Exergaming and Virtual Reality for Health: Implications for Cardiac Rehabilitation

Effects of exergaming and yoga on exercise capacity and physical and mental health in heart failure patients: a randomized sub-study

AIMS

This study aimed to explore effects of exergaming and medical yoga on exercise capacity, fatigue, shortness of breath, health-related quality of life, depression, and anxiety in patients with heart failure.

METHODS AND RESULTS

A randomized sub-study with a 3-month intervention and outcomes measures at baseline, 3, 6, and 12 months. Participants were recruited from heart failure clinics in Sweden. Treatment effects in change of outcomes were tested in an analysis of mixed-effects models with repeated measures. Change in outcomes was the dependent variable. The independent fixed-effect parameters were treatment group, time, and the interaction between treatment group and time.In total, 104 patients (37% women, mean age 71 ± 12, 48% in New York Heart Association Class II and 42% in III) were randomized to exergaming (n = 35), medical yoga (n = 33), or an active control group (n = 36). No statistically significant differences were found between these three groups on any of the outcome measures. Exergaming significantly improved exercise capacity, fatigue, shortness of breath, and physical health-related quality of life and medical yoga improved symptoms of fatigue and emotional health-related quality of life. The control group did not change on the exercise capacity, symptoms, health-related quality of life, or depressive or anxiety symptoms. The well-being score in patients in the control group significantly decreased at 3 months.

CONCLUSION

Both exergaming and medical yoga demonstrated positive impacts on outcomes when compared with a control group. Exergaming, characterized by its elevated physical intensity, exerted effects primarily on physical health, while medical yoga, as a mind-body intervention, exhibited influences on emotional well-being.

REGISTRATION

ClinicalTrial.gov: NCT01785121.

A Randomized Controlled Trial of Home-based Virtual Rehabilitation to Improve Adherence to Prescribed Home Therapy After Burn Injury: A Northwest Regional Burn Model System Trial

Daily rehabilitation after burn injury is vital for the prevention of function-limiting contractures. However, adherence to prescribed therapy following acute burn hospitalization has historically been low and not well-studied. Studies involving virtual reality technology have demonstrated an association with improved functional outcomes in burn therapy. We conducted a 5-year randomized controlled trial comparing 12 weeks of a home-based virtual rehabilitation (HBVR) system with standard burn therapy. Our primary outcome was adherence to prescribed home therapy, measured by e-diary self-report. Secondary outcomes included steps walked daily and patient-reported outcomes regarding stiffness, upper extremity function, and mobility. We enrolled 50 subjects, of which 48 provided data for analysis (23 HBVR, 25 control). Overall adherence to prescribed home therapy was low, 37.2% in the HBVR group and 60.0% in the control group. Reasons for nonadherence in the HBVR group included lack of time, engagement, and replacement of therapy with other physical activity. However, some subjects enjoyed HBVR and believed it aided their recovery. There was no difference in daily steps walked between the 2 groups. Daily walking gradually improved from 3500 steps per day in the first week after baseline and plateaued at 6000 steps per day at week 5. There were no differences in stiffness, upper extremity function, and mobility between the 2 groups at baseline and 3-, 6-, and 12-month follow-up. Subjects demonstrated improved upper extremity function and mobility in the first year after discharge, which coincided with increasing stiffness.

At-Home Immersive Virtual Reality Exergames to Reduce Cardiometabolic Risk Among Office Workers: Protocol for a Randomized Controlled Trial

BACKGROUND

The worldwide rise in the prevalence of noncommunicable diseases has increased the recognition of the need to identify modifiable risk factors for preventing and managing these diseases. The office worker, as a representative group of physically inactive workers, is exposed to risk factors for metabolic syndrome, which is a primary driver of noncommunicable diseases. The use of virtual reality (VR) exergames may offer a potential solution to the problem of increasing noncommunicable disease prevalence, as it can help individuals increase their physical activity levels while providing a more immersive experience.

OBJECTIVE

This exploratory study aims to examine the interventional efficacy of at-home immersive VR exergames on metabolic syndrome biomarkers among office workers. Additionally, it seeks to investigate the impacts of at-home immersive VR exergames on the active and sedentary behaviors of office workers.

METHODS

A 3-arm, single-blinded pilot randomized controlled trial will be conducted to examine the therapeutic effects of at-home immersive VR exergames. A total of 120 Chinese office workers, engaging in less than 150 minutes per week of moderate to vigorous intensity physical activity, will be recruited via a convenience sampling method. The participants, who will be tested over a 12-week period, will be randomly assigned to one of three groups: (1) the VR exergame intervention group, (2) the regular physical activity control group, and (3) the nonexercise control group. Throughout the 12-week trial, three categories of variables will be collected across the three groups: clinical risk factors associated with metabolic syndrome, active and sedentary behaviors, and demographics. To analyze variance among the groups, a mixed linear model will be applied to assess the efficacy of each group. Differences in metabolic syndrome clinical risk factors among all groups will be used to evaluate the effects of at-home immersive VR exergames. Changes in active and sedentary behaviors will also be used to determine the impacts of VR exergames on metabolic syndrome.

RESULTS

The ethics committee of Guangzhou University, China, approved this study on September 25, 2024. Participant recruitment will begin in early 2025 and continue for approximately 3 months. Data will be analyzed after the 12-week trial is completed, with full results expected to be presented in early 2026.

CONCLUSIONS

This study explores an emerging topic by applying an at-home immersive VR exergame intervention, potentially contributing to understanding the effects of an exergame program on metabolic syndrome risk among office workers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06556784; https://clinicaltrials.gov/study/NCT06556784.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/64560.

Factors That Influence Young Adults' Preferences for Virtual Reality Exergames in a Weight Control Setting: Qualitative Study

BACKGROUND

Obesity could compromise people's health and elevate the risk of numerous severe chronic conditions and premature mortality. Young adults are at high risk of adopting unhealthy lifestyles related to overweight and obesity, as they are at a phase marked by several significant life milestones that have been linked to weight gain. They gain weight rapidly and excess adiposity mostly accrues, compared with middle-aged and older adults when weight stabilizes or even decreases. Virtual reality exergames have the potential to increase physical activity in people's daily lives. However, the factors that influence young adults' preference for using virtual reality exergames for weight control remain unclear.

OBJECTIVE

The objective of this study is to identify, characterize, and explain the factors influencing young adults' preference for weight control using virtual reality exergames.

METHODS

This qualitative study used semistructured interviews. In total, 4 focus group interviews were conducted with 23 young adults aged between 18 and 25 years. The qualitative data were analyzed using the Colaizzi phenomenological methodology.

