Virtual reality and video games in cardiac rehabilitation programs. A systematic review

Acceptability of and Willingness to Use Virtual Reality Exergames for Weight Loss Among Young Adults With Overweight or Obesity in China: Qualitative Study

Background

Overweight and obesity seriously affect physical and psychological health worldwide. They are common public health issues in young adults who are considered a "vulnerable group" prone to adopt unhealthy lifestyles that can lead to overweight and obesity. Virtual reality exergames could help increase balance performance among patients with Parkinson disease and improve depression and pain interference among individuals with chronic neck pain. Still, limited research has been conducted on the use of virtual reality exergames among young adults with overweight and obesity, and their willingness and acceptability remain unclear.

objectives

This study aimed to assess the acceptability of and willingness to use virtual reality exergames for weight loss among young adults with overweight or obesity.

Methods

This was a qualitative study. Sixteen young adults with overweight or obesity were recruited in Guangzhou, China, and divided into 4 focus groups. They were interviewed between September and October 2023 through semistructured interviews. NVivo (version 14; Lumivero) was used to transcribe, code, and thematically analyze interviews.

Results

Four main themes and 8 subthemes emerged from the data. The main themes included perception of previous weight loss measures (regarded exercise and diet as the main measures for weight loss and difficulties in holding on to the weight loss methods), acceptability of virtual reality exergames (increasing opportunities for exercise, a powerful means for propelling doing exercise, positive impact on psychological well-being, and more appealing to office workers than students), willingness to use virtual reality exergames, and concerns (weight loss effect and other concerns).

Conclusions

Virtual reality exergames were seen as beneficial for maintaining exercise and promoting psychological well-being among young adults with overweight or obesity, despite concerns about effectiveness, cost, and privacy. Almost all young adults indicated their willingness to try these kinds of games if given the opportunity. These findings suggested that virtual reality exergames could be a promising tool for weight management in this population.

The application of metaverse in mental health

Rapid technological progress is reshaping human existence globally. The metaverse, a 3D digital realm merging virtual reality (VR) with physical space, exemplifies this fusion. Users can replicate and customize real-world elements within this immersive environment. Over the past decade, VR, augmented reality (AR), and mixed reality (MR) have become effective tools for addressing mental health conditions, offering solutions to the shortage of mental health professionals and limited access to care. However, extensive participation in 3D immersive gaming and social media can lead to insecurity, anxiety, depression, and addictive behaviors, particularly among young adults. This engagement may also impair attention spans, exacerbating symptoms in adolescents with attention deficit hyperactivity disorder. This research examines the impact of expanding metaverse applications on mental health, exploring both risks and benefits.

Feasibility of a Mobile Exergame for Patients with Heart Failure

Background: Physical activity is beneficial and recommended to improve outcomes for patients with heart failure (HF). Exergaming combines gaming technology with physical activity. Therefore, we developed a mobile exergame in a co-design process, the exergame would engage participants in physical activity anywhere and anytime. This study aims to assess the feasibility of a newly developed mobile exergame, heart farming, for patients with HF. Methods: A total of 14 participants with HF used the exergame on their smartphones for one month (9 Swedish and 5 Spanish participants; 9 males, mean 72 years, range 61-82 years). Participants were provided an introduction to the exergame, and follow-up was carried out regularly by telephone. Participants were advised to increase the daily walking duration by 10 minutes a day, based on the number of meters walked in the 6-minute walk test (6MWT). Areas of feasibility identified were acceptability, demand, implementation, and practicality, which were examined during telephone follow-ups and interviews, and data downloaded from the exergame. Results: Participants found the farming theme appealing, and coaching encouraged them to perform the exergame on a regular basis (acceptability). Based on the 6MWT, the personal goal for daily walking was set (mean of 704 meters, range 250-900 meters). Participants reported that daily goals and tasks were manageable. The exergame was perceived as appropriate to decrease sedentary time, and participants reported improved physical health (demand). The exergame was perceived as easy to learn and use, and adjustable to individual needs (implementation). Exergaming while walking and conversing with others was described as less convenient (practicality). Conclusion: Participants with HF valued personalized support and the exergame's farming theme was appealing. The goal to increase walking by 10 minutes a day was seen as a realistic way to reduce sedentary behavior. When introducing the exergame, it is essential to emphasize the importance of proper lighting, so meters walked are accurately recorded.

A Systematic Review and Meta-Analysis of Virtual and Traditional Physical Activity Programs: Effects on Physical, Health, and Cognitive Outcomes

(1) Background: The aim of this study was to conduct a systematic literature review and meta-analysis on the effects of virtual reality (VR) and traditional (TR) physical activity programs, analyzing their impact on the physical, health, and cognitive aspects of participants. The study sought to identify the advantages and limitations of both methods, taking into account previous research and potential areas for future studies. (2) Methods: The study protocol for this systematic review was registered at the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY202530015). The review followed PRISMA guidelines, and studies were selected based on their relevance to the research objectives using the PICOS model criteria. The authors applied a meta-analysis in addition to a systematic review to further ensure the accuracy of the results. Primary outcomes included physical and cognitive performance, while secondary outcomes encompassed participant perceptions and psychological effects. (3) Results: The findings indicate that VR training significantly enhances flexibility, motivation, and cognitive abilities, particularly in populations with limited access to traditional exercise methods. The most pronounced effects were observed in programs lasting 8 to 12 weeks with a moderate to high intensity. In contrast, TR showed superiority in developing strength, endurance, and cardiorespiratory functions. (4) Conclusions: VR offers significant benefits as an adjunct or alternative to TR, especially for individuals with limited resources or physical accessibility. However, variations in methodological approaches, short program durations, and sample heterogeneity highlight the need for further longitudinal research. Standardizing VR training duration and intensity is essential to ensure consistent and reliable outcomes.

Immersive virtual reality reduces depression, anxiety and stress in patients with cardiovascular diseases undergoing cardiac rehabilitation: A systematic review with meta-analysis

BACKGROUND

Current literature suggests that immersive virtual reality (IVR) could be an efficacious therapeutic approach for patients with cardiovascular diseases (CVD) undergoing cardiac rehabilitation program (CRP). However, this has only been affirmed in individual studies and is yet to be confirmed by a systematic review.

OBJECTIVES

To determine the efficacy of IVR interventions on depression, anxiety, and stress symptoms in patients with CVD.

METHODS

A meta-analysis was performed in line with PRISMA guidelines following a literature search between inception and June 2024 in PubMed, SCOPUS, WOS, CINAHL and PEDro for retrieving randomized controlled trials (RCTs) that compared the efficacy of IVR versus conventional CRPs on depression, anxiety and stress in patients with CVD. The PEDro scale was used to evaluate the methodological quality of the studies. Pooled effects were calculated using the Cohen's standardized mean difference (SMD) and its 95% confidence interval (95% CI), or mean difference (MD) if studies used the same measure.

RESULTS

Eight RCTs, providing data from 510 patients with CVD (63.8±5.4 years, 60% men), were included. The methodological quality was moderate (M=5.1±1 points). A large rehabilitative effect of IVR was found for reducing depression (SMD=-0.54; 95% CI -0.77 to -0.31; p<0.001), anxiety (SMD=-0.43; 95% CI -0.74 to -0.12; p=0.006) and stress (MD=-14.96; 95% CI -20.1 to -9.8; p<0.001). The findings suggest that combine IVR and CRP is the most appropriate approach for reducing depression, anxiety and stress.

CONCLUSION

IVR, especially when combined with a traditional CRP, reduces depression, anxiety and stress in patients with CVD.

Internet Gaming Disorder Among Rural Left-Behind Children in China: A Sociological Qualitative Study

Purpose

The rapid process of urbanization in China had led to a large number of laborers migrating from rural areas to cities, leaving their children behind in the rural areas. Internet gaming disorder (IGD) among left - behind children (LBC) had become a prominent social concern. Especially during the COVID-19 pandemic, LBC studied at home and had long-term exposure to electronic devices, which increased the risks and harms of IGD. The research aimed to analyze the formation, damage and factors of IGD among LBC sociologically, and explored its processes, harms and causes in China through data collection and in - depth analysis.

