JMIR SERIOUS GAMES

Wu et alOriginal Paper

Using Virtual Reality in a Rehabilitation Program for Patients
With Breast Cancer: Phenomenological Study
Shih-Chung Wu1, MD; Chia-Wen Chuang2,3, MSN; Wen-Chun Liao4,5, PhD; Chung-Fang Li2, MSN; Hsin-Hsin
Shih4,5, PhD
1

Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
3
Department of Public Health, China Medical University, Taichung, Taiwan
4School of Nursing, College of Healthcare, China Medical University, Taichung, Taiwan
5Department of Nursing, China Medical University Hospital, Taichung, Taiwan
2

Corresponding Author:
Wen-Chun Liao, PhD
School of Nursing
College of Healthcare, China Medical University
100 Section 1 Jingmao Road, Beitun District
Taichung, 406040
TaiwanPhone: 886 4-22053366
Email: wcl@mail.cmu.edu.tw

Abstract
Background: Surgery is an essential treatment for early-stage breast cancer. However, various side effects of breast cancer
surgery, such as arm dysfunction and lymphedema, remain causes for concern. Rehabilitation exercises to prevent such side
effects should be initiated within 24 hours after surgery. Virtual reality (VR) can assist the process of rehabilitation; however,the feasibility of applying VR for rehabilitation must be explored, in addition to experiences of this application.
Objective: This study explored patients’ attitudes toward and experiences of using VR for their rehabilitation to determine thefeasibility of such VR use and to identify potential barriers.
Methods: A phenomenological qualitative study was conducted from September to December 2021. A total of 18 patientswith breast cancer who had undergone surgical treatment were interviewed using open-ended questions. The Colaizzi 7-stepprocedure for phenomenological analysis was used for data analysis. To ensure high study reliability, this study followed
previously reported quality criteria for trustworthiness.
Results: Three themes were identified: (1) VR was powerful in facilitating rehabilitation, (2) early and repetitive upper limb
movements were an advantage of VR rehabilitation, and (3) extensive VR use had challenges to be overcome. Most of
the interviewed patients reported positive experiences of using VR for rehabilitation. Specifically, VR helped these patients
identify appropriate motion and angle limits while exercising; in other words, knowledge gained through VR can play a keyrole in the rehabilitation process. In addition, the patients reported that the use of VR provided them company, similar towhen a physiotherapist is present. Finally, the gamified nature of the VR system seemed to make VR-based rehabilitation
more engaging than traditional rehabilitation, particularly with respect to early rehabilitation; however, the high cost of VR
equipment made VR-based rehabilitation difficult to implement at home.
Conclusions: The interviewed patients with breast cancer had positive experiences in using VR for rehabilitation. The highcost of both VR equipment and software development presents a challenge for applying VR-based rehabilitation.
JMIR Serious Games 2024;12:e44025; doi: 10.2196/44025
Keywords: breast cancer; rehabilitation; virtual reality; VR; virtual reality design process; VR design process; feasibility;
accessibility