RESULTS

In total, 3 major factors were found to influence young adults' preference for virtual reality exergames in weight control settings: individual factors, social or environmental factors, and expectations of virtual reality exergames. Individual factors included experience with previous weight control methods, previous experience with virtual reality, psychological status, attitudes toward personal BMI, preference for exercise type, and acceptance of virtual reality exergames. Social or environmental factors included social definitions of beauty, weather or public health events, and knowledge of virtual reality provided. Expectations of virtual reality exergames included cost of the device, the fun of virtual reality exergames, supervision, modality of virtual reality exergames, feedback after exercise, convenience to use, and weight loss effect.

CONCLUSIONS

Young adults take various factors into account when deciding whether to use virtual reality exergames for weight control. These factors can inform the development and further refinement of devices, guides, and policies related to virtual reality exergames for controlling weight.

Active Video Games Using Virtual Reality Influence Cognitive Performance in Sedentary Female University Students: A Randomized Clinical Trial

BACKGROUND

Virtual reality (VR) is an emerging technology that is proving to be effective in encouraging physical activity (PA) and improving health. Although regular PA has many advantages, physical inactivity continues to be a significant global health concern. Using an ActivPAL for PA assessment, this study examines the effects of an active video game (AVG) using VR on cognitive function among female university students.

METHODS

We randomly divided 44 sedentary female university students (mean age 21.3 years, SD 1.12 years) into two groups, the control group and VR group. During the study period, the VR group was required to play the Beat Saber VR game for 20 min, while the control group was required to remain quiet. Their cognitive performance was evaluated using the Montreal Cognitive Assessment (MoCA)-Arabic version pre- and post-test, and the PA level and intensity were tracked using the ActivPAL.

RESULTS

There was a significant difference between the MoCA total score pre-test (mean = 22.3, SD = 2.25) and the MoCA total score post-test (mean = 23.4, SD = 2.48), t (23) = 1.87, p = 0.03. The VR game significantly influenced the naming, abstraction, and orientation components of the MoCA scale (all p ≤ 0.05). The intensity of PA generated by the VR game was equivalent to moderate-to-vigorous PA, with a mean of 4.98 metabolic equivalents of task (MET) (SD = 1.20).

CONCLUSIONS

The VR game improved the cognitive ability compared to the control group, suggesting that VR games have a positive impact on cognitive function. Physically inactive female university students have been found to benefit from VR games in terms of their cognitive function.

Effectiveness of virtual reality in cardiac rehabilitation patients for exercise capacity and negative emotions: A systematic review and meta-analysis

BACKGROUND

The significance of virtual reality (VR) technology as an alternative or complementary modality to traditional cardiac rehabilitation is of increasing interest. Numerous studies have examined the effects of virtual reality technology in cardiac rehabilitation patients, but the results have been inconsistent.

METHODS

We conducted a systematic search of the Cochrane Library, Web of Science, PubMed, Embase, Scopus, ProQuest, OVID, CINAHL, SinoMed, CNKI, WanFang, VIP Database, and ReadShow databases following the Program for Systematic Review and Meta-Analysis guidelines. The search included studies published up until June 30, 2024. The Cochrane Risk of Bias Tool was used to examine the methodological quality of the included randomized controlled studies. When feasible, a meta-analysis was performed to calculate the pooled effects using Review Manager (version 5.3). Otherwise, narrative summaries were performed.

RESULTS

A total of 11 studies with 1093 patients were included. The results of systematic review and meta-analysis showed that virtual reality technology improved patients' exercise capacity (mean difference: 53.26, 95% confidence interval [CI]: 45.14-61.37; P < .00001); anxiety (standardized mean difference [SMD]: -0.39, 95% CI: -0.69, -0.08, P = .01); depression (SMD: -0.48, 95% CI: -0.79, -0.17; P = .003); stress (SMD: -0.72, 95% CI: -1.03, -0.40; P < .00001); emotional tension (SMD: -0.81, 95% CI: -1.15, -0.47; P < .00001); emotional tension (SMD: -0.64, 95% CI: -0.98, -0.30; P = .0002), and intrapsychic stress (SMD: -0.56, 95% CI: -0.90, -0.23; P = .0009).

CONCLUSION

Virtual reality-based interventions can be effective in improving patients' exercise capacity and negative emotions. However, further research is needed to determine the efficacy of VR for other clinical outcomes.

The "FitBrain" program: implementing exergaming & dual-task exercise programs in outpatient clinical settings

Dual-task training and exergaming interventions are increasingly recognized for their potential to enhance cognitive, physical, and mood outcomes among older adults and individuals with neurological conditions. Despite this, clinical and community programs that use these interventions are limited in availability. This paper presents the "FitBrain" program, an outpatient clinical model that combines dual-task and exergaming interventions to promote cognitive and physical health. We review the scientific rationale supporting these methods, detail the structure and methodology of the FitBrain program, and provide examples of session designs that integrate dual-tasking through exergaming. The paper also addresses implementation considerations, such as tailoring interventions to specific populations, ensuring user-centered design, and leveraging accessible technologies. We discuss key challenges, including limited research on programs utilizing multiple technologies and cost constraints, and propose directions for future research to refine best practices and evaluate the comparative effectiveness of multimodal vs. singular interventions. This paper aims to inform clinicians and program developers on implementing dual-task and exergaming interventions within diverse clinical and community settings by offering a structured model and practical guidelines.

Effect of a patient health engagement (PHE) model on rehabilitation participation in patients with acute myocardial infarction after PCI: a study protocol for a randomized controlled trial

BACKGROUND

Participation in cardiac rehabilitation is low in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI). Although existing rehabilitation methods have achieved certain results, patient participation in exercise rehabilitation is not ideal. The Patient Health Engagement (PHE) model is designed to ensure that patients improve their participation in cognitive, emotional, behavioral, and other aspects in all phases of exercise rehabilitation. The purpose of this study is to confirm whether the rehabilitation method based on the PHE model improves the rate of patient participation and enhances the rehabilitation effect during cardiac rehabilitation in patients with acute myocardial infarction compared with the traditional rehabilitation model.