Patients and Methods

Between August 15, 2022, and March 25, 2023, with the consent of the participants, we conducted in - depth interviews with 21 sixth - grade students, 7 parents, and 7 teachers from 5 primary schools in Chinese rural areas. Employing the Grounded Theory method, we carried out three - level coding to analyze the interview data.

Results

The study found that left - behind children's IGD went through four processes: entering - immersing - exiting - re - entering video games. The causes involved the popularization of video game equipment, the deficiency of rural cultural infrastructure, incorrect guidance from parents and peers, as well as children's experiences in video games. Our analysis showed that IGD had a negative impact on children in four key aspects: cognition, physical and mental health, educational outcomes, and parent - child interaction.

Discussion

Left - behind children's IGD was a process from initial involvement to recurrence. The negative impacts of left - behind children's IGD interacted with each other. Multiple factors jointly led to left - behind children's IGD. Resolving children's IGD required the joint efforts of families, schools, communities, and the whole society.

New Technological Approaches in Occupational Therapy for Pediatric Cerebral Palsy: A Systematic Review

BACKGROUND/OBJECTIVES

Pediatric cerebral palsy (CP) is a neurological disorder that affects motor skills, posture, and muscle coordination, impacting children's daily functioning and quality of life. Treatment approaches in occupational therapy aim to enhance motor function and functional independence through a variety of rehabilitative techniques. Recently, new technologies-such as virtual reality, robotics, and assistive devices-have emerged as promising tools in occupational therapy to complement traditional interventions and potentially enhance motor and sensory outcomes in children with CP. This systematic review aims to analyze the effectiveness of these innovative technological interventions in the rehabilitation of children with CP.

METHODS

A systematic review was conducted and different scales were used to assess the risk of bias and methodological quality. The degree of evidence and level of recommendation were established according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The review adhered to PRISMA guidelines, with a comprehensive literature search performed across multiple databases, including Cochrane, Web of Science, and PubMed. This systematic review has been registered in the PROSPERO database with the registration number CRD42025630162.

RESULTS

The reviewed studies indicate that technologies such as functional electrical stimulation, robotic assistance, and adaptive devices have shown improvements in mobility, motor control, posture, strength, and autonomy in children with CP. Similarly, virtual environments support the correction of facial dysfunctions and enhance social interaction through video games and social networks. While these tools hold significant potential for rehabilitation, further adjustments are needed to achieve more consistent results.

CONCLUSIONS

Emerging technologies appear to be effective tools in occupational therapy for pediatric CP, with positive impacts on motor skills and functional capabilities. Nevertheless, further studies with larger sample sizes and rigorous methodological designs are necessary to confirm these findings and establish more robust evidence on their long-term efficacy.

Community-Dwelling Filipino Older Adults' Experiences with Virtual Coach for Health-Enhancing Physical Activity (HEPA): A Phenomenology

Background: Physical inactivity among older adults persists as one of the global burdens. Older adults' physical activity (PA) levels decline simultaneously with age, causing health problems and poor outcomes. Immersive interventions, such as mixed reality virtual coaches, are gaining the potential to provide innovative solutions to prevent physical inactivity among older adults. However, an in-depth understanding of older adults' experience in using virtual-coach-driven physical exercise programs remains unexplored. Purpose: This study explored the experiences of community-dwelling older adults in using a virtual-coach-driven physical exercise program. Design: This study applied a phenomenological design using the qualitative approach to determine the lived experiences of community-dwelling older adults about the mother project, the "Move and Groove for Older Adults Program" (Hataw at Sigla para kay Lolo at Lola), a virtual-coach-driven physical exercise program using MR. A semi-structured interview guide was crafted consisting of three domains (acceptability, barriers, and facilitators), each with two open-ended questions. MAXQDA was used to thematically analyze the qualitative data. Results: Nine key informants shared their experiences with the virtual coach-driven physical exercise program using mixed reality. Four themes were identified describing their experiences with the program: (1) "Looking around": Exploring MR technology, (2) "Looking after": Engaging with MR exercise peers, (3) "Looking at": Examining issues with MR technology devices, and (4) "Looking Ahead": Envisioning the future of MR exercises. Conclusions: The findings of this study introduced new concepts and challenged old notions regarding older adults' technological engagement. The virtual-coach-driven physical exercise program enabled the participants to explore the novel methodology, enhance peer relationships, examine potential issues, and envision a future of possibilities using the technology. These outcomes are pertinent for progressing studies, scholars, and technology developers in incorporating MR into gerontechnology for wellness and fullness of life in the aging population. The mother project of this study was retrospectively registered [ID NCT06136468].

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.

Unanticipated evolution of cardio-respiratory interactions with cognitive load during a Go-NoGo shooting task in virtual reality

The cardiovascular system interacts continuously with the respiratory system to maintain the vital balance of oxygen and carbon dioxide in our body. The interplay between the sympathetic and parasympathetic branches of the autonomic nervous system regulates the aforesaid involuntary functions. This study analyzes the dynamics of the cardio-respiratory (CR) interactions using RR Intervals (RRI), Systolic Blood Pressure (SBP), and Respiration signals after first-order differencing to make them stationary. It investigates their variation with cognitive load induced by a virtual reality (VR) based Go-NoGo shooting task with low and high levels of task difficulty. We use Pearson's correlation-based linear and mutual information-based nonlinear measures of association to indicate the reduction in RRI-SBP and RRI-Respiration interactions with cognitive load. However, no linear correlation difference was observed in SBP-Respiration interactions with cognitive load, but their mutual information increased. A couple of open-loop autoregressive models with exogenous input (ARX) are estimated using RRI and SBP, and one closed-loop ARX model is estimated using RRI, SBP, and Respiration. The impulse responses (IRs) are derived for each input-output pair, and a reduction in the positive and negative peak amplitude of all the IRs is observed with cognitive load. Some novel parameters are derived by representing the IR as a double exponential curve with cosine modulation and show significant differences with cognitive load compared to other measures, especially for the IR between SBP and Respiration.

The Application of a Serious Game Framework to Design and Develop an Exergame for Patients With Heart Failure

Reducing inactivity in patients with chronic disease is vital since it can decrease the risk of disease progression and mortality. Exergames are an innovative approach to becoming more physically active and positively affecting physical health outcomes. Serious games are designed for purposes beyond entertainment and exergames are serious games for physical activity. However, current commercial exergames might not optimally meet the needs of patients with special needs. Developing tailored exergames is challenging and requires an appropriate process. The primary goal of this viewpoint is to describe significant lessons learned from designing and developing an exergame for patients with chronic heart failure using the player-centered, iterative, interdisciplinary, and integrated (P-III) framework for serious games. Four of the framework's pillars were used in the design and development of a mobile exergame: player-centered design, iterative development of the game, interdisciplinary teamwork, and integration of play and serious content. The mobile exergame was developed iteratively in 7 iterations by an interdisciplinary team involving users and stakeholders in all iterations. Stakeholders played various roles during the development process, making the team stay focused on the needs of the patients and creating an exergame that catered to these needs. Evaluations were conducted during each iteration by both the team and users or patients according to the player-centered design pillar. Since the exergame was created for a smartphone, the assessments were conducted both on the development computer and on the intended platforms. This required continuous deployment of the exergame to the platforms and smartphones that support augmented reality. Our findings show that the serious game P-III framework needs to be modified in order to be used for the design and development of exergames. In this viewpoint, we propose an updated version of the P-III framework for exergame development including (1) a separate and thorough design of the physical activity and physical interaction, and (2) early and continuous deployment of the exergame on the intended platform to enable evaluations and everyday life testing.

The Application of Robotics in Cardiac Rehabilitation: A Systematic Review

Background and Objectives: Robotics is commonly used in the rehabilitation of neuro-musculoskeletal injuries and diseases. While in these conditions, robotics has clear benefits, it is unknown whether robotics will also enhance the outcome of cardiac rehabilitation. This systematic review evaluates the use of robotics in cardiac rehabilitation. Methods: A systematic literature search was conducted using PubMed (MEDLINE), CINAHL, AMED, SPORTDiscus, and the Physiotherapy Evidence Database. Longitudinal interventional studies were included if they met specified criteria. Two reviewers independently conducted title, abstract, and full-text screening and data extraction. The quality assessment and risk of bias were conducted according to the PEDRO scale and Cochrane Risk of Bias tool 2, respectively. Results: Four trials were included in this review out of 60 screened studies. The quality of the included studies was good with a low risk of bias. The trials used different robotic systems: Lokomat® system, Motomed Letto/Thera Trainer tigo, BEAR, and Myosuit. It was found that interventions that included the use of robotic assistance technologies improved the exercise capacity, VO2 max/peak, left ventricular ejection fraction, QOL, and physical functioning in people with cardiac diseases. Conclusions: Robotic assistance technologies can be used in cardiac rehabilitation programs. Further studies are needed to confirm the results and determine whether the use of robotics enhances intervention outcomes above standard interventions.

