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

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).

The Rationale Behind the Design Decisions in an Augmented Reality Mobile eHealth Exergame to Increase Physical Activity for Inactive Older People With Heart Failure

Unlabelled

Physical activity is important for everyone to maintain and improve health, especially for people with chronic diseases. Mobile exergaming has the potential to increase physical activity and to specifically reach people with poor activity levels. However, commercial mobile exergames are not specially designed for older people with chronic illnesses such as heart failure. The primary aim of this viewpoint is to describe the underlying reasoning guiding the design choices made in developing a mobile exergame, Heart Farming, tailored specifically for sedentary older people diagnosed with heart failure. The goal of the exergame is to increase physical activity levels by increasing the daily walking duration of patients with heart failure by at least 10 minutes. The rationale guiding the design decisions of the mobile exergame is grounded in the thoughtful integration of gamification strategies tailored for application in cardiovascular care. This integration is achieved through applying gamification components, gamification elements, and gamification principles. The Heart Farming mobile exergame is about helping a farmer take care of and expand a virtual farm, with these activities taking place while the patient walks in the real world. The exergame can be adapted to individual preferences and physical condition regarding where, how, when, and how much to play and walk. The exergame is developed using augmented reality so it can be played both indoors and outdoors. Augmented reality technology is used to track the patients' movement in the real world and to interpret that movement into events in the exergame rather than to augment the mobile user interface.

Balance Board or Motion Capture? A Meta-Analysis Exploring the Effectiveness of Commercially Available Virtual Reality Exergaming in Enhancing Balance and Functional Mobility Among the Elderly

Force platforms and motion capture are commonly used as feedback mechanisms in exergaming; nevertheless, their therapeutic effectiveness may vary. Therefore, the primary objective of this study was to evaluate the effectiveness of commercially available virtual reality (VR) exergaming systems on balance and functional mobility, with a supplementary analysis considering the administered dose of exergaming. The search was conducted in five databases. Commercially available exergaming platforms were classified into two categories: VR exergaming with a balance board (including Wii Balance Board) and motion capture (including Xbox Kinect). Two categories of control interventions (treatment as usual [TAU] and no treatment [NT]) were extracted. The meta-analysis was performed separately for static, dynamic, and proactive balance outcomes and for the aggregated results of all included outcomes with subgroup analysis of lower, moderate, and higher doses. In total, 28 studies with 1457 participants were included. Both exergaming systems were particularly effective in improving the single leg stance outcome. VR exergaming with motion capture was found to be more effective than TAU with a standardized mean difference (SMD) of 0.48 (P = 0.006) and NT (SMD = 0.86; P = 0.02). In conclusion, commercially available VR exergaming with a motion capture feedback mechanism has demonstrated effectiveness as an intervention for balance training when compared with NT. Specifically, high doses (above 134 minutes per week) appear to be more beneficial for healthy older adults. Moreover, the findings provide some weak evidence supporting the effectiveness of VR exergaming with a balance board for improving functional mobility, particularly when compared with NT.

Clinical application of virtual reality in patients with cardiovascular disease: state of the art

Virtual reality offers a multisensory experience to patients, allowing them to hear, watch, and interact in a virtual environment. Immersive virtual reality is particularly suitable for the purpose of completely isolating patients from the external environment to transport them away from the suffering related to the disease. On this state of the art, we summarize the available literature on the effectiveness of virtual reality on various physical and psychological outcomes in patients with atherosclerotic cardiovascular disease. Virtual reality has been employed in the cardiovascular field in various settings such as cardiac rehabilitation, interventional cardiology, and cardiac surgery. This technology offers promising opportunities to improve several outcomes related to cardiovascular disease, but further research is needed to entirely capture its benefits and to standardize the intervention.