METHODS/DESIGN

This is a single-center, double-blind, randomized, controlled trial that will enroll 128 patients. Patients with stable acute myocardial infarction after undergoing PCI who received cardiac rehabilitation and postoperative LVEF ≥ 40%, categorized into Killip class I ~ II and with age ≥ 18 years, will be included in the study. Exclusion criteria are mainly malignant arrhythmias, acute heart failure, congestive heart failure, and patients requiring intra-aortic balloon counterpulsation. Patients will be randomized in a 1:1 ratio to the intervention (1) and control (2) groups. Physicians, rehabilitation specialists, patients, and data collectors will be blinded during the study. A rehabilitator and a specialist nurse will conduct the cardiac rehabilitation. The specialist nurse will hand over the sealed bag containing patient information (group 1 or 2) to the physician. Group 1 will undergo cardiac rehabilitation through the PHE model, three times a week for 3 months. The rehabilitation program will be evaluated and adjusted in time from each period of the rehabilitation. Group 2 will be treated with routine cardiac rehabilitation. The rehabilitation participation rate of the two groups will be evaluated before and after 3 months of intervention. The primary outcome will be the level of patient participation in rehabilitation, and the secondary outcome will include general data of patients, postoperative rehabilitation indicators, cardiac rehabilitation knowledge-attitude-practice questionnaire, cardiovascular adverse events, and a brief mood scale.

EXPECTED OUTCOMES

We expect improved cardiac rehabilitation participation rates and rehabilitation outcomes in patients with acute myocardial infarction after undergoing PCI using the PHE model.

DISCUSSION

This approach may increase patient participation in rehabilitation, improve rehabilitation outcomes, and be widely implemented in hospitals and rehabilitation centers.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, ChiCTR2400085276 (Version 2.0 June 04, 2024),  https://www.chictr.org.cn .

TRIAL SPONSOR

Shandong Second Medical university, Weifang, Shandong. Contact name: Dechun Qin, Address: Shandong Second Medical university, Weifang Shandong. Email: 13562666589@163.com.

Enhancing medical education for undergraduates: integrating virtual reality and case-based learning for shoulder joint

BACKGROUND

The integration of Virtual Reality (VR) with Case-Based Learning (CBL) has the potential to revolutionise undergraduate medical education, particularly in complex subjects such as the anatomy and rehabilitation of the shoulder joint. This study aimed to explore the effectiveness of this innovative approach in enhancing learning outcomes and knowledge retention.

METHODS

This study employed a parallel-group, assessor-blinded randomised controlled trial (RCT) design. A comprehensive five-week educational programme was developed, combining traditional lecture-based learning with VR-enhanced CBL. The study involved 82 undergraduate students from China Medical University, who were divided into groups receiving different combinations of VR and CBL. Student performance was evaluated through tests and questionnaires.

RESULTS

In the anatomy-related courses, the integration of VR technology with CBL yielded significantly higher results (87.71 ± 5.60) compared to traditional methods (82.59 ± 6.64), with a statistically significant difference (P < 0.05). This provides compelling evidence of VR's potential to enhance student engagement and knowledge retention. In the context of physiotherapy-related courses, however, while the test scores of the VR-combined CBL group (81.85 ± 5.99) were marginally higher than those of the traditional CBL group (79.02 ± 7.57), this difference was not statistically significant (P > 0.05).

CONCLUSION

The present study provides preliminary evidence for the benefits of incorporating VR into medical education, particularly in anatomy. While the results are promising, further research is needed to explore the optimal integration of VR and CBL in rehabilitation studies and to assess their long-term impact on student learning and clinical performance.

TRIAL REGISTRATION

The study was registered with Chinese Clinical Trials Registry (Registration Number: ChiCTR2400089295) on 05/09/2024.

Exergames in exercise-based cardiac rehabilitation for patients with heart failure: a systematic review

AIM

The aim of this study was to systematically review the current literature on the use of exergames as an exercise-based cardiac rehabilitation intervention for patients with heart failure.

METHODS

PubMed, SCOPUS and CINAHL Plus databases were searched from January 2007 to August 2023. Studies considered eligible for inclusion had to report one or more of the following outcomes: functional capacity (e.g. VO 2 max), quality of life, mortality, hospital admissions, physical activity level, and engagement/satisfaction of the intervention. Only studies reported in English were included. Two reviewers independently assessed studies for their eligibility.

RESULTS

Two studies (in four reports) were included. Included studies reported only data on functional capacity (6-min walking test) and on physical activity level (accelerometers). Due to the low number of included studies, no meta-analysis was performed, and results were discussed narratively.

CONCLUSION

Exergames may potentially be a promising tool for exercise-based cardiac rehabilitation in patients with heart failure; however, the low number of included studies was insufficient to drawn proper conclusions. Benefits of exergames compared with traditional interventions could be the possibility of it being delivered at home, reducing some of the barriers that patients with heart failure must face. Further studies are required to assess the efficacy of exergame interventions in patients with heart failure, and to define proper guidelines to deliver exergame interventions in this population.This systematic review was registered on PROSPERO (CRD42023446948).

Virtual Reality-Based Exercise Rehabilitation in Cancer-Related Dysfunctions: Scoping Review

BACKGROUND

Virtual reality-based exercise rehabilitation (VRER) is a promising intervention for patients with cancer-related dysfunctions (CRDs). However, studies focusing on VRER for CRDs are lacking, and the results are inconsistent.

OBJECTIVE

We aimed to review the application of VRER in patients with CRDs.

METHODS

This scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist framework. Publications were included from the time of database establishment to October 14, 2023. The databases were PubMed, Embase, Scopus, Cochrane, Web of Science, ProQuest, arXiv, IEEE Xplore, MedRxiv, CNKI, Wanfang Data, VIP, and SinoMed. The population included patients with cancer. A virtual reality (VR) system or device was required to be provided in exercise rehabilitation as an intervention. Eligible studies focused on VRER used for CRDs. Study selection and data extraction were performed by 2 reviewers independently. Extracted data included authors, year, country, study type, groups, sample size, participant age, cancer type, existing or potential CRDs, VR models and devices, intervention programs and durations, effectiveness, compliance, satisfaction, and safety.

RESULTS

We identified 25 articles, and among these, 12 (48%) were randomized clinical trials, 11 (44%) were other experimental studies, and 2 (8%) were observational studies. The total sample size was 1174 (range 6-136). Among the 25 studies, 22 (88%), 2 (8%), and 1 (4%) included nonimmersive VR, immersive VR, and augmented reality, respectively, which are models of VRER. Commercial game programs (17/25, 68%) were the most popular interventions of VRER, and their duration ranged from 3 to 12 weeks. Using these models and devices, VRER was mostly applied in patients with breast cancer (14/25, 56%), leukemia (8/25, 32%), and lung cancer (3/25, 12%). Furthermore, 6 CRDs were intervened by VRER, and among these, postmastectomy syndromes were the most common (10/25, 40%). Overall, 74% (17/23) of studies reported positive results, including significant improvements in limb function, joint range of motion, edema rates, cognition, respiratory disturbance index, apnea, activities of daily living, and quality of life. The compliance rate ranged from 56% to 100%. Overall, 32% (8/25) of studies reported on patient satisfaction, and of these, 88% (7/8) reported satisfaction with VRER. Moreover, 13% (1/8) reported mild sickness as an adverse event.