Efficacy of interventions and techniques on adherence to physiotherapy in adults: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Adherence to physiotherapeutic treatment and recommendations is crucial to achieving planned goals and desired health outcomes. This overview of systematic reviews synthesises the wide range of additional interventions and behaviour change techniques used in physiotherapy, exercise therapy and physical therapy to promote adherence and summarises the evidence of their efficacy.

METHODS

Seven databases (PEDro, PubMed, Cochrane Library, Web of Science, Scopus, PsycINFO and CINAHL) were systematically searched with terms related to physiotherapy, motivation, behaviour change, adherence and efficacy (last searched on January 31, 2023). Only systematic reviews of randomised control trials with adults were included. The screening process and quality assessment with AMSTAR-2 were conducted independently by the two authors. The extracted data was synthesised narratively. In addition, four meta-analyses were pooled in a panoramic meta-analysis.

RESULTS

Of 187 reviews identified in the search, 19 were included, comprising 205 unique trials. Four meta-analyses on the effects of booster sessions, behaviour change techniques, goal setting and motivational interventions showed a significantly small overall effect (SMD 0.24, 95% CI 0.13, 0.34) and no statistical heterogeneity (I2 = 0%) in the panoramic meta-analysis. Narrative synthesis revealed substantial clinical and methodological diversity. In total, the certainty of evidence is low regarding the efficacy of the investigated interventions and techniques on adherence, due to various methodological flaws. Most of the RCTs that were included in the reviews analysed cognitive and behavioural interventions in patients with musculoskeletal diseases, indicating moderate evidence for the efficacy of some techniques, particularly, booster sessions, supervision and graded exercise. The reviews provided less evidence for the efficacy of educational and psychosocial interventions and partly inconsistent findings. Most of the available evidence refers to short to medium-term efficacy. The combination of a higher number of behaviour change techniques was more efficacious.

CONCLUSIONS

The overview of reviews synthesised various potentially efficacious techniques that may be combined for a holistic and patient-centred approach and may support tailoring complex interventions to the patient's needs and dispositions. It also identifies various research gaps and calls for a more holistic approach to define and measure adherence in physiotherapy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021267355.

Virtual and augmented reality in cardiovascular care in low and middle income country

The global health sector has witnessed an escalating integration of Virtual Reality (VR) and Augmented Reality (AR) technologies, particularly in high-income countries. The application of these cutting-edge technologies is gradually extending to Low- and Middle-Income Countries (LMICs), notably in the domain of cardiovascular care. AR and VR technologies are revolutionizing cardiovascular care by offering solutions for diagnosis, medical training, and surgical planning. AR and VR provide detailed and immersive visualizations of cardiac structures, aiding in diagnosis and intervention planning. In cardiovascular care, VR reduces patient-reported pain, eases anxiety, and accelerates post-procedural recovery. AR and VR are also valuable for life support training, creating immersive and controlled learning environments. AR and VR have the potential to significantly impact healthcare in low- and middle-income countries with enhanced accessibility and affordability. This review outlines the existing spectrum of VR and AR adoption and its burgeoning utility in the cardiovascular domain within LMICs.

Exercise-based gaming in patients with multiple sclerosis: A systematic review and meta-analysis

Background

Multiple sclerosis presents a significant burden, with balance disturbances impacting patients' daily living. Conventional therapies have been supplemented with technological advancements like virtual reality (VR) and exergaming, providing engaging, multisensory rehabilitation options.

Objective

This study aimed to synthesize evidence on exergaming's role in multiple sclerosis treatment, particularly to evaluate the impact of exergaming on cognitive, motor, and psychological outcomes in patients with multiple sclerosis.

Methods

A systematic review and subsequent meta-analysis design were employed. An extensive search was conducted up to June 2023 across five electronic databases - Web of Science, Scopus, PubMed, Cochrane, and EMBASE. The data extraction process from the selected studies was conducted independently. The risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool 1 (ROB1) and the National Institutes of Health (NIH) assessment tool. Continuous outcomes were consolidated as mean differences (MD) with 95% confidence intervals (CIs). Meta-analyses were performed using RevMan ver. 5.4.

Results

Out of 1,029 studies, 27 were included for meta-analysis. There were no significant differences in cognitive outcomes between the exergaming and the no-intervention group or the Conventional Physiotherapy and Rehabilitation interventions (CPRh) subgroups. However, the Symbol Digit Modalities Test (SDMT) showed a statistically significant difference in favor of exergaming in the no-intervention subgroup (MD = 5.40, 95% CI [0.08, 10.72], p = 0.05). In motor outcomes, exergaming only demonstrated better results in the 6-minute walking test compared to the no-intervention group (MD = 25.53, 95% CI [6.87, 44.19], p = 0.007). The Berg Balance Scale score in both studied subgroups and the Timed Up and Go (TUG) test in the no-intervention group favored exergaming. In terms of psychological outcomes, the Beck Depression Inventory did not reveal any significant differences, while the Modified Fatigue Impact Scale (MFIS) score favored exergaming in the CPRh subgroup.

Conclusion

Exergaming shows promise for enhancing cognitive and motor functions, motivation, adherence, and quality of life in MS patients, which is beneficial for nurses. It can be tailored to individual preferences and easily conducted at home, potentially serving as a viable alternative to traditional rehab programs, especially during relapses. However, further research is necessary to fully understand its optimal and lasting benefits.

Can virtual reality have effects on cardiac rehabilitation? An overview of systematic reviews

OBJECTIVE

This paper aims to provide a review of the use of virtual reality in cardiac rehabilitation.

BACKGROUND

Can virtual reality technology improve outcomes in patients with cardiovascular disease? The question is still open.

DESIGN

Systematic review and meta-analyses.

METHODS

A literature search was conducted in the Embase, the Cochrane Library, PubMed, Web of Science, China National Knowledge Infrastructure Database, Wanfang Database, and China Biological Medicine Database. Databases were searched to July 2023. The inclusion criteria were as follows: the nature of the studies was set as a systematic review; the research participants were patients with cardiovascular diseases undergoing cardiac rehabilitation; the research content was a comparison of virtual reality effects between other care approaches. A Measurement Tool to Assess Systematic Reviews was employed to evaluate the quality of included studies and judge the overall certainty of evidence by using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. When there were differences between the outcomes, we used the RevMan 5.3 to recalculate.

RESULTS

A total of 7 reviews were included in our synthesis, including 3 low-quality articles and 4 very low-quality articles. Virtual reality was effective in improving patients' depression symptoms, anxiety, stress, and improving athletic ability, but it remains unknown whether virtual reality is effective for other outcomes or not.

CONCLUSIONS

Virtual reality can effectively improve the mental health of patients with cardiovascular disease. However, its role in improving other health indicators such as adherence, satisfaction, and quality of life has not been shown.

Non-Immersive Virtual Reality-Based Therapy Applied in Cardiac Rehabilitation: A Systematic Review with Meta-Analysis

BACKGROUND

The aim of this systematic review with meta-analysis was to assess the effectiveness of non-immersive virtual reality (niVR) active videogames in patients who underwent cardiac rehabilitation (CR).

METHODS

A systematic review with meta-analysis, according to the PRISMA guidelines and previously registered in PROSPERO (CRD42023485240), was performed through a literature search in PubMed (Medline), SCOPUS, WOS, and PEDro since inception to 21 November 2023. We included randomized controlled trials (RCTs) that assessed the effectiveness of an niVR intervention, in comparison with conventional CR and usual care, on aerobic capacity and cardiovascular endurance (physical function), anxiety, depression, and quality of life (QoL). The risk of bias in individual studies was assessed using the Cochrane risk of bias tool. Effect size was estimated using Cohen's standardized mean difference (SMD) and its 95% confidence interval (95% CI) in a random-effects model.

