 = strongly agree).

Patients in the immersive virtual reality group will also complete the Presence Questionnaire (PQ), a self-report tool that measures perceived presence in the VR environment across four domains: Engagement, Immersion/Adaptation, Sensory Fidelity, and Interface Quality. The PQ uses a 5-point Likert scale, with higher scores reflecting a stronger sense of presence.

Physical activity assessment will be conducted using the International Physical Activity Questionnaire (IPAQ). The short version consists of seven open-ended questions, allowing estimation of the time spent per week in different dimensions of physical activity (walking, moderate and vigorous activities) and physical inactivity (sitting time). Based on IPAQ scoring guidelines, patients can be classified as: very active, active, irregularly active, or sedentary.

Muscle strength will be assessed using the Medical Research Council (MRC) manual muscle test. This evaluation involves testing key upper limb muscles (shoulder abduction, elbow flexion, wrist extension) and lower limb muscles (hip flexion, knee extension, ankle dorsiflexion) against the examiner's resistance. Strength is rated on a scale from 0 (no muscle activation) to 5 (full range of motion against full examiner resistance). Classification is based on the degree of muscle contraction or range of motion for each muscle evaluated. The total score ranges from 0 (complete tetraparesis) to 60 points (normal muscle strength).

Patient mobility will be assessed using the ICU Mobility Scale. This scale ranges from 0 to 10 within a single domain, where a score of 0 indicates very low mobility (e.g., the patient performs only passive exercises in bed), and a score of 10 indicates high mobility (e.g., the patient walks independently without assistance).

The International Classification of Functioning, Disability and Health (ICF) will be used to describe functionality and disability related to health conditions, considering body functions and structures, activity limitations, and participation restrictions in the patient's environment. A customized checklist adapted to the ICU context of Hospital Sírio-Libanês will be used in this study. Qualifiers specify the level of functioning, ranging from 0 (no impairment) to 4 (complete impairment). Codes 8 and 9 indicate lack of information or not applicable. In the body structure category, three qualifiers are used to describe the nature of the impairment. In the activity and participation category, two qualifiers are used: performance and capacity. For environmental factors, a positive score (1 to 4) indicates facilitators, while a negative score (-1 to -4) indicates barriers.

The diagnosis and monitoring of delirium during ICU stay will be performed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). This is a quick and accurate tool for diagnosing delirium in critically ill patients, combining sedation and delirium monitoring.

Cognitive functions will be assessed using the Montreal Cognitive Assessment (MoCA), a brief screening tool that evaluates a wide range of cognitive domains, including executive functions, visuospatial abilities, naming, memory recall, digits, sentence repetition, abstract reasoning, and orientation. MoCA is considered effective for detecting mild cognitive impairment and dementia. The test is simple and quick to administer, taking approximately 20 minutes. The maximum score is 30 points, with a cutoff of 26; scores above 26 are considered normal.

To assess discomfort, the Numeric Rating Scale (NRS) will be used. This is a unidimensional tool that measures discomfort intensity and is suitable for conscious and communicative adult patients. Assessments will be performed before and after the rehabilitation protocol.

For pain assessment, patients will be asked to rate their pain on a scale from 0 to 10, where 0 represents no pain and 10 indicates the worst possible pain.

The same scale will be used to evaluate the perception of anxiety and stress, quantifying the intensity of these psychological variables.

The feasibility of the protocol will be measured through the adherence rate to immersive virtual reality therapy sessions. Adherence will be calculated as a percentage (%) using the formula: number of rehabilitation sessions completed / total number of eligible sessions × 100. In this study, a value above 70% will be considered indicative of good feasibility of the rehabilitation protocol.

Fall risk will be assessed using the Johns Hopkins Fall Risk Assessment Tool. This scale stratifies and establishes personalized preventive measures for hospitalized patients. The total score categorizes patients as low risk (0-5 points), moderate risk (6-13 points), or high risk (14-35 points).

The presence of symptoms will be evaluated using the Simulator Sickness Questionnaire (SSQ), which assesses the presence and intensity of 16 symptoms, including general discomfort, fatigue, headache, eye strain, difficulty focusing, increased salivation, sweating, nausea, poor concentration, "heavy head," blurred vision, dizziness (eyes open/closed), vertigo, abdominal discomfort, and belching. Symptom intensity is rated as 0 (none), 1 (mild), 2 (moderate), or 3 (severe).