Training using a commercial immersive virtual reality system on hand–eye coordination and reaction time in students: a randomized controlled trial

Abstract

The implementation of VR games opens up a wide range of opportunities for the development of dexterity, speed and precision of movements among various professional groups. The aim of this study was to investigate the effects of a commercial immersive VR music game on hand–eye coordination and reaction time speed in students. This study enrolled 32 individuals, randomly assigned to the experimental or control group. The intervention consisted of a 15-min training session of the immersive music game “Beat Saber”, once a day for 5 consecutive days. The primary outcomes included reaction time measurements: the plate tapping test and the ruler-drop test (Ditrich's test), trial making test (TMT) A and TMT B to assess coordination and visual attention, likewise VR sickness assessment by Virtual Reality Sickness Questionnaire (VRSQ). The secondary outcome included an energy expenditure assessment (SenseWear Armband). The data analysis revealed a statistically significant improvement in hand–eye coordination in the experimental group, with no improvement in the control group. The results were similar in measurements of reaction time. Analysis of the VRSQ questionnaire results showed a statistically significant reduction in oculomotor domain symptoms and total score during successive training days. The immersive VR music game has the potential to improve reaction time and hand–eye coordination in students.

Graphical abstract

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.

International Physical Activity Questionnaire Short Form and accelerometer-assessed physical activity: concurrent validity using six cut-points in HF patients

AIMS

Physical activity (PA) is an important target for improving clinical outcomes in heart failure (HF) patients. Nonetheless, assessing the daily PA profile in this population is a challenging task, traditionally performed using self-report questionnaires such as the International PA Questionnaire Short Form (IPAQ-SF). This study aimed to evaluate the concurrent validity of the IPAQ-SF and accelerometer-assessed PA using six published cut-points in patients with HF and reduced or mildly reduced ejection fraction.

METHODS AND RESULTS

The concordance between the IPAQ-SF and a hip-worn accelerometer regarding daily time spent performing moderate to vigorous PA in bouts of at least 10 min was assessed in 53 participants for seven consecutive days using six different cut-points (Barnett, Dibben, Mark, Sanders, Troiano, and Vaha-Ypya). Spearman's correlation and Bland-Altman plots were used to evaluate concurrent validity between methods. Regressions were used to study the association between patient variables, wear protocol (waking hour or 24 h), and absolute bias. The kappa index was used to evaluate the concordance between IPAQ-SF and accelerometry for classifying patients as active or non-active. All analyses were re-run using non-bouted metrics to investigate the effect of bouted versus non-bouted analysis. The IPAQ-SF and accelerometry showed low to negligible correlation (ρ = 0.12 to 0.37), depending on the cut-point used. The regression analysis showed that the absolute bias was higher in participants following the waking-hour protocol at all cut-points except Dibben's (P ≤ 0.007). The concordance between the two methods to classify patients as active and non-active was low when using Mark (κ = 0.23) and Barnett (κ = 0.34) cut-points and poor for the remaining cut-points (κ = 0.03 to 0.18). The results of the sensitivity analysis showed negligible to low correlation using non-bouted metrics (ρ = 0.27 to 0.33).

CONCLUSIONS

Moderate to vigorous PA measures using IPAQ-SF and accelerometers are not equivalent, and we do not encourage researchers to use IPAQ-SF alone when assessing PA in HF patients. Moreover, applying personalized collection and processing criteria is important when assessing PA in HF patients. We recommend following the 24 h protocol and selecting cut-points calibrated in patients with cardiovascular diseases. Finally, it is necessary to develop a new tailored questionnaire that considers walking intensity and is adjusted to the current World Health Organisation recommendations, which use non-bouted metrics.

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.

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.

Exploring the barriers and facilitators experienced by patients with heart failure when using popular exergaming platforms for self-management-a systematic review

Objective

To systematically explore the barriers and facilitators experienced by patients with heart failure when using the most popular commercially-accessible digital exergaming platforms for self-management.

Methods

A systematic literature search was conducted in: Embase, SCOPUS, PubMed, and ProQuest. Qualitative/mixed methods studies published in English between 2000 and 2024, including adults >18 years with heart failure using digital gaming platforms for exercise as self-management (i.e. Microsoft Xbox/Kinect, Sony PlayStation®, Nintendo™ Wii) were considered. Risk of bias was assessed using the Critical Appraisal Skills Program. The grounded theory method was used to extract, analyze, and synthesize the data.

Results

Three articles which qualitatively reported on the experiences of the patients with heart failure when using Nintendo™ Wii for self-management were included. Seventy-nine participants (male and female, age 32-81 years) were included in the studies. The three included studies were of high quality. Extracted qualitative data were grouped into subthemes, which were grouped into main themes, namely, Engagement, Apathy, Convenience, Health-related benefits and Gaming Platforms. The main themes were categorized into Barriers and Facilitators. Patients reported that gaming platforms were simple, easy to use, interesting, and motivating (Facilitators). Boredom while playing specific games, preferring other activities and technical issues were reported as Barriers.

