Home-based Virtual Reality Exercise Program During the Maintenance Stage of Cardiac Rehabilitation: A Randomized Controlled Trial

Vieira, Ágata; Melo, Cristina; Noites, Andreia; Machado, Jorge; Mendes, Joaquim

doi:10.36660/ijcs.20190177

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International Journal of Cardiovascular Sciences

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Original Article • Int. J. Cardiovasc. Sci. 36 • 2023 • https://doi.org/10.36660/ijcs.20190177 copy

Home-based Virtual Reality Exercise Program During the Maintenance Stage of Cardiac Rehabilitation: A Randomized Controlled Trial

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Home-based virtual reality technology may become an alternative to cardiac rehabilitation.

Objectives:

To evaluate the effects of a specific, home-based exercise program, performed either through a virtual reality (Kinect) or a conventional format (booklet) in the maintenance stage of cardiac rehabilitation for six months on functional muscle strength of the lower limbs, physical activity and exercise tolerance.

Methodology:

This is a randomized clinical trial (ClinicalTrials.gov — NCT02753829) with individuals with coronary artery disease from a hospital in Porto, Portugal, randomly allocated to an experimental group “1” (EG1; n = 11), submitted to a virtual reality exercise program (Kinect); an experimental group “2” (EG2; n = 11), submitted to an exercise program described in a booklet (conventional format); or a control group (CG) (n=11), submitted to routine care. Parameters of functional muscle strength of the lower limbs (sit-to-stand test), physical activity (accelerometer) and exercise tolerance (stress test) were assessed and compared between the groups. Descriptive and inferential statistics were applied, with 95% with a significance level of 0.05.

Results:

Significant improvements in functional muscle strength of the lower limbs were observed in EG1 compared to EG2, at three months (19.5 ± 7.7 versus 11.9 ± 4.7, p = 0.042), and at six months (23.0 ± 7.7 versus 14.6 ± 4.6, p = 0.027) of intervention.

Conclusions:

The program did not demonstrate superior results, in relation to the control group and among the different formats, in physical activity and effort tolerance. In relation to the functional muscle strength of the lower limbs, the virtual reality format showed significantly better results when compared to the conventional format only.

Keywords:
Technology; coronary disease; exercise; cardiac rehabilitation

Stages		Exercise	Description
Warm-up – 10 minutes		1. March “in place”	Flexion of the hips, bringing the right elbow forward at the same time that the left knee is up; repeat on the opposite side and keep alternating sides without moving forward. After 3 months, lift the knees up to the chest, at the waist level.
Conditioning	Strength 20–25 minutes	2. Squatting	With feet hip-width, sitting into a squat position, keeping heels and toes on the ground; knees are bent to a 90-degree angle.
	(calculate the individual number of repetitions according to 65-70% of reserve HR)		After three months, perform two sets with a 1-minute break in between.
		3. "Crossing"	Keeping the “march in place” perform the first diagonal pattern (flexion, adduction, and external rotation movements of the shoulder) of the proprioceptive neuromuscular facilitation technique.
			After 3 months, perform two sets, with a 1-minute break in between of the second diagonal pattern (flexion, abduction, and external rotation movements of the shoulder).
		4. Ankle movement	Plantar dorsiflexion/flexion of the ankles, standing up.
			After 3 months, perform three sets with 1-minute break in between.
		5. Backwards movement of the arms	Keeping the “march in place”, perform extension, abduction and external rotation of the glenohumeral joint at maximum amplitude. At the end of the movement, do 10 brief insistences.
			After three months, perform two sets with a 1-minute break in between.
		6. Sitting and standing	Sit on a chair with the upper limbs crossed over the chest.
			Sit in a controlled manner; after three months, lower the height of the chair.
	Endurance 35–45 minutes	7. Stepping forward, sideways and backwards	Perform the semi-step forward and backward with bilateral flexion of the upper limbs, and lateral semi-step with abduction and external rotation of the upper limbs.
	(calculate the individual number of repetitions according to 65-70% of reserve HR)		After three months, perform two sets with a 1-minute break in between.
		8. Walking –30 minutes	After three months, if possible, increase to 60 minutes.
Stretching –6 minutes		9. Calf muscle stretching	Stretch the triceps surae 4 repetitions/maintain 15 s
Stretching –6 minutes		10. Anterior forearm muscle stretching	Stretch the wrist flexors 4 repetitions/maintain 15 s

