Virtual Reality-based Rehabilitation in the Treatment and Prevention of Sarcopenia of Older Residents in Caring Facilities - a Pilot Study in Rural Southern Taiwan
Phase: NA
Conditions: Sarcopenia
Sponsor: Cishan Hospital, Ministry of Health and Welfare

Virtual reality-based rehabilitation in the treatment of sarcopenia 
among residents in rural caring facilities  
[study protocol] 
Sheng-hui Tuana, Che-Wei Linb, Yi-JhenWub, Hung-Tzu Sua 
 
a Department of Rehabilitation Medicine, Cishan Hospital, Ministry of Health and 
Welfare, Kaohsiung, Taiwan; No.60, Zhongxue Rd., Cishan District, Kaohsiung City 
84247, Taiwan (R.O.C.) 
b Department of Biomedical Engineering, National Cheng Kung University, Tainan, 
Taiwan; No.1, University Road, Tainan City 701, Taiwan (R.O.C.) 
 
Project administrator: SHENG-HUI TUAN, M.D., Department of Rehabilitation 
Medicine, Cishan Hospital, Ministry of Health and Welfare, No.60, Zhongxue Rd., 
Cishan District, Kaohsiung City 84247, Taiwan (R.O.C.) 
Phone number: +88676615523, ext 1006; Fax number: +88676618638 
e-mail：pj73010@hotmail.com 
 
NCT number: NCT03809104 
Date of the document: December, 08, 2019 
 
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[Study protocol] 
 
Subject Characteristics and Ethical Statements 
It was a prospective non-randomized controlled study, conducting at southern rural Taiwan from 
January 2019 to Octobor 2019. Older adults aged more than 60 and lived in the nursing home or went 
to daycare center regularly were recruited for screening. All the residents with sufficient cognitive 
function and physical fitness to perform training that lasts for 30 minutes and meeting the criteria of 
sarcopenia by AWGS as the following (1) muscle mass less than 7.0 kg/m2 for men and 5.7 kg/m2 for 
women by using bio-impedance analysis and (2) handgrip strength less than 26 kg for men and 18 kg 
for women or usual gait speed less than 0.8 m/s), participated the final VR-REH. Participants with the 
presence of significant cardiopulmonary disease with oxygen supplement, uncontrollable high blood 
pressure,recent infection, or other diseases prohibited to participate in sports exercise by the American 
College of Sports Medicine (ACSM) guideline are excluded(1). To determine the sample size, the 
G*Power software (version 3.1.9.2, for Windows was used. The alpha level and the power were set as 
0.05 and 0.8. The effect size was set at high effect (0.8) and the minimal estimated sample size was 15 
subjects. 
 
VR-based rehabilitation programs 
The program was combined with progressive resistant training and functional movement of dominant 
upper limb. The device of the VR included one computer, one Oculus Rift headset, one constellation, 
and one Leap Motion sensor (Figure 1). The Oculus Rift headset uses an organic light-emitting diode 
(LED) panel for each eye, each having a resolution of 1080×1200. These panels have a refresh rate of 
90 Hz and globally refresh. Oculus Rift headset is portable, lightweight, and works with standard PC 
hardware. Constellation is the positional tracking system of Oculus Rift, used to track the position of 
the user's head as well as other VR devices, consisting of external infrared tracking sensors that 
optically track specially designed VR devices(2). The hand-hold sensor we used was Leap Motion 
rather than Oculus Touch controller since the hand dexterity of our participants was insufficient 
generally. The Leap Motion controller is a small universal serial bus peripheral device and could be 
mounted onto a VR headset. Leap motion is designed for hand tracking in VR by using two 
monochromatic infrared cameras and three infrared LEDs. It could observe a roughly hemispherical 
area, to a distance of about 1 meter(3).   
The software used in the VR-REH contained 4 different commercialized VR games, including (1) 
Leap Motion Blocks ®(2) Slum Ball VR Tournament ®(3) VR Super Sports ®10th edition- Basketball 
(4) VR Super Sports ®10th edition- Soccer (Figure 2), listed in performing order.We analyzed the tasks 
according to the basis of the motor learning theory of Gentile and selected the game based on body 
stability and stationary conditions for initial practice(4) (Table 1). Each game was performed by the 
participants for 6 minutes with the assistance by a well-trained physiotherapist assistant (PTA). There 
was a one to two minutes break between each game for switching the setting and adjustment for the 
Oculus Rift headset. One designed mass would be held on the dominant hand of the participants and 
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the weight increased gradually during the duration of the VR-REH, adjusted by each participant’s 
ability. There was also one 5-minute warm-up and cool-down exercise before and after the VR-REH, 
respectively. Based on the recommendation of ACSM(1) and previous studies(5), the VR-REH lasted 
for 12 weeks, twice per week, and 40 minutes per time. There was at least 1-day break between each 
training. 
 