RESULTS

Nine RCT that met the inclusion criteria were included in the meta-analysis. The meta-analysis showed a moderate-to-large effect favoring niVR active videogames included in CR in increasing aerobic capacity and cardiovascular endurance (SMD = 0.74; 95% CI 0.11 to 1.37; p = 0.021) and reducing anxiety (SMD = -0.66; 95% CI -1.13 to -0.2; p = 0.006). Only 4.8% of patients reported adverse events while performing niVR active videogames.

CONCLUSIONS

Inclusion of niVR active videogames in CR programs is more effective than conventional CR in improving aerobic capacity and cardiovascular endurance and in reducing anxiety.

Effects of virtual reality-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: A meta-analysis

BACKGROUND

Virtual reality (VR)-based pulmonary rehabilitation has been used in the management of chronic obstructive pulmonary disease (COPD). The efficacy of VR-based pulmonary rehabilitation for improving lung function in patients with COPD is controversial. Therefore, the aim of this meta-analysis was to evaluate the efficacy of VR combined with pulmonary rehabilitation for lung function in patients with COPD.

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was performed in the Cochrane Library, EMBASE, Web of Science, PubMed, and China National Knowledge Infrastructure databases from inception to February 1, 2023. All included studies were randomized controlled trials that assessed VR combined with pulmonary rehabilitation for COPD patients. The effect size was calculated with standardized mean difference (SMD) and its 95% confidence interval (CI). The Cochrane Collaboration tool was used to assess the risk of bias. Publication bias was assessed by Egger test.

RESULTS

A total of 11 studies met the inclusion criteria and were included in this study. The combined effect size showed that VR combined with pulmonary rehabilitation was more effective than pulmonary rehabilitation alone at improving forced expiratory volume in 1 second% (SMD: 0.51; 95% CI 0.19,0.82; P = .002), forced expiratory volume in 1 second/forced vital capacity (SMD: 0.71; 95% CI 0.49,0.93; P < .001), dyspnea (SMD: -0.44; 95% CI -0.66, -0.22; P < .001), and 6-minute walking test (SMD: 059; 95% CI 0.39, 0.79; P < .001). In addition, the VR combined with pulmonary rehabilitation improved depression (SMD: -0.34; 95% CI -0.05, -0.03; P = .033) and anxiety mood (SMD: -0.57; 95% CI -1.11, -0.04; P = .036) compared with the pulmonary rehabilitation group.

CONCLUSION

This meta-analysis indicated that VR regimens could be used to enhance the therapeutic effect of pulmonary rehabilitation in patients with COPD. However, as a rapidly evolving field, more well-designed randomized controlled trials are needed to determine the impact of VR-based pulmonary rehabilitation on COPD patients.

Effect of cardiac rehabilitation therapy on depressed patients with cardiac insufficiency after cardiac surgery

This study aims to analyze the effect of cardiac rehabilitation therapy on cardiac autonomic nervous function in patients with cardiac insufficiency complicated with anxiety depression after cardiac operation to provide a reference for clinical practice. A total of 109 patients subject to cardiac operation in our hospital from January 2020 to March 2023 were enrolled as study subjects, including 50 patients who received conventional rehabilitation therapy (control group) and 69 patients who received cardiac rehabilitation therapy (research group). Before and after treatment, the left ventricular ejection fraction (LVEF) and central venous pressure (CVP) were determined, and the level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) was measured. Low frequency/high frequency (LF/HF), standard deviation of normal to normal (SDNN), and root mean of successive square differences (RMSSD) were measured by a multi-lead ECG system. Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), Pittsburgh Sleep Quality Index (PSQI), Activity of daily living (ADL), and Barthel Index (BI) were applied for corresponding investigations, as well as the 6-min walk test (6MWT). After treatment, the research group showed higher LVEF, CVP, LF/HF, SDNN, and RMSSD, and lower NT-proBNP, SAS, and SDS than the control group (P < 0.05). Significantly elevated ADL score, BI, and 6MWT and reduced PSQI were observed in both groups after treatment, with more remarkable changes in the research group (P < 0.05). In conclusion, cardiac rehabilitation therapy effectively improved the cardiac function of patients with cardiac insufficiency complicated with anxiety and depression after the cardiac operation and alleviated their negative emotions.

Improving Adherence to Physical Therapy in the Development of Serious Games: Conceptual Framework Design Study

BACKGROUND

Insufficient levels of treatment adherence can have adverse effects on the outcomes of physical rehabilitation. To address this issue, alternative approaches to traditional therapies, such as serious games, have been designed to enhance adherence. Nevertheless, there remain gaps in the development of serious games concerning the effective implementation of motivation, engagement, and the enhancement of treatment adherence.

OBJECTIVE

This study aims to design a conceptual framework for the development of serious games that incorporate essential adherence factors to enhance patient compliance with physical rehabilitation programs.

METHODS

We formulated a conceptual framework using iterative techniques inspired by a conceptual framework analysis. Initially, we conducted a comprehensive literature review, concentrating on the critical adherence factors in physical rehabilitation. Subsequently, we identified, categorized, integrated, and synthesized the concepts derived from the literature review to construct the conceptual framework.

RESULTS

The framework resembles a road map, comprising 3 distinct phases. In the initial phase, the patient's characteristics are identified through an initial exploration. The second phase involves the development of a serious game, with a focus on enhancing treatment adherence by integrating the key adherence factors identified. The third phase revolves around the evaluation of the serious game. These phases are underpinned by 2 overarching themes, namely, a user-centered design and the GameFlow model.

CONCLUSIONS

The conceptual framework offers a detailed, step-by-step guide for creating serious games that incorporate essential adherence factors, thereby contributing to improved adherence in the physical rehabilitation process. To establish its validity, further evaluations of this framework across various physical rehabilitation programs and user groups are necessary.

A Comparison Between Cardiac Telerehabilitation Program and Outpatient Hospital-Based Cardiac Rehabilitation Program for Patients Undergoing Coronary Artery Bypass Graft (CABG) Surgery: A Review

Coronary artery disease (CAD) is a prevalent and possibly fatal cardiovascular ailment, and it is treated surgically by coronary artery bypass grafting (CABG). The coronary arteries, which supply the heart with oxygen and nutrients, are the most commonly affected. Even though CABG is a frequently employed procedure to restore cardiac blood flow, prolonged rehabilitation is necessary for long-term success. For patients with heart disease, cardiac rehabilitation (CR) involves a comprehensive therapeutic approach. It consists of risk mitigation, regular exercise, health education, and efficient stress management. Information and communication technology is used in telerehabilitation (TR), a rehabilitation service that offers a flexible choice that improves self-management. This study examined novel approaches and effective intervention elements while comparing cardiac TR with center-based programs in terms of risk factor management, patient commitment, and satisfaction.

Rehabilitation Technologies for Chronic Conditions: Will We Sink or Swim?

INTRODUCTION

Chronic conditions such as stroke, Parkinson's disease, spinal cord injury, multiple sclerosis, vestibular disorders, chronic pain, arthritis, diabetes, chronic obstructive pulmonary disease (COPD), and heart disease are leading causes of disability among middle-aged and older adults. While evidence-based treatment can optimize clinical outcomes, few people with chronic conditions engage in the recommended levels of exercise for clinical improvement and successful management of their condition. Rehabilitation technologies that can augment therapeutic care-i.e., exoskeletons, virtual/augmented reality, and remote monitoring-offer the opportunity to bring evidence-based rehabilitation into homes. Successful integration of rehabilitation techniques at home could help recovery and access and foster long term self-management. However, widespread uptake of technology in rehabilitation is still limited, leaving many technologies developed but not adopted.

METHODS

In this narrative review, clinical need, efficacy, and obstacles and suggestions for implementation are discussed. The use of three technologies is reviewed in the management of the most prevalent chronic diseases that utilize rehabilitation services, including common neurological, musculoskeletal, metabolic, pulmonary, and cardiac conditions. The technologies are (i) exoskeletons, (ii) virtual and augmented reality, and (iii) remote monitoring.