CONCLUSIONS

We found that around half of the studies reported using VRER in patients with breast cancer and postmastectomy dysfunctions through nonimmersive models and commercial game programs having durations of 3-12 weeks. In addition, most studies showed that VRER was effective owing to virtualization and interaction. Therefore, VRER may be an alternate intervention for patients with CRDs. However, as the conclusions were drawn from data with acknowledged inconsistencies and limited satisfaction reports, studies with larger sample sizes and more outcome indictors are required.

A New Player in the Game: Can Exergame Be of Support in the Management of Atrial Fibrillation?

Atrial fibrillation (AF) is the most common form of cardiac arrhythmia, currently affecting 2-3% of the world's population. Traditional exercise and physical activity interventions have been successfully implemented in the management of AF, with the aim of improving patients' quality of life and their exercise capacity, as well as reducing their mortality rate. Currently, new technology-mediated approaches to exercise, defined as exergame, have been shown to be successful in the delivery of exercise home-based interventions in patients with cardiovascular diseases. However, data on the effects of exergame on AF are not yet available. In this paper, we summarise the current literature on the role of traditional exercise in AF and how it affects the pathophysiology of this condition. We also review the current literature on exergame and its employment in cardiac rehabilitation and suggest its potential role in the management of AF patients. A review of the evidence suggests that traditional exercise (of light-to-moderate intensity) is beneficial in patients with AF. Additionally, exergame seems to be a promising approach for delivering exercise interventions in patients with cardiovascular diseases. Exergame may be a promising tool to improve the quality of life and exercise capacity in patients with AF, with the additional advantage of being remotely delivered, and the potential to increase patients' engagement. Proper guidelines are required to prescribe exergame interventions, considering the principles of traditional exercise prescription and applying them to this new e-health approach. Further studies are needed to validate the use of exergame in patients with AF.

Exergaming (physically active video gaming) for mental health service users in a community mental health care setting: an ethnographic observational feasibility study

BACKGROUND

People with severe and enduring mental illness experience health inequalities with premature mortality; lifestyle behaviours are known to be contributing factors with low levels of physical activity reported. Facilitating physical activity to help maintain or improve health for those who are disadvantaged is essential. Exergaming (gaming involving physical movement) is increasingly used to improve physical activity across the lifespan and for those with a range clinical conditions; this might offer a way to increase physical activity for those with severe mental illness. The aim of this study was to explore engagement of mental health service users with exergaming to increase physical activity in a community mental health care setting.

METHODS

An ethnographic observational feasibility study was undertaken through participant observation and semi-structured interviews. A gaming console was made available for 2 days per week for 12 months in a community mental health setting. A reflexive thematic analysis was performed on the data.

RESULTS

Twenty one mental health service users engaged with the intervention, with two thirds exergaming more than once. One participant completed the semi-structured interview. Key themes identified from the observational field notes were: support (peer and staff support); opportunity and accessibility; self-monitoring; and perceived benefits. Related themes that emerged from interview data were: benefits; motivators; barriers; and delivery of the intervention. Integrating these findings, we highlight social support; fun, enjoyment and confidence building; motivation and self-monitoring; and, accessibility and delivery in community mental health care context are key domains of interest for mental health care providers.

CONCLUSIONS

We provide evidence that exergaming engages people with SMI with physical activity. The value, acceptability and feasibility of open access exergaming in a community mental health service context is supported. Facilitating exergaming has the potential to increase physical activity for mental health service users leading to possible additional health benefits.

Intensity of a Physical Exercise Programme Executed through Immersive Virtual Reality

Evidence suggests that moderate to vigorous physical activity (MVPA) is necessary for health benefits. Immersive virtual reality is a technology that uses images, sounds, and tactile sensations from a simulated world to encourage healthy behaviours and physical activity. The aims of this research are (1) to determine the duration and intensity of physical activity performed through immersive virtual reality; (2) to determine differences in physical activity intensity according to gender.

METHODS

A nonprobabilistic convenience sample composed of 39 university students of physical education pedagogy, who performed, through immersive virtual reality, a physical activity programme composed of three levels that progressively increased in complexity. Physical activity intensity was measured using accelerometers.

RESULTS

Of the three levels, the most complex was not the one that produced the most minutes of MVPA. The three levels added up to 08:53 min of MVPA. No significant differences were found when comparing them by sex.

CONCLUSIONS

The results of this study suggest that an exercise programme delivered through immersive virtual reality generates MVPA levels, with no major differences between sexes. Further research is needed to confirm the contribution of immersive virtual reality to physical activity.

Effects of Virtual Reality in the Rehabilitation of Parkinson's Disease: A Systematic Review

BACKGROUND

Parkinson's disease is characterised by the loss of balance and the presence of walking difficulties. The inclusion of rehabilitation therapies to complement pharmacological therapy allows for comprehensive management of the disease. In recent years, virtual reality has been gaining importance in the treatment of neurological diseases and their associated symptoms. Therefore, the objective of this systematic review was to analyse the effectiveness of virtual reality on balance and gait in patients with Parkinson's disease.

METHODS

This study is a systematic review conducted following PRISMA's statements. An electronic search of the literature was carried out in the following databases: PubMed, Cochrane, Dialnet, Scopus, Web of Science, PsycINFO and Science Direct PEDro. The inclusion criteria were controlled and non-controlled clinical trials published in the last 12 years in English or Spanish, in which virtual reality was applied to treat balance and gait impairments in patients with Parkinson's disease.

RESULTS

20 studies were finally included in this review. A total of 480 patients participated in the included studies. All patients were diagnosed with Parkinson's disease. Most of the investigations used the Nintendo Wii + Balance Board or the Microsoft Kinect TM combined with the Kinect Adventures games as a virtual reality device.

CONCLUSIONS

According to the results of this literature review, virtual reality-based interventions achieve good adherence to treatment, bring innovation and motivation to rehabilitation, and provide feedback as well as cognitive and sensory stimulation in patients with Parkinson's disease. Therefore, virtual reality can be considered an alternative for personalised rehabilitation and for home treatment.