Baseline screening and outcome measurements 
Every participant went through fourevaluations in this study. The first evaluation was the baseline 
evaluation, which was done to make sure the subjects meet the definition sarcopenia before the 
VR-REH. The second, third, and fourth evaluation was conducted at 4, 8, and12 weeks after VR-REH, 
respectively.The primary outcomes included appendicular skeletal muscle mass (ASMM) index 
(ASMMI), dominant hand grip strength (HGS), and usual gait speed while the secondary outcomes 
were the range of motion (ROM) of joints of the dominant upper limbs, the strength of the biceps and 
tricepsbrachii muscles, and the scores of box and block test (BBT). 
 
Anthropometry and Body Composition 
Vector bioelectric impedance analysis (VBIA) was used in this study to measure the body 
composition of participants. VBIA was performed with the bioelectrical impedance vector analysis 
software by using the resistance–reactance graph method(6). Zeus 9.9 PLUS (Jawon Medical Co. Ltd., 
KungsangBukdo, South Korea) was used to analyze the body composition. The machine sent a minute 
electric current and measured the body composition by using personal data that have been saved 
(height, weight, sex, age, and newly calculated body impedance) via the tetrapolar electrode method 
(electrodes were located on both hands, both soles of the feet, and both ankles of participants with 
frequencies of 1, 5, 50, 250, 550, and 1,000 kHz and a current of 360 uA). ASMMI was defined as 
appendicular skeletal muscle mass (kg) divided by height squared (m2)(7). 
 
Measurement of dominant hand grip strength 
The measurements of the HGS were determined by means of the JAMAR-Dynamometer (J A Preston 
Corporation, New York, USA) using all five notches. It is a hydraulic instrument measuring the 
isometric strength in kilograms and numerous studies have investigated the reliability of it in different 
older populations(8). Each participant was shown the correct handling and positioning of the 
instruments: they were asked to sit straight, with the upper arm in a neutral position and a 90° flexion 
of the elbow. The forearm was held in neutral position and the wrist at a 0 to 30° extension. The 
instrument was held freely: neither the hand nor the forearm was allowed to rest on a surface(9). Three 
measurements were done and recorded as the average of the three measurements and the participants 
rested for 1 minute in between measurements.  
 
Measurement of the gait speed 
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We evaluated the usual gait speed bymeasuring the time it took for a participant to walk on a 6 
meter-long corridor without barrier as suggested by AWGS(7). Timing started after the subject walking 
and stopped at the point when a subject reached a distance of 6 meters. The gait speed was measured 
twice and the final measurement was the average of the two. The participant was allowed to rest for 10 
minutes in between measurements. 
 
Measurement of range of motion of joints of dominant upper extremity 
ROMs of dominant upper extremity that are easily limited in older adults were measured by 
goniometer under standard positions(10), including shoulder flexion, abduction, and external rotation; 
elbow flexion and extension; forearm supination and pronation; and wrist flexion and extension.  
 