RESULTS

Effectiveness evidence backing the use of technology in rehabilitation is growing but remains limited by high heterogeneity, lack of long-term outcomes, and lack of adoption outcomes.

CONCLUSION

While rehabilitation technologies bring opportunities to bridge the gap between clinics and homes, there are many challenges with adoption. Hybrid effectiveness and implementation trials are a possible path to successful technology development and adoption.

Motion-based technology to support motor skills screening in developing children: A scoping review

BACKGROUND

Acquiring motor skills is fundamental for children's development since it is linked to cognitive development. However, access to early detection of motor development delays is limited.

AIM

This review explores the use and potential of motion-based technology (MBT) as a complement to support and increase access to motor screening in developing children.

METHODS

Six databases were searched following the PRISMA guidelines to search, select, and assess relevant works where MBT recognised the execution of children's motor skills.

RESULTS

164 studies were analysed to understand the type of MBT used, the motor skills detected, the purpose of using MBT and the age group targeted.

CONCLUSIONS

There is a gap in the literature aiming to integrate MBT in motor skills development screening and assessment processes. Depth sensors are the prevailing technology offering the largest detection range for children from age 2. Nonetheless, the motor skills detected by MBT represent about half of the motor skills usually observed to screen and assess motor development. Overall, research in this field is underexplored. The use of multimodal approaches, combining various motion-based sensors, may support professionals in the health domain and increase access to early detection programmes.

Merging virtual and physical experiences: extended realities in cardiovascular medicine

Technological advancement and the COVID-19 pandemic have brought virtual learning and working into our daily lives. Extended realities (XR), an umbrella term for all the immersive technologies that merge virtual and physical experiences, will undoubtedly be an indispensable part of future clinical practice. The intuitive and three-dimensional nature of XR has great potential to benefit healthcare providers and empower patients and physicians. In the past decade, the implementation of XR into cardiovascular medicine has flourished such that it is now integrated into medical training, patient education, pre-procedural planning, intra-procedural visualization, and post-procedural care. This review article discussed how XR could provide innovative care and complement traditional practice, as well as addressing its limitations and considering its future perspectives.

Effectiveness of virtual reality interventions on physiological and psychological outcomes of adults with cardiovascular disease: A systematic review and meta-analysis

PURPOSE

The aim of this study was to provide evidence of the effectiveness of virtual reality interventions on the physiological and psychological outcomes of adults with cardiovascular disease.

DESIGN

A systematic review and meta-analysis.

METHODS

Database searches were carried out in CINAHL, Cochrane Central, Web of Science, PubMed, Scopus, Science Direct, and Ovid without restriction of year up to December 2021. The study was carried out in accordance with PRISMA 2020 and Cochrane 2021 recommendations. The intervention effects were pooled using the random effects model. The Risk of Bias 2 tool was' used to assess the risk of bias. Heterogeneity and publication bias were also assessed.

FINDINGS

In total, 14 trials were included. The included studies found a significantly higher effect on anxiety (Hedge's g = -0.85, 95% CI: -1.55 to -0.14, p = 0.01) and a medium effect on physical functional capacity (Hedge's g = 0.54, 95% CI: 0.01 to 1.08, p = 0.05), stress (Hedge's g = -0.36, 95% CI: -0.60 to -0.11, p = 0.01), and depression (Hedge's g = -0.39, 95% CI: -0.68 to -0.11, p = 0.01) compared to the control group. The Cochrane GRADE approach showed low level evidence for the effect of virtual reality on anxiety and moderate level evidence for stress, depression, and physical functional capacity.

CONCLUSIONS

The effect size and grade evaluation results showed that virtual reality may be an effective intervention to reduce anxiety, stress, and depression and to increase physical functional capacity in patients with cardiovascular disease. However, more study is necessary in order to establish evidence.

REGISTRATION

Registered in the PROSPERO database: PROSPERO international prospective register of systematic reviews Registration number: CRD42022296578.

Rehabilitation Is the Main Topic in Virtual and Augmented Reality and Physical Activity Research: A Bibliometric Analysis

Researchers' interest in finding practical applications for virtual reality (VR) and augmented reality (AR) technologies has increased as new devices have become cheaper and more accessible, being used in entertainment, healthcare, and rehabilitation fields, among others. This study aims to provide an overview of the current state of scientific literature related to VR, AR, and physical activity (PA). A bibliometric analysis of studies published between 1994 and 2022 was conducted using The Web of Science (WoS), applying the traditional bibliometric laws and using the VOSviewer software for data and metadata processing. The results revealed an exponential increase in scientific production between 2009 and 2021 (R² = 94%). The United States (USA) was the country/region with the most relevant co-authorship networks (72 papers); the most prolific author was Kerstin Witte, and the most prominent was Richard Kulpa. The most productive journal's core was composed of high-impact and open access journals. A great thematic diversity was found according to the most used keywords by the co-authors, highlighting concepts such as rehabilitation, cognition, training, and obesity. Then, the research related to this topic is in an exponential development phase, with great interest in the rehabilitation and sports sciences fields.

The impact of Virtual Reality on Anxiety and Functional Capacity in Cardiac Rehabilitation: A Systematic Review and Meta-analysis

BACKGROUND

The overall utilization of cardiac rehabilitation (CR) is low despite its proven benefits in secondary prevention. Virtual reality (VR), a novel method of rehabilitation, may increase overall compliance. The purpose of this systematic review and meta-analysis is to synthesize evidence and report whether the addition of VR leads to an improvement in anxiety and functional capacity (FC) compared to standard CR.

METHODS

A comprehensive search strategy was used to search the online databases for the randomized controlled trials (RCTs) on VR-CR. Statistical analysis was performed using Stata SE version 17.0 (College Station, TX) and RevMan5.

RESULTS

A total of 747 study participants were part of 7 studies included in the meta-analysis. Three studies were part of the narrative synthesis. Anxiety showed significant improvement in VR-CR compared to standard CR (SMD -0.32, 95% CI -0.61, -0.03). There was no significant improvement in FC between VR-CR and the standard CR (SMD 0.077, 95% CI -1.24, 1.32).

CONCLUSION

VR-CR significantly improved CR-related anxiety compared to standard CR. However, no significant improvement in FC was found in VR-CR compared to the standard CR. Further studies are needed to assess the impact of non-immersive and immersive VR on FC.

Influence of Two Exercise Programs on Heart Rate Variability, Body Temperature, Central Nervous System Fatigue, and Cortical Arousal after a Heart Attack

Cardiovascular diseases (CVD) are the leading cause of death globally. Cardiac rehabilitation (CR) programs' benefits are overall consensual; however, during exercise, progressive physiological effects have not been studied yet in cardiac patients. Our study aims to analyze physiological parameters of thermography, heart rate variability (HRV), blood pressure, central nervous system (CNS) fatigue, and cortical arousal in heart attack patients (HAP) who belong to CR programs of High-Intensity Interval Training (HIIT) and Moderate-intensity Continuous Training (MICT) compared to healthy participants. In this case control study, two HAP patients (both male, age 35 and 48, respectively) and two healthy people (both male, age 38 and 46, respectively) were randomly assigned in a 1:1:1:1 allocation ratio to one of four groups: cardiac MICT, cardiac HIIT, control MICT, and control HIIT. The HIIT at ≈85-95% of peak heart rate (HR) was followed by a one-minute recovery interval at 40% peakHR, and MICT at ≈70-75% of peakHR. Outcome measurements included thermography, HRV, blood pressure, CNS fatigue, and cortical arousal; The HAP presents more than twice the CNS fatigue in MICT than control participants, but HIIT has almost the same CNS fatigue in HAP and control. In addition, both of the HAP groups presented higher temperatures in the chest. The HIIT protocol showed better physiological responses during exercise, compared to MICT in HAP.