Fully immersive virtual reality exergames with dual-task components for patients with Parkinson's disease: a feasibility study

BACKGROUND

Dual-task training in Parkinson's disease (PD) improves spatiotemporal gait parameters, cognition, and quality of life. Virtual reality (VR) has been used as a therapeutic tool for patients to participate in activities in a safe environment, engage in multisensory experiences, and improve motivation and interest in rehabilitation. This study aimed to investigate the feasibility of fully immersive VR exergames with dual-task components in patients with PD.

METHODS

We developed VR exergames (go/no-go punch game, go/no-go stepping game, and number punch game) to improve habitual behavior control using motor-cognitive dual-task performance in patients with PD. The participants underwent 10 sessions 2-3 times a week, consisting of 30 min per session. The Unified Parkinson's Disease Rating Scale, Timed Up and Go test (TUG) under single- and dual-task (cognitive and physical) conditions, Berg balance scale (BBS), Stroop test, trail-making test, and digit span were evaluated before and after intervention. The Simulator Sickness Questionnaire (SSQ) was used to assess VR cybersickness. Usability was assessed using a self-reported questionnaire.

RESULTS

Twelve patients were enrolled and completed the entire training session. The mean age of participants was 73.83 ± 6.09 years; mean disease duration was 128.83 ± 76.96 months. The Hoehn and Yahr stages were 2.5 in seven patients and 3 in five patients. A significant improvement was observed in BBS and Stroop color-word test (p = 0.047 and p = 0.003, respectively). TUG time and dual-task interferences showed positive changes, but these changes were not statistically significant. The median SSQ total score was 28.05 (IQR: 29.92), 13.09 (IQR: 11.22), and 35.53 (IQR: 52.36) before, after the first session, and after the final session, respectively; the differences were not significant. Overall satisfaction with the intervention was 6.0 (IQR: 1.25) on a 7-point Likert-type scale.

CONCLUSIONS

Fully immersive VR exergames combined with physical and cognitive tasks may be used for rehabilitation of patients with PD without causing serious adverse effects. Furthermore, the exergames using dual-task components improved executive function and balance. Further development of VR training content may be needed to improve motor and dual-task performances. Trial registration NCT04787549 ( https://clinicaltrials.gov/ct2/show/NCT04787549 ).

Effects of exergaming in older individuals with mild cognitive impairment and dementia: A systematic review and meta-analysis

BACKGROUND

Non-pharmaceutical interventions have been implemented for people with dementia or mild cognitive impairment (MCI). Researchers have used exergaming in dementia to alleviate cognitive decline in patients with dementia.

AIMS

We assessed the effects of exergaming interventions on MCI and dementia.

METHODS

We conducted a systematic review and meta-analysis (PROSPERO [CRD42022347399]). PubMed, Cochrane Library, Web of Science, CINAHL, and Embase electronic databases were searched for randomized controlled trials (RCTs). The impact of exergaming on cognitive function, physical performance, and quality of life in patients with MCI and dementia was investigated.

RESULTS

Ten RCTs met the eligibility criteria and were included in our systematic review. The results of the meta-analysis demonstrated a statistically significant difference in the Mini-mental State Examination, Montreal Cognitive Assessment, Trail Making Test, Chinese version of the Verbal Learning Test, Berg Balance Scale, Short Physical Performance Battery, and Physical Activity Scale for the Elderly in people with dementia and MCI who participated in exergaming. However, there were no significant improvements in the Activities of Daily Living, Instrumental Activity of Daily Living or Quality of Life.

CONCLUSION

Although there were significant differences in cognitive and physical functions, these results should be interpreted with caution because of heterogeneity. The additional benefits of exergaming remain to be confirmed in future studies.

A Systematic Review and Meta-analysis of the Effect of Active Video Games on Postural Balance

OBJECTIVE

To conduct a comprehensive systematic review and meta-analysis of the effects of active video game (AVG) interventions on postural balance across all ages in populations with and without neurologic impairments, using all types of platforms.

DATA SOURCE

Six databases (PubMed, PsycINFO, Sport Discus, MEDLINE, Web of Science, and Google Scholar) were reviewed by December 31, 2020.

STUDY SELECTION

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42020204191). For inclusion, a study must be original, published in English peer-reviewed venues and employed AVGs as the sole or primary intervention to enhance, maintain, or regain postural balance. At least 2 within- or between-subjects conditions must be included with ≥10 participants per condition.

DATA EXTRACTION

Three reviewers independently performed data extraction and assessed the risk of bias.

DATA SYNTHESIS

129 studies were identified, with 102 eligible for meta-analysis. The total number of tested participants was 6407 (60.0% women, M_age=55.1 years, range=3-99 years, SD=22.6). The average intervention duration was 35.6 min/session with 3.1 sessions/week for 7.6 weeks. The overall effect favored AVG interventions (Hedges' g=0.469; 95% confidence interval [CI]=0.407-0.531). Although the overall study quality was relatively low, the analysis expectedly indicated significantly larger effects (P<.001) for AVG-interventions over passive controls (Hedges' g=0.627; 95% CI=0.466-0.788), but importantly also favored AVG-interventions over conventional treatment (Hedges' g=0.389; 95% CI=0.311-0.468). All clinical populations responded positively, although with different effect sizes (P=.023). Children experienced larger treatment effects (Hedges' g=0.550; 95% CI=0.336-0.764), closely followed by seniors (Hedges' g=0.529; 95% CI=0.402-0.656). The largest intervention effect on balance improvements was seen in healthy people without a medical condition (Hedges' g=0.609; 95% CI=0.465-0.753).

CONCLUSIONS

AVGs can produce postural balance improvements and better postural maintenance. All populations could benefit from AVG interventions.

Application of Virtual Reality Technology in Clinical Practice, Teaching, and Research in Complementary and Alternative Medicine

Background

The application of virtual reality (VR) in clinical settings is growing rapidly, with encouraging results. As VR has been introduced into complementary and alternative medicine (CAM), a systematic review must be undertaken to understand its current status.

Aim

This review aims to evaluate and summarize the current applications of VR in CAM, as well as to explore potential directions for future research and development.

Methods

After a brief description of VR technology, we discuss the past 20 years of clinical VR applications in the medical field. Then, we discuss the theoretical basis of the combination of VR technology and CAM, the research thus far, and practical factors regarding usability, etc., from the following three main aspects: clinical application, teaching, and scientific research. Finally, we summarize and propose hypotheses on the application of VR in CAM and its limitations.

Results

Our review of the theoretical underpinnings and research findings to date leads to the prediction that VR and CAM will have a significant impact on future research and practice.

