Exergame: A Gamelike Exercise to Improve Motor Functions and Physical Activities in Diabetic Patients Undergoing Hemodialysis

Abstract

Background: Balance, mobility, falls, and foot problems are serious detriments for the diabetic patients undergoing hemodialysis (HD) treatment. In addition, the HD process often leaves them too fatigued to engage in any physical activity or daily exercise, further deteriorating their motor functions. Exercise would be effective for this population. However, due to the time availability, post-dialysis fatigue, as well as limitation of transportation to exercise facility, the conventional exercise is impractical. Objective: We are developing an interactive foot and ankle exercise game that can be played during HD sessions to improve mobility and balance, as well as reduce foot problems. In this study, we examined the feasibility and effectiveness of this innovative wearable sensor based non-weight bearing exercise (Exergame) to improve daily physical activity in diabetic patients undergoing HD treatment. Methods: Thirty-three diabetic subjects receiving HD treatment were recruited and randomized into an intervention group (IG: n = 15, age = 62.2 ± 7.6 years, BMI = 29.1 ± 6.1 kg/m2) and a control group (CG: n = 18, age = 66.6 ± 8.7 years, BMI = 32.5 ± 9.0 kg/m2). Both groups underwent a 4-week ankle and foot exercise program (30 minutes per session, two sessions per week) during HD process. The IG received exercise via the Exergame program, which uses wearable sensors attached on subject's feet. The subject's 3-dementional ankle and foot movements were visualized in real-time on a computer screen placed in front of him/her. The subject played some game-like tasks by moving and rotating the foot and ankle. The difficulty level of the task was gradually increased depends on ability of the subject (like a game) from a simple flexion-extension movement to more complex movements including medial-lateral movement with different range of motion. The CG received traditional foot and ankle exercise without technology. Daily physical activity data was assessed for 48 hours (day and night) at baseline and post 4-week exercise, using a validated wearable sensor (PAMSysTM). Daily physical activity was quantified by duration spent in each main posture (i.e. lying, sitting, standing, and walking) and activities (e.g. postural transition, sedentary behavior, etc). Results: All IG subjects achieved to complete all exercise tasks indicating the feasibility of the Exergame platform. No adverse event or difficulty were reported indicating practicality of the exercise program. None subject in the IG was dropped out during the 4-week exercise program. Low dropout rate may indicate acceptability of the proposed Exergame platform. At the end of intervention, subjects in the IG were more active than subjects in the CG. In summary, the IG performed 53% more posture transitions to walking (Cohen's d effect size = 0.5) and 39% more posture transitions between sitting and walking (d = 0.5), when compared to the CG. Subjects in the IG also had significant less sedentary behavior than subjects in the CG. In summary, subjects in the IG spent 5% less time on sitting and lying (p = 0.049, d = 0.7), as well as 47% more time on standing and walking (p = 0.049, d = 0.7), when compared to subjects in the CG. Conclusions: This study demonstrated feasibility, acceptability, and effectiveness of an innovative Exergame program to improve daily physical activity in diabetic patients undergoing HD treatment. The key innovation of the proposed intervention is its practicality to be done during HD process, which could address the limitations of prior exercise interventions in HD patients, for example the low adherence of therapeutic exercise. Further studies should be addressed to confirm the observation with larger sample sizes.

Application of Wearables to Facilitate Virtually Supervised Intradialytic Exercise for Reducing Depression Symptoms

“…Recent advances in wearable technology have opened new opportunities to design virtually supervised exercise which can be applied anytime and anywhere [24][25][26]. To address the gaps described above, we have developed a low-intensity game-based non-weight-bearing lower extremities exercise program we called exergame, which can be performed during the hemodialysis treatment inside a regular dialysis clinic.…”

Impact of virtual reality interventions on haemodialysis patients: A scoping review

“…Missing outcome data due to attrition and loss of data were not accounted for in these studies during analysis (Chou et al, 2018; Maynard et al, 2019) and there was apparent omission of discussion regarding missing data interpretation. The method used to conceal the allocation sequence was not described to determine whether intervention allocations could have been foreseen in advance of, or during, enrolment (Maynard et al, 2019; Segura‐Ortí & García‐Testal, 2019; Segura‐Orti et al, 2019a; Zhou et al, 2017). Only one RCT reported allocation concealment (Segura‐Ortí et al, 2019b).…”

“…A similar RCT conducted in Spain (Segura‐Orti et al, 2019b) demonstrated that a nonimmersive VR exercise program during haemodialysis improved health‐related quality of life however the improvement was lost once the exercise program stopped. Two RCTs conducted in Qatar (Zhou et al, 2017, 2018) demonstrated visible improvement in ankle stability, gait and postural balance from VR as an intervention amongst patients with diabetes undergoing haemodialysis. Two quasi‐experimental studies, conducted in South Korea (Cho & Sohng, 2014) and Taiwan (Chou et al, 2018), showed that VR exercise programs improved physical fitness and body composition, and reduced fatigue in patients with end‐stage kidney disease receiving haemodialysis.…”

“…Half of the included studies ( n = 6) (Bers et al, 2001; Burrows et al, 2020; Segura‐Ortí & García‐Testal, 2019; Starr‐Glass, 2020; Zhou et al, 2017, 2020) described the safety of the VR technology in haemodialysis patients (adults and children) as an outcome, with all six studies reporting no VR‐associated adverse events during haemodialysis sessions. Of these six studies three used immersive VR media (Bers et al, 2001; Burrows et al, 2020; Starr‐Glass, 2020).…”

“…The rapid advancement of VR technology means that the VR systems used in the included studies are outdated compared with currently available VR technology. In this review, there were studies published in 2001 (Bers et al, 2001) and 2014 (Cho & Sohng, 2014) and 2017 (actual conduct of research may be earlier than 2017) (Zhou et al, 2017). These outdated VR systems may have affected the experience of the participants and had an impact on treatment effects reported in different aspects of the quality of life of the participants.…”