Combining physical and virtual worlds for motor-cognitive training interventions: Position paper with guidelines on technology classification in movement-related research

Efficient movements require intact motor and cognitive function. There is a growing literature on motor-cognitive interventions to improve the overall quality of life of healthy or diseased older people. For such interventions, novel technological advances are crucial not only in terms of motivation but also to improve the user experience in a multi-stimuli world, usually offered as a mixture of real and virtual environments. This article provides a classification system for movement-related research dealing with motor-cognitive interventions performed in different extents of a virtual environment. The classification is divided into three categories: (a) type of digital device with the associated degree of immersiveness provided; (b) presence or absence of a human-computer interaction; and (c) activity engagement during training, defined by activity >1.5 Metabolic Equivalent of task. Since virtual reality (VR) often categorizes different technologies under the same term, we propose a taxonomy of digital devices ranging from computer monitors and projectors to head-mounted VR technology. All immersive technologies that have developed rapidly in recent years are grouped under the umbrella term Extended Reality (XR). These include augmented reality (AR), mixed reality (MR), and VR, as well as all technologies that have yet to be developed. This technology has potential not only for gaming and entertainment, but also for research, motor-cognitive training programs, rehabilitation, telemedicine, etc. This position paper provides definitions, recommendations, and guidelines for future movement-related interventions based on digital devices, human-computer interactions, and physical engagement to use terms more consistently and contribute to a clearer understanding of their implications.

Understanding how virtual reality forest experience promote physiological and psychological health for patients undergoing hemodialysis

Growing research has found that exposing patients to forest landscapes through technology improves their health. However, studies on the effects of nature therapy sessions on particularly vulnerable groups that require frequent regular treatment such as patients of chronic kidney disease (CKD) is lacking. This study aims to understand the effects of watching panoramic videos of forest walks through virtual reality (VR) headsets on patients. We also examine the effects of the frequency of virtual exposure to forests on the physiological and psychological parameters of patients undergoing dialysis. Twenty-four dialysis patients with a mean age of 65.11 year underwent a virtual nature intervention over the course of 3 weeks. The intervention consists of 3 numbers of 6-min 360-degree nature videos delivered using VR headsets. We measured heart rate variability (HRV) and heart rate (HR) using continuous electrocardiographic (ECG) monitoring and assessed their emotional states using a questionnaire survey and in-depth interviews. The results showed that the initial 6 min of watching of the panoramic videos through VR headsets resulted in significantly reduced HR and sympathetic nerve activity and increased positive emotional responses. However, repeated VR exposure did not further improve the physiological health of the respondents. Considering these results, the use of VR headsets to watch 6-min nature videos indoors can be used to enhance the positive psychological responses among dialysis and bed-ridden patients. As this study is preliminary, future random controlled trials are needed to compare and determine the best dose, content, and delivery methods of such an intervention.

Integrating virtual reality and exergaming in cognitive rehabilitation of patients with Parkinson disease: a systematic review of randomized controlled trials

INTRODUCTION

In recent years, growing attention is rising to virtual reality (VR) tools and exergaming in rehabilitation management of patients with Parkinson disease (PD). However, no strong evidence supports the effectiveness of these cutting-edge technologies on cognitive function and the integration of these promising tool in the rehabilitation framework of PD patients is still challenging. Therefore, the present systematic review of randomized controlled trials (RCTs) aimed at assessing the effects of VR and exergames/telerehabilitation in the cognitive rehabilitation management of patients with PD.

EVIDENCE ACQUISITION

PubMed, Scopus and Web of Science databases were systematically searched up to February 14^th, 2022, to identify RCTs assessing patients with PD undergoing cognitive rehabilitation including VR or exergames/telerehabilitation. The intervention was compared to conventional rehabilitation protocols. The primary outcome was cognitive function. The quality assessment was performed following the Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). PROSPERO registration code: CRD42022319788.

EVIDENCE SYNTHESIS

Out of 1419 identified studies, 66 articles were assessed for eligibility, and, at the end of the screening process, 10 studies were included in the present systematic review. Five RCTs (50%) assessed the exergaming devices, reporting significant positive results on cognitive outcomes scales (Trail Making test scale, Digit Span backward, MoCA, and MyCQ score). The other 5 RTCs (50%) assessed VR approaches, reporting significant improvement in executive functions. The RoB 2 showed an overall high risk of bias for the 40% of studies included.

CONCLUSIONS

Exergaming and VR might be considered promising rehabilitation interventions in the cognitive rehabilitation framework of PD patients. Further high-quality studies are needed to define the role of exergames and VR in a comprehensive rehabilitation approach aiming at improving the multilevel cognitive impairment characterizing patients with PD.

The effects of virtual reality technology on reducing pain in wound care: A meta-analysis and systematic review

Virtual reality (VR) technology has been widely used in clinical nursing care in recent years. We aimed to systematically evaluate the effect and safety of VR technology on pain control in wound care, to provide evidence and support for clinical wound care. We searched PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, China Biomedical Literature Database, China National Knowledge Infrastructure (CNKI), Wanfang Data Knowledge Service Platform, and Chinese Science and Technology Journal databases for randomised controlled trials (RCTs) on the application of VR technology in wound care up to December 20, 2021. Two researchers independently assessed the quality of the included RCTs and extracted associated data. RevMan5.3 statistical software was used for data analysis. 13 RCTs involving 1258 adult patients were included, of whom 588 patients underwent VR intervention. VR technology intervention could reduce the VAS score(MD = -1.13, 95%CI:-2.01~-0.26, P < .001), pain cognition score(MD = -3.94, 95%CI:-4.59 ~ -3.30, P < .001), pain emotion score(MD = -5.21, 95%CI: -10.46 ~ -0.04, P < .001), pain sensation score (MD = -4.94, 95%CI: -9.46 ~ -0.42, P = .03) and blood pressure(MD = -4.66, 95%CI: -8.63 ~ -0.69, P = .02) during would care. There were no significant differences on the heart rate (MD = -1.85, 95%CI: -5.71 ~ -2.01, P = .45) and VR interestingness (MD = 28.96, 95%CI: -22.10 ~ 80.02, P = .27) of the VR group and control group. No publication biases among the synthesised outcomes were found (all P > .001). VR technology can effectively reduce the pain degree and sensation of patients during wound care, which may be an effective auxiliary non-drug method used for pain relief during wound care.

Scare-Away Risks: The Effects of a Serious Game on Adolescents’ Awareness of Health and Security Risks in an Italian Sample

Digital games can be defined as games supported by audiovisual apparatus and based on storytelling. This work aims to frame video games in the recent perspective offered by positive psychology and focuses on risk perception and on the promotion of protective behaviors in adolescent students, by means of a new Italian ad hoc created digital game named ‘Scare-away risks’ (Scacciarischi). In its storytelling, the different characters must defeat monsters that symbolically represent potential risks in home, school and work contexts. On this basis, the present study assumes that playing video games, as an engaging and motivating activity, can improve the adolescents’ psychological perception of home, school and work risks. To verify these hypotheses, a quasi-experiment comparing students who played Scacciarischi (experimental group) with a control group was conducted. At the end of the game, a questionnaire was administered to 149 participants, balanced for gender, investigating (a) the level of engagement during the game, (b) the perceived risks, (c) the locus of control, (d) the protective behavior intentions. The results showed that playing Scacciarischi is related to higher levels of engagement, internal locus of control, risk perception and protective behavioral intentions. In addition, both engagement and internal locus of control act as precursors of the other two variables. Finally, reflections about the importance of the engaging experience of Scacciarischi in the domain of safety, prevention and health issues are proposed.

SnacktivityTM, Giant Games and Immersive Virtual Reality Exercises: A Rapid Narrative Review of These New Physical Activity Practices among Older People Living in Nursing Homes and Long-Term Care Facilities

In developed countries, the increasing number of older adults raises many public health challenges. Physical activity can enable healthy aging, as it is beneficial for both mental and physical health. Despite this, not all older adults engage in physical activity or have access to it. To counteract this, new physical practices such as SnacktivityTM, giant games and immersive virtual reality exercises are being developed. The main objective of this rapid narrative review is to summarize the effects of SnacktivityTM, giant games and immersive Virtual Reality (VR) exercise among older adults living in nursing homes and long-term care facilities. A scientific review was performed using the search engines PubMed, PsycInfo and Web of Science on 7 July 2022. Fifty-nine items are identified in total, and five items are included in the literature review. Synthesis of the studies shows that immersive virtual reality and giant games improve the motivation and enjoyment of older adults and are beneficial for their functional abilities. Furthermore, no interventional studies have tested the effect of SnacktivityTM in older adults. This review suggests that future studies should be conducted to further explore the effects of these new physical activity practices in older adults living in nursing homes or long-term care facilities.