Conclusion

Although there is still much research needed to advance the science in this area, we strongly believe that VR applications will become indispensable tools in the toolbox of CAM researchers and practitioners and will only grow in relevance and popularity in the era of digital health.

Objectively measured physical activity in patients with heart failure: a sub-analysis from the HF-Wii study

AIMS

Physical activity (PA) is important in patients with heart failure (HF) to improve health outcomes. The adherence to PA is low, and therefore, novel approaches are necessary to increase PA. We aimed to determine the difference in PA in patients with HF who have access to exergaming compared to patients who received motivational support and to explored predictors of a clinically relevant change in non-sedentary time between baseline and 3 months.

METHODS AND RESULTS

In total, 64 patients (mean age 69 ± 9 years, 27% female) wore an accelerometer 1 week before and 1 week after the intervention. Data were analysed using logistic regression analysis. Patients spent 9 h and 43 min (±1 h 23 min) during waking hours sedentary. There were no significant differences in PA between patients who received an exergame intervention or motivational support. In total, 30 of 64 patients achieved a clinically relevant increase in non-sedentary time. Having grandchildren [odds ratio (OR) 7.43 P = 0.03], recent diagnosis of HF (OR 0.93 P = 0.02), and higher social motivation (OR 2.31 P = 0.03) were independent predictors of a clinically relevant increase of non-sedentary time.

CONCLUSION

Clinicians should encourage their patients to engage in alternative approaches to improve PA and reduce sedentary habits. Future exergaming interventions should target individuals with chronic HF who have low social motivation and a low level of light PA that may benefit most from exergaming. Also (non-familial), intergenerational interaction is important to enabling patients in supporting patients in becoming more active.

Use of interventions involving virtual reality tasks during the climacteric: a systematic review

Technological advances have been impacting health care worldwide. Our study aimed to research the literature systematically to determine the impact of technological treatments versus conventional treatments on the quality of life of climacteric women. The study was registered on PROSPERO (CRD42021241638). We searched seven databases, including PRISMA, using mesh terms. After screening for eligibility, we selected five clinical trials, and applying the snowball technique we were able to include four more articles, totaling nine articles that used technology-based interventions (virtual reality games) during the climacteric. The total study population consisted of 298 climacteric women. Two studies evaluated a technology-based treatment for pelvic floor, one for urinary incontinence symptoms, three for postural balance, one for cardiorespiratory capacity, one for osteoporosis and one study for lower back pain. The studies showed that the technological treatments improved pelvic floor strength, balance, cardiorespiratory fitness and bone mineral density when compared to conventional treatments. Improvement was linked to adherence to training and a high level of satisfaction during the training sessions. Technology-based treatments appear to be a viable alternative to conventional treatments in improving the quality of health, with benefits for the cardiovascular, genitourinary and skeletal systems, and ultimately for the overall quality of life.

Understanding and assessing gamification in digital healthcare interventions for patients with cardiovascular disease

Gamification is defined as the use of game design elements in contexts other than gaming to increase user engagement and experience. Gamification in cardiovascular care can contribute to positively change health behaviour with possible effects and benefits on physical health and mental well-being. Based on previous literature, in this article we describe: the conceptualization of gamification, the five gamification principles for gamified digital health programmes or applications, the six most common game elements used to impact health behaviour applied in gamified digital health interventions and finally scientifically validated instruments to use for assessment of gamification in terms of self-reported psychological outcomes.

Cardiovascular Disease Screening in Women: Leveraging Artificial Intelligence and Digital Tools

Cardiovascular disease remains the leading cause of death in women. Given accumulating evidence on sex- and gender-based differences in cardiovascular disease development and outcomes, the need for more effective approaches to screening for risk factors and phenotypes in women is ever urgent. Public health surveillance and health care delivery systems now continuously generate massive amounts of data that could be leveraged to enable both screening of cardiovascular risk and implementation of tailored preventive interventions across a woman's life span. However, health care providers, clinical guidelines committees, and health policy experts are not yet sufficiently equipped to optimize the collection of data on women, use or interpret these data, or develop approaches to targeting interventions. Therefore, we provide a broad overview of the key opportunities for cardiovascular screening in women while highlighting the potential applications of artificial intelligence along with digital technologies and tools.

CardioVR-ReTone—Robotic Exoskeleton for Upper Limb Rehabilitation following Open Heart Surgery: Design, Modelling, and Control

Following cardiac surgery, patients experience difficulties with the rehabilitation process, often finding it difficult, and therefore lack the motivation for rehabilitation activities. As the number of people aged 65 and over will rise by 207 percent globally by 2050, the need for cardiac rehabilitation will significantly increase, as this is the main population to experience heart problems. To address this challenge, this paper proposes a new robotic exoskeleton concept with 12 DoFs (6 DoFs on each arm), with a symmetrical structure for the upper limbs, to be used in the early rehabilitation of cardiac patients after open-heart surgery. The electromechanical design (geometric, kinematic, and dynamic model), the control architecture, and the VR-based operating module of the robotic exoskeleton are presented. To solve the problem of the high degree of complexity regarding the CardioVR-ReTone kinematic and dynamic model, the iterative algorithm, kinetic energy, and generalized forces were used. The results serve as a complete model of the exoskeleton, from a kinematic and dynamic point of view as well as to the selection of the electric motors, control system, and VR motivation model. The validation of the concept was achieved by evaluating the exoskeleton structure from an ergonomic point of view, emphasizing the movements that will be part of the cardiac rehabilitation.

Effect of the Nintendo Ring Fit Adventure Exergame on Running Completion Time and Psychological Factors among University Students Engaging in Distance Learning during the COVID-19 Pandemic: A Randomized Prospective Study (Preprint)

Background

The COVID-19 outbreak has not only changed the lifestyles of people globally but has also resulted in other challenges, such as the requirement of self-isolation and distance learning. Moreover, people are unable to venture out to exercise, leading to reduced movement, and therefore, the demand for exercise at home has increased.

Objective

We intended to investigate the relationships between a Nintendo Ring Fit Adventure (RFA) intervention and improvements in running time, cardiac force index (CFI), sleep quality (Chinese version of the Pittsburgh Sleep Quality Index score), and mood disorders (5-item Brief Symptom Rating Scale score).