Variable		EG1 (n = 11)	EG2 (n = 11)	CG (n = 11)
Age (years)		55 ± 9.0	59 ± 11.3	59 ± 5.8
BMI (kilogram/meter²2 Lavie CJ, Thomas RJ, Squires RW, Allison TG, Milani RV. Exercise Training and Cardiac Rehabilitation in Primary and Secondary Prevention of Coronary Heart Disease. Mayo Clin Proc. 2009;84(4):373-83. doi: 10.1016/S0025-6196(11)60548-X. https://doi.org/10.1016/S0025-6196(11)60... )		27.4 ± 3.0	26.9 ± 4.7	28.0 ± 3.6
Counts (counts/minute)		355.4 ± 144.6	365.1 ± 138.5	424.9 ± 82.6
Professional status	Active	7 (64%)	2 (18%)	5 (45%)
Professional status	Not active	4 (36%)	9 (82%)	6 (55%)
Reason for hospitalization	ACS with no elevation of the ST segment	6 (55%)	6 (55%)	5 (45%)
	ACS with elevation of the ST segment	5 (45%)	3 (27%)	6 (55%)
	Stable chest angina and post-angioplasty	0	2 (18%)	0
Cardiovascular risk factors	Dislipidemia	10 (91%)	9 (82%)	8 (73%)
	Obesity	2 (18%)	2 (18%)	4 (36%)
	Diabetes Mellitus	2 (18%)	3 (27%)	1 (9%)
	Hypertension	5 (45%)	6 (55%)	8 (73%)
	Smoking	5 (45%)	5 (45%)	4 (36%)
	Family background	1 (9%)	1 (9%)	2 (18%)
Medications	Platelet Antiaggregants	9 (82%)	11 (100%)	10 (91%)
	Beta Blockers	8 (73%)	9 (82%)	8 (73%)
	Statins	9 (82%)	11 (100%)	11 (100%)
	Anti-hypertensives	4 (36%)	4 (36%)	6 (55%)
	Vasodilators	1 (9%)	3 (27%)	5 (45%)
	Calcium channel blockers	0	1 (9%)	1 (9%)
Cardiovascular risk	Low	7 (64%)	7 (64%)	8 (73%)
Cardiovascular risk	Moderate	4 (36%)	4 (36%)	3 (27%)

Variable	Group	M0 X ± SD	M1 X ± SD	M2 X ± SD
Sit-to-stand test (number of stand- ups)	EG1	14.3 ± 2.8 (n = 11)	19.5 ± 7.7 (n = 11)	23.0 ± 7.7 (n = 11)
	EG2	10.8 ± 4.6 (n = 11)	11.9 ± 4.7 (n = 11)	14.6 ± 4.6 (n = 11)
	CG	16.0 ± 6.8 (n = 11)	19.6 ± 8.2 (n = 10)	22.3 ± 8.8 (n = 11)
	p	0.062^a a p-values with the ANOVA test.	0.023 ^a a p-values with the ANOVA test.	0.018 ^a a p-values with the ANOVA test.
	Post-hoc	–	EG1 > EG2 p = 0.042^b b p-values for the Tukey post-hoc test. EG2 < CG p = 0.046^b b p-values for the Tukey post-hoc test.	EG1 > EG2 p = 0.027^b b p-values for the Tukey post-hoc test. EG2 < CG p = 0.046^b b p-values for the Tukey post-hoc test.