The Effectiveness of Virtual Reality Interventions on Smoking, Nutrition, Alcohol, Physical Activity and/or Obesity Risk Factors: A Systematic Review

To our knowledge, no systematic reviews have examined the effectiveness of virtual reality (VR) interventions across all smoking, nutrition, alcohol, physical activity, and/or obesity (SNAPO) risk factors. This systematic review assessed the effectiveness of VR interventions on reducing SNAPO risks compared to control groups or other interventions. MEDLINE, EMBASE, Scopus, PsycINFO, and CENTRAL were searched to identify eligible studies published to 7 October 2021. Two reviewers independently completed screening, data extraction and quality assessment. Twenty-six studies were included, five on smoking, twelve on physical activity (PA), six on obesity, one on PA and obesity, one on obesity and nutrition, and one on obesity, nutrition and PA. VR was effective for smoking cessation in three studies and for smoking reduction in four studies. Seven studies had significantly higher PA in the VR group, and one study found significantly higher PA in a comparator group. Two studies showed VR was more effective at reducing BMI or weight than comparators. Three multiple health risks studies showed mixed results. The remaining studies found no significant difference between VR and control/comparators. VR appears promising for the treatment of smoking, nutrition, PA, and obesity risks; however, further randomised trials are needed.

Implementation of ISO/IEEE 11073 PHD SpO2 and ECG Device Specializations over Bluetooth HDP following Health Care Profile for Smart Living

Current m-Health scenarios in the smart living era, as the interpretation of the smart city at each person’s level, present several challenges associated with interoperability between different clinical devices and applications. The Continua Health Alliance establishes design guidelines to standardize application communication to guarantee interoperability among medical devices. In this paper, we describe the implementation of two IEEE agents for oxygen saturation level (SpO2) measurements and electrocardiogram (ECG) data acquisition, respectively, and a smartphone IEEE manager for validation. We developed both IEEE agents over the Bluetooth Health Device Profile following the Continua guidelines and they are part of a telemonitoring system. This system was evaluated in a sample composed of 10 volunteers (mean age 29.8 ± 7.1 y/o; 5 females) under supervision of an expert cardiologist. The evaluation consisted of measuring the SpO2 and ECG signal sitting and at rest, before and after exercising for 15 min. Physiological measurements were assessed and compared against commercial devices, and our expert physician did not find any relevant differences in the ECG signal. Additionally, the system was assessed when acquiring and processing different heart rate data to prove that warnings were generated when the heart rate was under/above the thresholds for bradycardia and tachycardia, respectively.

Virtual reality exercises at home for post COVID-19 condition: a feasibility study

BACKGROUND

Between 30-76% of COVID-19 patients have persistent physical and mental symptoms, sometimes up to 9 months after acute COVID-19. Current rehabilitation is mostly focused on the physical symptoms, while experts have agreed on the need for a biopsychosocial approach. A novel approach such as Virtual Reality (VR) rehabilitation at home might benefit patients and therapists, especially considering the expected rush of patients with post-COVID-19-condition needing rehabilitation.

OBJECTIVE

To investigate the feasibility of self-administered VR exercises at home for post COVID-19-condition.

METHODS

This is a single-arm feasibility study in an outpatient care setting. Patients who needed physiotherapy because of post COVID-19 condition were included as determined by the treating physiotherapist. Participants performed VR physical exercises at home for a period of 6 weeks and were allowed to perform VR mental exercise apps available at the VR platform to reduce stress and anxiety and promote cognitive functioning. Main outcomes were related to feasibility, i.e. duration and frequency of VR use, safety i.e. adverse events, patient satisfaction, and reasons to withdraw. Physical performance, daily activities, cognitive functioning, anxiety and depression, and quality of life were measured before and after.

RESULTS

Forty-eight patients were included. One patient did not start VR and seven patients (15%) withdrew, mostly due to dizziness. Almost 70% of participants reported any adverse event during VR exercising. However, only 25% recalled these events at the end of the intervention period. The majority of patients described VR as having a positive influence on their recovery and the global satisfaction score was 67%. Average VR use was 30 minutes per session 3-4 times a week for 3-6 weeks. Overall use of VR applications was almost equally distributed over the three sets of VR exercises (physical, relaxing, cognitive). However, use frequency of physical exercises seemed to decrease over time, whereas use of cognitive and relaxation exercises remained stable. Physical performance and quality of life outcomes were significantly improved after six weeks.

CONCLUSIONS

VR physical exercises at home is feasible and safe with good acceptance in a significant percentage of patients with post COVID-19 condition.

CLINICALTRIAL

ClinicalTrials.gov NCT04505761.

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.

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.

An sEMG-Controlled Forearm Bracelet for Assessing and Training Manual Dexterity in Rehabilitation: A Systematic Review

Background: The ability to perform activities of daily living (ADL) is essential to preserving functional independence and quality of life. In recent years, rehabilitation strategies based on new technologies, such as MYO Armband^®, have been implemented to improve dexterity in people with upper limb impairment. Over the last few years, many studies have been published focusing on the accuracy of the MYO Armband^® to capture electromyographic and inertial data, as well as the clinical effects of using it as a rehabilitation tool in people with loss of upper limb function. Nevertheless, to our knowledge, there has been no systematic review of this subject. Methods: A systematically comprehensive literature search was conducted in order to identify original studies that answered the PICO question (patient/population, intervention, comparison, and outcome): What is the accuracy level and the clinical effects of the MYO Armband^® in people with motor impairment of the upper limb compared with other assessment techniques or interventions or no intervention whatsoever? The following data sources were used: Pubmed, Scopus, Web of Science, ScienceDirect, Physiotherapy Evidence Database, and the Cochrane Library. After identifying the eligible articles, a cross-search of their references was also completed for additional studies. The following data were extracted from the papers: study design, disease or condition, intervention, sample, dosage, outcome measures or data collection procedure and data analysis and results. The authors independently collected these data following the CONSORT 2010 statement when possible, and eventually reached a consensus on the extracted data, resolving disagreements through discussion. To assess the methodological quality of papers included, the tool for the critical appraisal of epidemiological cross-sectional studies was used, since only case series studies were identified after the search. Additionally, the articles were classified according to the levels of evidence and grades of recommendation for diagnosis studies established by the Oxford Center for Evidence-Based Medicine. Also, The Cochrane Handbook for Systematic Reviews of Interventions was used by two independent reviewers to assess risk of bias, assessing the six different domains. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed to carry out this review. Results: 10 articles with a total 180 participants were included in the review. The characteristics of included studies, sample and intervention characteristics, outcome measures, the accuracy of the system and effects of the interventions and the assessment of methodological quality of the studies and risk of bias are shown. Conclusions: Therapy with the MYO Armband^® has shown clinical changes in range of motion, dexterity, performance, functionality and satisfaction. It has also proven to be an accurate system to capture signals from the forearm muscles in people with motor impairment of the upper limb. However, further research should be conducted using bigger samples, well-defined protocols, comparing with control groups or comparing with other assessment or therapeutic tools, since the studies published so far present a high risk of bias and low level of evidence and grade of recommendation.

The Use of Virtual Therapy in Cardiac Rehabilitation of Male Patients with Coronary Heart Disease: A Randomized Pilot Study

The study aimed to evaluate the effectiveness of virtual reality therapy (VRT) in the treatment of anxiety-depressive disorders and in reducing stress levels in a group of men with coronary heart disease (CHD) participating in cardiac rehabilitation (CR). The study included 34 men with CHD who were assigned to the experimental group (EG) or the control group (CG). CR in the EG was supported by 8 VRT sessions, while CR in the CG was supplemented with 8 SAT sessions. Anxiety-depressive disorders were assessed using the Hospital Anxiety and Depression Scale (HADS). Perceived stress was assessed using the Perception of Stress Questionnaire (PSQ). In the EG, all measured parameters improved after the intervention. Significant reductions in HADS total score, the HADS-A, general stress score, emotional tension, and the external stress were obtained. In the CG, a deterioration in all measured parameters was observed. Significant changes were obtained in the general stress score and intrapsychic stress. The analysis between groups showed that the effectiveness of psychological interventions significantly differed between groups. The study results confirmed that supplementing standard CR with VRT leads to an improvement in the mental state of the patients and thus has a positive effect on the course of CR. However, the small sample size and high withdrawal rate prompt cautious interpretation of the results.