Methods

This was a randomized prospective study and included 80 students who were required to complete a 1600-meter outdoor run before and after the intervention, the completion times of which were recorded in seconds. They were also required to fill out a lifestyle questionnaire. During the study, 40 participants (16 males and 24 females, with an average age of 23.75 years) were assigned to the RFA group and were required to exercise for 30 minutes 3 times per week (in the adventure mode) over 4 weeks. The exercise intensity was set according to the instructions given by the virtual coach during the first game. The remaining 40 participants (30 males and 10 females, with an average age of 22.65 years) were assigned to the control group and maintained their regular habits during the study period.

Results

The study was completed by 80 participants aged 20 to 36 years (mean 23.20, SD 2.96 years). The results showed that the running time in the RFA group was significantly reduced. After 4 weeks of physical training, it took females in the RFA group 19.79 seconds (P=.03) and males 22.56 seconds (P=.03) less than the baseline to complete the 1600-meter run. In contrast, there were no significant differences in the performance of the control group in the run before and after the fourth week of intervention. In terms of mood disorders, the average score of the RFA group increased from 1.81 to 3.31 for males (difference=1.50, P=.04) and from 3.17 to 4.54 for females (difference=1.38, P=.06). In addition, no significant differences between the RFA and control groups were observed for the CFI peak acceleration (CFIPA)_walk, CFIPA_run, or sleep quality.

Conclusions

RFA could either maintain or improve an individual’s physical fitness, thereby providing a good solution for people involved in distance learning or those who have not exercised for an extended period.

Trial Registration

ClinicalTrials.gov NCT05227040; https://clinicaltrials.gov/ct2/show/NCT05227040

Virtual and Augmented Reality in Cardiovascular Care: State-of-the-Art and Future Perspectives

Applications of virtual reality (VR) and augmented reality (AR) assist both health care providers and patients in cardiovascular education, complementing traditional learning methods. Interventionalists have successfully used VR to plan difficult procedures and AR to facilitate complex interventions. VR/AR has already been used to treat patients, during interventions in rehabilitation programs and in immobilized intensive care patients. There are numerous additional potential applications in the catheterization laboratory. By using AR, interventionalists could combine visual fluoroscopy information projected and registered on the patient body with data derived from preprocedural imaging and live fusion of different imaging modalities such as fluoroscopy with echocardiography. Persistent technical challenges to overcome include the integration of different imaging modalities into VR/AR and the harmonization of data flow and interfaces. Cybersickness might exclude some patients and users from the potential benefits of VR/AR. Critical ethical considerations arise in the application of VR/AR in vulnerable patients. In addition, digital applications must not distract physicians from the patient. It is our duty as physicians to participate in the development of these innovations to ensure a virtual health reality benefit for our patients in a real-world setting. The purpose of this review is to summarize the current and future role of VR and AR in different fields within cardiology, its challenges, and perspectives.

Evaluation of the Impact of Virtual Reality-Enhanced Cardiac Rehabilitation on Depressive and Anxiety Symptoms in Patients with Coronary Artery Disease: A Randomised Controlled Trial

The aim of this study was to assess the efficacy of virtual reality (VR)-enhanced cardiac rehabilitation (CR) in reducing the intensity of depression and anxiety symptoms in patients undergoing phase II of CR in ambulatory conditions. One hundred participants (mean age 65.7 years) were divided randomly into two groups. Both groups took part in eight sessions of standard CR (three times per week). The experimental group was additionally supported by eight sessions of VR therapy using the VR TierOne device and the control group by eight sessions of Schultz Autogenic Training. The Hospital Anxiety and Depression Scale (HADS) was used as the primary outcome measure. The Perception of Stress Questionnaire was used as the secondary outcome measure. The data from 77 participants were subject to analysis. Post-intervention, in the experimental group, the overall HADS score was statistically significantly reduced by 13.5%, HADS-Depression by 20.8%, and the general stress level by 12.8% (p < 0.05). In the control group, the scores of the HADS, HADS-Anxiety and the general stress level were statistically significantly higher, by 4.8%, 6.5%, and 4.9%, respectively. VR-enhanced CR for individuals with cardiovascular disease reduced the level of anxiety and depression symptoms compared to standard CR.

Comparison Between Conventional Intervention and Non-immersive Virtual Reality in the Rehabilitation of Individuals in an Inpatient Unit for the Treatment of COVID-19: A Study Protocol for a Randomized Controlled Crossover Trial

Background: The new human coronavirus that leads to COVID-19 (coronavirus disease 2019) has spread rapidly around the world and has a high degree of lethality. In more severe cases, patients remain hospitalized for several days under treatment of the health team. Thus, it is important to develop and use technologies with the aim to strengthen conventional therapy by encouraging movement, physical activity, and improving cardiorespiratory fitness for patients. In this sense, therapies for exposure to virtual reality (VR) are promising and have been shown to be an adequate and equivalent alternative to conventional exercise programs.

Aim: This is a study protocol with the aim of comparing the conventional physical therapy intervention with the use of a non-immersive VR software during COVID-19 hospitalization.

Methods: Fifty patients hospitalized with confirmed diagnosis of COVID-19 will be divided in two groups under physiotherapy treatment using conventional or VR intervention: Group A: participants with COVID-19 will start the first day of the protocol with VR tasks in the morning and then in the second period, in the afternoon, will perform the conventional exercises (n = 25) and Group B: participants with COVID-19 will start the first day with conventional exercises in the morning and in the second period, in the afternoon, will perform activity with VR (n = 25). All participants will be evaluated with different motor and physiologic scales before and after the treatment to measure improvements.

Conclusion: Considering the importance of benefits from physical activity during hospitalization, VR software shows promise as a potential mechanism for improving physical activity. The results of this study may provide new insights into hospital rehabilitation.

Trial Registration:ClinicalTrials.gov, identifier: NCT04537858. Registered on 01 September 2020.

Immersive virtual reality health games: a narrative review of game design

BACKGROUND

High quality head-mounted display based virtual reality (HMD-VR) has become widely available, spurring greater development of HMD-VR health games. As a behavior change approach, these applications use HMD-VR and game-based formats to support long-term engagement with therapeutic interventions. While the bulk of research to date has primarily focused on the therapeutic efficacy of particular HMD-VR health games, how developers and researchers incorporate best-practices in game design to achieve engaging experiences remains underexplored. This paper presents the findings of a narrative review exploring the trends and future directions of game design for HMD-VR health games.

METHODS

We searched the literature on the intersection between HMD-VR, games, and health in databases including MEDLINE, Embase, CINAHL, PsycINFO, and Compendex. We identified articles describing HMD-VR games designed specifically as health applications from 2015 onwards in English. HMD-VR health games were charted and tabulated according to technology, health context, outcomes, and user engagement in game design.

