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.
• 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