Conclusion

This review provides the first insights into the barriers and facilitators patients with heart failure experience when using popular digital exergaming platforms to participate in exercise programs in the self-management of their condition. However, few high-quality studies exist which limits the conclusions made and warrants further research in this area.

Virtual Reality in Clinical Nursing Practice Over the Past 10 Years: Umbrella Review of Meta-Analyses

Background

Virtual reality (VR) has shown promising levels of effectiveness in nursing education, pain management, and rehabilitation. However, meta-analyses have discussed the effects of VR usage in nursing unilaterally and inconsistently, and the evidence base is diffuse and varied.

Objective

We aimed to synthesize the combined evidence from meta-analyses that assessed the effects of nurses using VR technology on nursing education or patient health outcomes.

Methods

We conducted an umbrella review by searching for meta-analyses about VR intervention in clinical nursing practice on Web of Science, Embase, Cochrane, and PubMed, and in reference lists. Eligible studies were published in English between December 1, 2012, and September 20, 2023. Meta-analyses of ≤2 intervention studies and meta-analyses without 95% CI or heterogeneity data were excluded. Characteristic indicators, population information, VR intervention information, and 95% CIs were extracted. A descriptive analysis of research results was conducted to discern relationships between VR interventions and outcomes. I2 and P values were used to evaluate publication bias. AMSTAR (A Measurement Tool to Assess Systematic Reviews) 2 and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) checklist were used to appraise literature quality.

Results

In total, 768 records were identified; 74 meta-analyses were included for review. The most reported VR study conditions were neuronursing (25/74, 34%), pediatric nursing (13/74, 18%), surgical and wound care (11/74, 15%), oncological nursing (11/74, 15%), and older adult nursing (10/74, 14%). Further, 30% (22/74) of meta-analyses reported publication bias, and 15% (11/74) and 8% (6/74) were rated as "high" based on AMSTAR 2 and the GRADE checklist, respectively. The main outcome indicators among all included meta-analyses were pain (37/214, 17.3%), anxiety (36/214, 16.8%), cognitive function (17/214, 7.9%), balance (16/214, 7.5%), depression (16/214, 7.5%), motor function (12/214, 5.6%), and participation in life (12/214, 5.6%). VR treatment for cognition, pain, anxiety, and depression was effective (all P values were <.05), while the utility of VR for improving motor function, balance, memory, and attention was controversial. Adverse effects included nausea, vomiting, and dizziness (incidence: range 4.76%-50%). The most common VR platforms were Pico VR glasses, head-mounted displays, the Nintendo Wii, and the Xbox Kinect. VR intervention duration ranged from 2 weeks to 12 months (typically ≥4 wk). VR session length and frequency ranged from 5 to 100 minutes and from 1 to 10 times per week, respectively.

Conclusions

VR in nursing has positive effects-relieving patients' pain, anxiety, and depression and improving cognitive function-despite the included studies' limited quality. However, applying VR in nursing to improve patients' motor function, balance, memory, and attention remains controversial. Nursing researchers need to further explore the effects and standard operation protocols of VR in clinical practice, and more high-quality research on VR in nursing is needed.

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.

High-intensity interval training versus moderate-intensity continuous training on patient quality of life in cardiovascular disease: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to compare the effects of high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) on the quality of life (QOL) and mental health (MH) of patients with cardiovascular disease (CVDs). Web of Science, Medline, Embase, Cochrane (CENTRAL), CINAHL, China National Knowledge Infrastructure, Wanfang, and China Science and Technology Journal databases were searched from their date of establishment to July, 2023. A total of 5798 articles were screened, of which 25 were included according to the eligibility criteria. The weighted mean difference (WMD) and standardized mean difference (SMD) were used to analyze data from the same and different indicator categories, respectively. The fixed-effects model (FE) or random-effects model (RE) combined data based on the between-study heterogeneity. There were no statistically significant differences regarding QOL, physical component summary (PCS), mental component summary (MCS), and MH, including depression and anxiety levels, between the HIIT and MICT groups [SMD = 0.21, 95% confidence interval (CI)  - 0.18-0.61, Z = 1.06, P = 0.290; SMD = 0.10, 95% CI  - 0.03-0.23, Z = 1.52, P = 0.128; SMD = 0.07, 95% CI  - 0.05-0.20, Z = 1.13, P = 0.25; SMD = - 0.08, 95% CI  - 0.40-0.25, Z = - 0.46, P = 0.646; WMD = 0.14. 95% CI  - 0.56-0.84, Z = 0.39, P = 0.694, respectively]. HIIT significantly improved PCS in the coronary artery disease (CAD) population subgroup relative to MICT. HIIT was also significantly superior to MICT for physical role, vitality, and social function. We conclude that HIIT and MICT have similar effects on QOL and MH in patients with CVD, while HIIT is favorable for improving patients' self-perceived physiological functioning based on their status and social adjustment, and this effect is more significant in patients with CAD.