Impact of COVID-19 lockdown restrictions on cardiac rehabilitation participation and behaviours in the United Kingdom

BACKGROUND

COVID-19 lockdown measures led to the suspension of centre-based cardiac rehabilitation (CR). We aimed to describe the impact of lockdown on CR behaviours and perceptions of efficacy in a sample of CR participants.

METHODS

An online survey was conducted amongst CR participants from May to October 2020, COVID-19-related lockdown restrictions. Anthropometric data, participant-determined levels of motivation and self-perceived efficacy, CR practices etc., pre- and post-lockdown, were collected.

RESULTS

The probability of practicing CR in public gyms and hospitals decreased 15-fold (47.2% pre-, 5.6% post-lockdown; OR[95% CI] 0.065[0.013; 0.318], p < 0.001), and 34-fold (47.2% pre, 2.8% post; OR[95% CI] 0.029[0.004; 0.223], p < 0.001), respectively. Amongst participants, 79.5% indicated that their CR goals had changed and were 78% less likely to engage in CR for socialization after lockdown (47.2% pre, 16.7% post; OR[95% CI] 0.220[0.087; 0.555]; p = 0.002). The probability of receiving in-person supervision decreased by 90% (94.4% pre, 16.7% post; OR[95% CI] 0.011[0.002; 0.056]), while participants were almost 7 times more likely to use online supervision (11.1% pre, 44.4% post; OR[95% CI] 6.824[2.450; 19.002]) (both p < 0.001). Fifty percent indicated that their enjoyment of CR was lower than before lockdown and 27.8% reported they would be less likely to continue with CR in the newer format.

CONCLUSIONS

Lockdown was associated with considerable changes in how CR was practiced, motivation levels and willingness to continue with CR. Further research is warranted to develop and improve strategies to implement in times when individuals cannot attend CR in person and not only during pandemics.

Effects of Exergaming in Patients with Cardiovascular Disease Compared to Conventional Cardiac Rehabilitation: A Systematic Review and Meta-Analysis

Background: Exercise-based cardiac rehabilitation (CR) programs are used for improving prognosis and quality of life in patients with cardiovascular disease (CVD). Nonetheless, adherence to these programs is low, and exercise-based CR programs based on virtual reality (i.e., exergaming) have been proposed as an alternative to conventional CR programs. However, whether exergaming programs are superior to conventional CR programs in patients with CVD is not known. Objective: This systematic review with meta-analysis was conducted to explore whether exergaming enhances exercise capacity, quality of life, mental health, motivation, and exercise adherence to a greater extent than conventional CR programs in patients with CVD. Method: Electronic searches were carried out in PubMed, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases up to June 2021. Meta-analyses were performed using robust variance estimation with small-sample corrections. The effect sizes were calculated as the mean differences (MD) or standardized mean differences (SMD) as appropriate. The SMD magnitude was classified as trivial (<0.20), small (0.20−0.49), medium (0.50−0.79), or large (≥0.80). Heterogeneity was interpreted based on the I2 statistics as low (25%), moderate (50%), or high (75%). Results: Pooled analyses showed no differences between exergaming and conventional CR programs for enhancing exercise capacity (i.e., distance covered in the six-minute walk test) (MD+ = 14.07 m (95% confidence interval (CI) −38.18 to 66.32 m); p = 0.426) and mental health (SMD+ = 0.17 (95% CI −0.36 to 0.70); p = 0.358). The results showed a small, statistically nonsignificant improvement in quality of life in favor of exergaming (SMD+ = 0.22 (95% CI = −0.37 to 0.81); p = 0.294). Moderate heterogeneity was found for exercise capacity (I2 = 53.7%), while no heterogeneity was found for quality of life (I2 = 3.3%) and mental health (I2 = 0.0%). Conclusions: Exergaming seems not to be superior to conventional CR programs for improving exercise capacity, quality of life, or mental health in patients with CVD.

Efficacy of Virtual Reality and Exergaming in Improving Balance in Patients With Multiple Sclerosis: A Systematic Review and Meta-Analysis

Multiple sclerosis (MS) is one of the most common causes of neurological progressive disease and can lead to loss of mobility, walk impairment, and balance disturbance. Among several rehabilitative approaches proposed, exergaming and virtual reality (VR) have been studied in the recent years. Active video game therapy could reduce the boredom of the rehabilitation process, increasing patient motivation, providing direct feedback, and enabling dual-task training. Aim of this systematic review was to assess the efficacy of exergaming and VR for balance recovery in patients with MS. PubMed, Scopus, and Web of Science were systematically searched from the inception until May 14, 2021 to identify randomized controlled trials (RCTs) presenting: patients with MS as participants, exergaming and VR as intervention, conventional rehabilitation as comparator, and balance assessment [Berg Balance Scale (BBS)] as outcome measure. We also performed a meta-analysis of the mean difference in the BBS via the random-effects method. Out of 93 records, this systematic review included and analyzed 7 RCTs, involving a total of 209 patients affected by MS, of which 97 patients performed exergaming or VR and 112 patients underwent conventional rehabilitation. The meta-analysis reported a significant overall ES of 4.25 (p < 0.0001), showing in the subgroup analysis a non-significant ES of 1.85 (p = 0.39) for the VR and a significant ES of 4.49 (p < 0.0001) for the exergames in terms of the BBS improvement. Taken together, these findings suggested that balance rehabilitation using exergames appears to be more effective than conventional rehabilitation in patients affected by MS.

Cardiac Rehabilitation Early after Sternotomy Using New Assistive VR-Enhanced Robotic Exoskeleton-Study Protocol for a Randomised Controlled Trial

(1) Background and objective: Cardiac rehabilitation (CR) means delivering health education by structured exercises with the means of risk reduction, in a cost-effective manner. Well-conducted CR improves functional capacity, decreases re-hospitalization, and reduces mortality up to 25%. We bring to attention the protocol of a randomised control trial with the aim of validating the prototype of an assistive upper-body robotic exoskeleton system enhanced with a non-immersive virtual reality exergame (CardioVR-ReTone) in patients who undergone cardiac surgery. (2) Methods: Description of the CardioVR-ReTone system and the technical specification, followed by the group selection, randomization and evaluated variables. (3) Expected results: The primary outcome measurement is the modification of life quality at the end of the CR exercise training program. Secondary outcomes will encompass measurements of sternal stability, muscular activity, cardiac response to exercise, pain level and compliance/adherence to CR. (4) Conclusions: Implementing these novel features of the CardioVR-ReTone system, addressability, and efficacy of CR, so problematic in certain situations and especially in cardiac surgery, will be greatly facilitated, being independent of the skills and availability of the rehabilitation therapist.

The Effects of Exergames on Muscle Architecture: A Systematic Review and Meta-Analysis

Muscle architectural parameters play a crucial role in the rate of force development, strength, and sports performance. On the other hand, deteriorated muscle architectural parameters are associated with injuries, sarcopenia, mortality, falls, and fragility. With the development of technology, exergames have emerged as a complementary tool for physical therapy programs. The PRISMA 2020 statement was followed during the systematic review and meta-analysis. CENTRAL, CINAHL, PROQUEST, PubMed, and OpenGrey databases were searched last time on 22 September 2021. In total, five controlled trials were included in the systematic review. Twelve weeks of virtual dance exercise (Dance Central game for Xbox 360®) showed a medium effect on the improvement of hamstrings (g = 0.55, 95% CI (−0.03, 1.14), I2 = 0%) and the quadriceps femoris muscle cross-sectional area (g = 0.58, 95% CI (0.1, 1.00), I2 = 0%) in community-dwelling older women. Additionally, a four-week virtual balance-training program (the ProKin System) led to significant increments in the cross-sectional areas of individual paraspinal muscles (14.55–46.81%). However, previously investigated exergame programs did not show any medium or large effects on the architectural parameters of the medial gastrocnemius muscle in community-dwelling older women. Distinct exergame programs can be used as a complementary therapy for different prevention and rehabilitation programs.

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.