Variable		Group	M0 X ± SD	M2 X ± SD	M3 X ± SD
Accelerometer	Sedentary physical activity (minutes/day)	EG1	646.2 ± 66.3 (n = 11)	675.2 ± 54.5 (n = 9)	677.7 ± 30.6 (n = 9)
		EG2	592.6 ± 82.5 (n = 11)	601.4 ± 95.0 (n = 11)	601.2 ± 89.1 (n = 11)
		CG	607.2 ± 81.0 (n = 10)	591.7 ± 62.6 (n = 10)	576.0 ± 90.0 (n = 9)
		p	0.257^a a p-values with the ANOVA test.	0.043^a a p-values with the ANOVA test.	0.023 ^a a p-values with the ANOVA test.
		Post- hoc	–	NS	EG1 > CG p = 0.024^b b p-values for the Tukey post-hoc test.
	Mild physical activity (minutes/day)	EG1	116.8 ± 31.5 (n = 11)	112.3 ± 16.8 (n = 9)	110.3 ± 22.8 (n = 9)
		EG2	143.9 ± 42.2 (n = 11)	128.3 ± 49.1 (n = 11)	121.0 ± 39.1 (n = 11)
		CG	153.4 ± 59.1 (n = 10)	152.2 ± 51.4 (n = 10)	175.1 ± 96.0 (n = 9)
		p	0.170^a a p-values with the ANOVA test.	0.145^a a p-values with the ANOVA test.	0.063^a a p-values with the ANOVA test.
	Moderate to vigorous physical activity (minutes/day)	EG1	59.4 ± 32.5 (n = 11)	40.9 ± 18.6 (n = 9)	58.4 ± 31.6 (n = 9)
		EG2	54.6 ± 22.3 (n = 11)	44.2 ± 16.4 (n = 11)	47.2 ± 14.5 (n = 11)
		CG	71.9 ± 17.5 (n = 10)	57.1 ± 16.4 (n = 10)	60.4 ± 10.9 (n = 9)
		p	0.286^a a p-values with the ANOVA test.	0.104^a a p-values with the ANOVA test.	0.308^a a p-values with the ANOVA test.
	Counts (counts/minute)	EG1	355.4 ± 144.6 (n = 11)	279.9 ± 117.4 (n = 9)	341.0 ± 146.9 (n = 9)
		EG2	365.1 ± 138.5 (n = 11)	301.2 ± 113.8 (n = 11)	317.2 ± 71.3 (n = 11)
		CG	424.9 ± 82.6 (n = 11)	371.3 ± 81.7 (n = 10)	407.8 ± 99.5 (n = 9)
		p	0.411^a a p-values with the ANOVA test.	0.154^a a p-values with the ANOVA test.	0.182^a a p-values with the ANOVA test.

Variable		Group	M0 X ± DP	M3 X ± DP
Stress test	MET	EG1	11.9 ± 1.6 (n = 10)	11.9 ± 1.3 (n = 10)
		EG2	10.8 ± 1.9 (n = 11)	10.7 ± 1.9 (n = 10)
		CG	11.2 ± 2.6 (n = 11)	11.1 ± 2.7 (n = 9)
		p	0.497^a a p-values with the ANOVA test.	0.395^a a p-values with the ANOVA test.
	Test time (seconds)	EG1	690.5 ± 120.9 (n = 10)	693.90 ± 98.4 (n = 10)
		EG2	612.0 ± 148.1 (n = 11)	600.7 ± 145.9 (n = 10)
		CG	639.6 ± 191.0 (n = 11)	631.7 ± 193.9 (n = 9)
		p	0.520^a a p-values with the ANOVA test.	0.379^a a p-values with the ANOVA test.
	Maximum double product	EG1	23032.0 ± 3536.2 (n = 10)	24646.7 ± 2946.2 (n = 9)
		EG2	22853.2 ± 4198.7 (n = 11)	23629.5 ± 5024.6 (n = 10)
		CG	20840.0 ± 4223.7 (n = 11)	24119.4 ± 5673.9 (n = 9)
		p	0.383^a a p-values with the ANOVA test.	0.896^a a p-values with the ANOVA test.

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