Comparison of Exergames Versus Conventional Exercises on the Health Benefits of Older Adults: Systematic Review With Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Conventional exercises (CEs) can provide health benefits for older adults, but the long-term exercise adherence rate is low. As an emerging, stimulating, and self-motivating strategy, exergames (EGs) are defined as combinations of exercises and games that users carry out through physical actions. They can promote exercise, but the health effects of EGs versus CEs on the physical function and mental health (cognitive function, depression, and quality of life) of older adults remain controversial.

OBJECTIVE

The aim of the study is to compare the health benefits of EGs versus those of CEs for the physical function and mental health of older adults.

METHODS

A comprehensive search was conducted from the earliest available date to February 2023 in the following 6 databases: PubMed, Web of Science, Embase, Cochrane, CINAHL, and PsycINFO. All English-language randomized controlled trials comparing the effects of EGs versus those of CEs on the physical function and mental health of older adults, with nearly same physical activity between the 2 interventions, were included. Risk of bias was independently evaluated by 2 authors using the Cochrane risk of bias in randomized trials tool. Two authors independently extracted data. We followed the Cochrane Handbook of Systematic Reviews of Interventions to process and analyze the data for meta-analysis. Standardized mean differences (SMDs) and 95% CIs were used for continuous data, and random models were used for analyses.

RESULTS

We included 12 studies consisting of 919 participants in total. Of these, 10 studies were eventually included in the meta-analysis. The results showed that EGs versus CEs exhibited no significant differences in physical (P=.13; τ2=0.31; χ26=26.6; I2=77%; SMD=0.37; 95% CI -0.11 to 0.86) or cognitive function (P=.63; τ2=0.01; χ23=3.1; I2=4%; SMD=0.09; 95% CI -0.27 to 0.44) effects.

CONCLUSIONS

Our findings indicate no significant difference between EGs and CEs in improving the physical function and cognitive function of older adults. Future studies are required to compare the effects of EGs versus those of CEs on cognitive function according to cognitive status, quantify the "dose-effect" relationship between EGs and health benefits, and evaluate the effects of different types and devices of EGs with regard to the health benefits of older adults.

TRIAL REGISTRATION

PROSPERO CRD42022322734; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=322734.

Commercial exergames for rehabilitation of physical health and quality of life: a systematic review of randomized controlled trials with adults in unsupervised home environments

Background

Commercial exergames are widely available tools that can support physical rehabilitation at home. However, the effects of the unsupervised use of commercial exergames in home environments are not yet clear. Hence, we provide a systematic review on the effects of unsupervised commercial exergaming at home on adults' physical health (RQ1) and quality of life (RQ2). We also scrutinize adults' experiences with exergaming at home regarding participant support, adherence, and adverse outcomes (RQ3).

Methods

We searched Web of Science, PsycINFO, PubMed, Embase, and CINAHL for peer-reviewed randomized controlled trials with adults in need of rehabilitation. Overall, 20 studies (1,558 participants, 1,368 analyzed) met our inclusion criteria. The quality of evidence was assessed with the Cochrane risk of bias tool.

Results

Effects of unsupervised commercial exergaming at home on physical health were higher in seven studies and similar in five studies regarding the respective comparison or control conditions; eight studies reported non-significant findings. Of the 15 studies that also examined effects on quality of life, improvements were higher in seven studies and similar in two studies regarding the respective comparison or control conditions; results were non-significant in six studies. Participant support consisted of setup of the exergaming system, instructions, training, and contact with participants. Adherence was high in eight studies, moderate in six studies, and low in one study. Adverse outcomes related to exergaming were found in four studies and were at most moderate. Concerning the quality of evidence, six studies were related to a high risk of bias due to outcome reporting bias or ceiling effects in the primary outcome. Additionally, 10 studies yielded some concerns, and four studies were related to a low risk of bias.

