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
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
Parallel
Traditional treatment program
Other interventionThe study will be conducted over a total of 6 weeks, with sessions held 3 days per week. Each session will last approximately 45-60 minutes. All participants will undergo a virtual reality-assisted core stabilization exercise program under the supervision of a physical therapist in a safe environment. The following basic core stabilization exercises will be performed in both groups: * Diaphragmatic breathing and abdominal bracing * Pelvic tilt (posterior/anterior) * Bridge exercise * Opposite arm-leg lift in quadrupedal position * Seated and standing trunk stabilization exercises * Dynamic balance and weight transfer exercises
External Focus of Attention Virtual Reality Exercise
Other interventionParticipants 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.
Internal Focus of Attention Virtual Reality Exercise
Other interventionParticipants 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.
Frailty Level
Frailty will be assessed using the Frailty Assessment Screening Tool (FAST-TR). FAST-TR is a validated and reliable screening instrument designed to identify frailty risk in older adults and includes physical, functional, and psychosocial components. Higher scores indicate greater frailty risk.
Balance Performance
Static and dynamic balance performance will be objectively assessed using the Biodex Balance System. The Biodex Balance System is a valid and reliable device widely used to evaluate postural control in older adults. Static balance will be assessed using the Postural Stability Test, which measures overall, anterior-posterior, and medial-lateral stability indices. Dynamic balance will be evaluated using the Limits of Stability (LOS) test, which assesses the participant's ability to voluntarily control their center of gravity within their base of support..
Fall risk
Fall risk will be evaluated using the Fall Risk Test protocol of the Biodex Balance System. This test objectively quantifies the individual's risk of falling by measuring balance performance on an unstable platform under standardized conditions. The Biodex Fall Risk Index provides an overall score, with higher scores indicating greater fall risk.
Pain Intensity
Low back pain intensity will be evaluated using the Visual Analog Scale (VAS). Participants will rate their perceived pain intensity on a 10-cm horizontal line ranging from "no pain" to "worst imaginable pain." Higher scores indicate greater pain severity. Pain will be assessed to reflect pain experienced at rest and during daily activities.
Sarcopenia Risk
Sarcopenia risk will be assessed using the SARC-T questionnaire. The SARC-T is a practical and reliable screening tool used to identify sarcopenia risk in community-dwelling older adults. Higher scores indicate increased risk of sarcopenia.
Functional Lower Extremity Strength and Performance
Functional lower extremity strength and performance will be evaluated using the Five Times Sit-to-Stand Test (5xSTS). Participants will be instructed to stand up and sit down five times as quickly as possible from a standard-height chair without using their arms. Test duration will be recorded in seconds, with longer times indicating reduced functional performance and increased fall risk.
Depression Level
Depressive symptoms will be assessed using the Beck Depression Inventory (BDI). The BDI is a validated self-report questionnaire commonly used to evaluate depressive symptoms in older adults. Higher scores indicate greater levels of depression.
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