Measurement of dominant biceps and triceps brachii muscle strength 
We used MicroFET®3(Hoggan Health Industries, West Jordan, UT) to measure the maximal 
voluntary isometric contraction (MVIC) of the biceps and tricepsbrachii muscles. MicroFET®3 is an 
electronic hand-held dynamometer that could detect 0-150 lbs force with high reliability and 
validity(11). To measure the MVIC of biceps brachii muscle, the participant was asked to lie on the 
treatment table with elbow forming a 90-degree angle to the horizontal such that the arm is 
perpendicular to the limb and the tester placed MicroFET®3 on the ventral side of the arm and align it 
with the ulnar styloid of the participant. Then, the tester exerted a resistant force towards the device and 
encouraged the participant to against the force with their maximum strength. To measure the MVIC of 
triceps brachii muscle, the procedure was the same as in measurement of biceps brachii muscle except 
that the tester placed the device on the dorsal side of the participant’s arm(12). The MVIC was 
measured twice and the final measurement was the average of the two. The participant was allowed to 
rest for 1 minute in between measurements. 
 
The box and block test 
 The set-up of the BBT includes a wooden box with 150 wooden blocks inside. The wooden box is 
divided into two compartments. One filled with blocks, and the other is empty. During this test, the 
patient is seated upright in a chair and needs to transfer the wooden blocks, one by one, from one 
compartment to the other. The patient is scored based on the number of blocks he or she can transfer 
from one compartment to the other in 60 seconds. The BBT has high test-retest reliability and validity 
and could measure the unilateral gross manual dexterity in different populations(13). 
 
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Figure 1. 
 
The hardware of the virtual-reality based rehabilitation. The participant sat or stood 1 meter in 
front of the screen and was supervised by one well-trained caregiver. 
A: Oculus Rift Headset 
B: Oculus constellation: sensor for headset 
C: Leap Motion: sensor for hand movement 
D: Hand-hold device 
 
 
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Figure 2. 
 
The software of the virtual-reality based rehabilitation. 
A: Leap Motion Blocks ® 
Leap Motion Blocks ® offers a platform in which the subjects can play freely with blocks- they 
can create blocks, grab, push, pile and throw blocks around. The subjects are guided to perform 
a sequence of actions in the game. First, they need to pinch and stretch with both of their hands 
to create several blocks. Then, they need to push, pile and throw blocks around. 
B: Slum ball VR tournament ® 
In Slum Ball VR Tournament®, objects such as tin cans and balls will keep flying towards the 
player, and the player needs to hit the upcoming objects back to specific location. 
C: VR Sports- basketball ® 
D: VR Sports- soccer ® 
In VR Super Sports ® 10th edition- Basketball, player needs to keep grabbing a basketball and 
throwing it out into the basket while the participant becomes the goalkeeper of a soccer game and 
needs to use both of their hands to block the upcoming ball. 
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12. Stark T, Walker B, Phillips JK, Fejer R, Beck R. Hand-held dynamometry 
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Figure Captions 
Fig. 1 
The hardware of the virtual-reality based rehabilitation. The participant sat or stood 1 meter in front of 
the screen and was supervised by one well-trained caregiver. 
A: Oculus Rift Headset 
B: Oculus constellation: sensor for headset 
C: Leap Motion: sensor for hand movement 
D: Hand-hold device  
 
Fig. 2 
The software of the virtual-reality based rehabilitation. 
A: Leap Motion Blocks ® 
Leap Motion Blocks ® offers a platform in which the subjects can play freely with blocks- they can 
create blocks, grab, push, pile and throw blocks around. The subjects are guided to perform a sequence 
of actions in the game. First, they need to pinch and stretch with both of their hands to create several 
blocks. Then, they need to push, pile and throw blocks around. 
B: Slum ball VR tournament ® 
In Slum Ball VR Tournament®, objects such as tin cans and balls will keep flying towards the player, 
and the player needs to hit the upcoming objects back to specific location. 
C: VR Sports- basketball ® 
D: VR Sports- soccer ® 
In VR Super Sports ® 10th edition- Basketball, player needs to keep grabbing a basketball and 
throwing it out into the basket while the participant becomes the goalkeeper of a soccer game and 
needs to use both of their hands to block the upcoming ball. 
 
 
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