Discussion

This systematic review summarizes promising evidence that the unsupervised use of commercial exergames can support and complement rehabilitation measures in home environments. Still, future studies based on larger samples and using more recent commercial exergames are needed to obtain more high-quality evidence on the effects of different exercise prescriptions. Overall, considering the necessary precautions, the unsupervised use of commercial exergames at home can improve the physical health and quality of life in adults with needs for physical rehabilitation.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022341189, identifier: PROSPERO, Registration number: CRD42022341189.

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.

Impact of virtual reality on cardiac rehabilitation-related anxiety: a protocol for systematic review and meta-analysis

Introduction

Cardiac rehabilitation has proven beneficial in cardiovascular patients and is strongly recommended for secondary prevention after a coronary event. However, overall utilisation of cardiac rehabilitation is often low. The addition of novel methods of rehabilitation may increase overall compliance with cardiac rehabilitation. The use of virtual reality (VR) has been adopted in a variety of therapeutic ways such as physical rehabilitation in neurological diseases, rehabilitation for various psychiatric illnesses and postcancer rehabilitation in breast cancer survivors. In our meta-analysis, we wish to assess whether the addition of VR (fully immersive or non-immersive) leads to an improvement in anxiety and functional capacity compared with standard cardiac rehabilitation at any phase of the rehabilitation process.

Method and analysis

This systematic review and meta-analysis protocol was structured according to the published Preferred Reporting for Systematic Review and Meta-analysis—Protocol guidelines. We will devise a search strategy to use online databases to search for the randomised controlled trials. Inclusion criteria and exclusion criteria will be defined. The articles will be reviewed by two independent reviewers and any conflict will be adjudicated through discussion. The bias in the selected studies will be assessed using Cochrane risk-of-bias tool for randomised trials (RoB 2). The outcome of interest will be anxiety and functional capacity. Effect estimates will be reported as standardised mean difference with 95% CI. Fixed effect model will be used if I2<60%, otherwise random effect model will be used to estimate the effect size.

Ethics and dissemination

There will be no direct involvement of the patient or the public in the conception, design, data collection and analysis of this systematic review and meta-analysis. Results of this systematic review and meta-analysis will be disseminated via journal articles. In accordance with the guidelines, our systematic review protocol is prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 07 August 2022.

PROSPERO ID

CRD 42022342736.

ExerG: adapting an exergame training solution to the needs of older adults using focus group and expert interviews

BACKGROUND

Exergames are playful technology-based exercise programs. They train physical and cognitive functions to preserve independence in older adults (OAs) with disabilities in daily activities and may reduce their risk of falling. This study gathered in-depth knowledge and understanding of three different user groups' experiences in and relevant needs, worries, preferences, and expectations of technology-based training, to develop an exergame training device for OAs.

METHODS

We conducted a qualitative study using semi-structured focus group interviews of primary (OAs in geriatric or neurological rehabilitation) and secondary (health professionals) end users, as well as expert interviews of tertiary end users (health insurance experts or similar), exploring user perspectives on adjusting an existing exergame to OAs' needs. Voice-recorded interviews were transcribed by researchers and analyzed using thematic analysis (TA) following an inductive, data-driven, iterative approach.

RESULTS

We interviewed 24 primary, 18 secondary, and 9 tertiary end users at two rehabilitation centers in Austria and Switzerland. Our TA approach identified five to six themes per user group. Themes in the primary end user group reflected aspects of safety, training goals, individuality, game environment, social interactions, and physical and technical overload. Themes in the secondary end user group comprised facets of meaningfulness, distraction through the game environment, safety, gamification elements, the availability and accessibility of the exergame. Tertiary end users' themes addressed aspects of financial reimbursement, suitable target populations, professional training for the handling of exergame devices, training goals, and concerns about the use of exergames in geriatric rehabilitation.

CONCLUSIONS

In conclusion, an exergame for OAs must be safe, motivating and fully adaptable to the target group while promoting the return to or preservation of autonomy and independence in daily life. Our findings contribute to developing hard- and software extensions for the ExerG training device. Further research is needed to expand the validity of our findings to larger populations.