FINDINGS

We identified 29 HMD-VR health games from 2015 to 2020, with the majority addressing health contexts related to physical exercise, motor rehabilitation, and pain. These games typically involved obstacle-based challenges and extrinsic reward systems to engage clients in interventions related to physical functioning and pain. Less common were games emphasizing narrative experiences and non-physical exercise interventions. However, discourse regarding game design was diverse and often lacked sufficient detail. Game experience was evaluated using primarily ad-hoc questionnaires. User engagement in the development of HMD-VR health games primarily manifested as user studies.

CONCLUSION

HMD-VR health games are promising tools for engaging clients in highly immersive experiences designed to address diverse health contexts. However, more in-depth and structured attention to how HMD-VR health games are designed as game experiences is needed. Future development of HMD-VR health games may also benefit from greater involvement of end-users in participatory approaches.

Home-based exercise can be beneficial for counteracting sedentary behavior and physical inactivity during the COVID-19 pandemic in older adults

The novel pandemic called coronavirus disease 2019 (COVID-19), as a global public health emergency, seems to be having a major impact on physical activity (PA) behaviors. Older adults are at high risk of death from the severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). Health authorities around the world have been implementing preventive health measures, including quarantine and self-isolation, to mitigate the COVID-19 outbreak. This period is characterized by the cessation of outdoor exercising. During this period of lockdown, PA has been one of the rare reasons for going out in some countries. To avoid the harmful effects of periods of exercise cessation, PA could be prescribed to older adults, which is of great importance for breaking their sedentary lifestyle and improving their immunity. The present review discusses the potential impacts of the COVID-19 pandemic on sedentary behavior and physical inactivity in older adults. The importance of performing PA to reduce the harmful effects of the COVID-19 pandemic is discussed, and useful recommendations on home-based exercise for the older adults to maintain their level of independence, physical and mental health as well as their well-being are provided.

Effects of Virtual Reality on Cardiac Rehabilitation Programs for Ischemic Heart Disease: A Randomized Pilot Clinical Trial

(1) Background: The aim of the present study was to determine the effects of a virtual reality (VR) program, as a complementary tool to a conventional cardiac rehabilitation (CR) program in phase II of patients with ischemic heart disease compared to a conventional treatment group. (2) Methods: A single blinded randomized clinical trial was conducted. The patients were randomized to a control group (CG) or an experimental group (EG). The EG carried out a training based on VR of aerobic exercise using the XBOX ONE console and Kinect sensor. Ergometry, metabolic equivalents (METS), Functional Independence Measure, 6-min walk test (6MWT), the Short Form Health Survey-36 Questionnaire (SF-36), the Beck Depression Inventory-II, and the degree of satisfaction and adherence to treatment were used as outcome measures. (3) Results: Our results showed no statistically significant differences between the two groups. Statistical analysis within group for the EG showed statistically significant changes in the variables HR final ergometry, ergometry minutes, % ergometry, METS, final HR 6MWT, 6MWT distance, 6MWT number of laps, and for the SF-36 and Beck Depression Inventory-II. (4) Conclusion: A VR-based video game program, as an adjunct tool to a CR program, showed improvements in ergometry, METS, resistance to fatigue and health-related quality of life with excellent adherence and satisfaction perceived by patients with ischemic heart disease in phase II.

An Immersive Virtual Reality Exergame for People with Parkinson’s Disease

Parkinson’s disease is a neurodegenerative disorder that affects primarily motor system. Physical exercise is considered important for people with Parkinson’s disease (PD) to slow down disease progression and maintain abilities and quality of life. However, people with PD often experience barriers to exercises that causes low-level adherence to exercise plans and programs. Virtual Reality (VR) is an innovative and promising technology for motor and cognitive rehabilitation. Immersive VR exergames have potential advantages by allowing for individualized skill practice in a motivating interactive environment without distractions from outside events. This paper presents an immersive virtual reality (VR) exergame aiming at motor training on fingers and hand-and-eye coordination. The results from the usability study indicate that immersive VR exergames have potential to provide motivating and engaging physical exercise for people with PD. Through this research, we hope to contribute to evidence-based design principles for task-specific immersive VR exergames for patients with Parkinson’s Disease.

Effect of virtual reality-simulated exercise on sympathovagal balance

Discovery of therapeutic avenues to provide the benefits of exercise to patients with enforced sedentary behavior patterns would be of transformative importance to health care. Work in model organisms has demonstrated that benefits of exercise can be provided to stationary animals by daily intermittent stimulation of adrenergic signaling. Here, we examine as a proof of principle whether exposure of human participants to virtual reality (VR) simulation of exercise can alter sympathovagal balance in stationary humans. In this study, 24 participants performed 15 minutes of cycling exercise at standardized resistance, then repeated the exercise with a virtual reality helmet that provided an immersive environment. On a separate day, they each controlled a virtual environment for 15 minutes to simulate exercise without actual cycling exercise. Response to each treatment was assessed by measuring heart rate (HR), norepinephrine, and heart rate variability, and each participant's response to virtual exercise was compared internally to his/her response to the actual cycling. We found that neither post-exercise norepinephrine nor post-exercise HR was significantly increased by VR simulation. However, heart rate variability measured during virtual exercise was comparable to actual cycling in participants that engaged in moderate exercise, but not in those that engaged in high-intensity exercise. These findings suggest that virtual exercise has the potential to mimic some effects of moderate exercise. Further work will be needed to examine the longitudinal effects of chronic exposure to VR-simulated exercise.

Psychological and Physiological Responses in Patients with Generalized Anxiety Disorder: The Use of Acute Exercise and Virtual Reality Environment

Virtual exercise therapy is considered a useful method by which to encourage patients with generalized anxiety disorder (GAD) to engage in aerobic exercise in order to reduce stress. This study was intended to explore the psychological and physiological responses of patients with GAD after cycling in a virtual environment containing natural images. Seventy-seven participants with GAD were recruited in the present study and randomly assigned to a virtual nature (VN) or a virtual abstract painting (VAP) group. Their electroencephalogram alpha activity, perceived stress, and levels of restorative quality and satisfaction were assessed at baseline and after an acute bout of 20 min of moderate-intensity aerobic exercise. The results showed that both the VN and VAP groups showed significantly higher alpha activity post-exercise as compared to pre-exercise. The VN group relative to the VAP group exhibited higher levels of stress-relief, restorative quality, and personal satisfaction. These findings imply that a virtual exercise environment is an effective way to induce a relaxing effect in patients with GAD. However, they exhibited more positive psychological responses when exercising in such an environment with natural landscapes.