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JMIR SERIOUS GAMESIntroduction
Breast cancer is a major global health problem. In Taiwan,
more than 10,000 women are diagnosed with breast cancer every year; approximately 80% of these diagnoses are
early-stage breast cancer and most require surgical treatment[1]. More than 1 in 5 women who are breast cancer survivors
might eventually develop upper limb lymphedema [2]. In
addition, the life expectancy of patients with stage 0 to stage
3 breast cancer is 20 to 32 years [3]. Breast cancer treatments
include surgery, radiation therapy, chemotherapy, endocrine
therapy, and targeted therapy. Because of advancements indiagnosis and treatment in recent years, the 5-year relative
survival rate of breast cancer is now higher than 80% [4].
However, both ancillary dissection and axillary radiation are
known to increase the incidence of lymphedema and axillary
web syndrome [5]; associated symptoms include pain, upper
extremity weakness, paresthesia, and limited range of motion(ROM), each of which can not only delay the commencement of radiation therapy but also lead to patients being
unable to perform basic self-care tasks. This is a problem
because less-mobile patients are more likely to experienceside effects after surgery; for example, a frozen shoulder is aside effect that commonly occurs in the short term as a resultof immobility after surgery [6]. These associated symptoms
may persist for up to 1.5 years after surgery and therefore
predispose patients to depression and other mental healthconditions that can become long-term health problems [7,8].
Studies have suggested that the early commencementof postoperative rehabilitation exercises, including upper
extremity abduction and flexion exercises, can reduce therisk of upper extremity pain and dysfunction [9,10]. Although
the optimal time to start ROM exercises remains unclear,
one study suggested that activity recovery tends to be more
successful following earlier rehabilitation [11]. Typically,
rehabilitation is recommended to be commenced within thefirst 7 days after surgery, with shoulder ROM initiallybeing limited to 90° [12]. Hence, a patient’s willingness toundergo rehabilitation after surgery to prevent their arms frombecoming motionless is essential. However, after surgery, apatient’s motivation to undergo physical rehabilitation tends
to be low because of wound pain and fear of movement[13,14].
Virtual reality (VR) can reduce fear of movement
and improve motivation to engage in rehabilitation. In
addition, VR can promote compliance and rehabilitation
success among patients [15-17]. Furthermore, VR appears
to be effective in increasing shoulder ROM compared withstandard physiotherapy for postoperative rehabilitation inpatients with breast cancer [18]. The use of VR for rehabilitation is not new; however, feasibility studies that use
VR to provide individualized, progressive practice for arm
movements after surgery for breast cancer remain scarce.
Feasibility research is often conducted prior to a randomized
controlled trial [19]. In recent years, most studies investigating VR for rehabilitation in patients with breast cancer haveused a randomized controlled design and have been prospective, adequately powered, and methodologically rigorous.
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Wu et alNevertheless, according to According to the recommendations of the VR-CORE (Clinical Outcomes Research Experts)[20], the development of new VR content should include
3 phases: VR1 to VR3. VR1 provides guidance for thedevelopment of new VR content; VR2 constitutes earlytesting related to the feasibility, acceptability, tolerability,
and initial clinical efficacy of VR; and VR3 evaluates theefficacy of VR in comparison with controls. Bypassing
feasibility and accessibility tests to jump immediately toclinical trials may lead to a gap between program development and bedside application and cause barriers to implementing VR in practice. Even though there is sound evidence
that VR is effective in improving rehabilitation effects inpatients with breast cancer, VR is not currently used in many
clinical settings. According to Brennan et al [21], barriers
to the implementation of VR include usability problems,
cognitive limitations, cost, a lack of patient safety, low patient
motivation, and negative patient responses. In addition, VR’s
unfamiliarity to many patients may dampen their willingness
to use VR [22]; thus, patients’ attitudes, experiences, andopinions related to VR must be understood. Further explorations of feasibility and accessibility are recommended for theuse of VR in health care [23,24].
To the best of our knowledge, most studies regarding
postoperative rehabilitation in patients with breast cancer
have been clinical trials (ie, VR3) that evaluated only
treatment effects, such as pain, grip power, muscle power, orROM; VR2 studies are skipped. This study used a phenomenological approach to investigate the feasibility andexperiences of a VR rehabilitation program (ie, this was a
VR2 study) in patients with breast cancer. Therefore, thisstudy was conducted to answer the following questions: (1)What are the lived experiences of patients using VR forarm rehabilitation? (2) How do they perceive the process? In
answering these questions, this study determined the clinicaleffectiveness of and barriers to VR rehabilitation as a prelude
to a definitive randomized controlled trial.

Methods
Design and Development of the VR
SystemThe VR system in this study was designed and developedin accordance with the VR–CORE–VR1 guidelines [20].
Our VR design team was a multidisciplinary team comprising users and technicians. The rehabilitation program wasdeveloped in 3 stages. The first stage was based on inspiration gained through empathy. Specifically, interviews were
held with 2 patients who were invited to share their rehabilitation experiences and express their perspectives andopinions to facilitate the design of an effective VR-based
treatment program. The interview questions in this stage
considered (1) smart device use behavior and (2) willingness and acceptability to use VR rehabilitation systems.
The second stage involved ideation through team collaboration. Specifically, our team comprised experts in surgery,rehabilitative physicians, and software engineering, as well
as a case manager. Innovative ideas were generated through
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Wu et almethods such as brainstorming and collective ideation, andthe ideas that were most suitable for prototyping were thencompiled. The third stage involved prototyping based on user
feedback. Specifically, further discussions were held withthe aforementioned 2 patients to obtain further information.
Our team then built prototypes to test 3 VR rehabilitation
exercises prior to implementation (Table 1). Ultimately, we
extracted 3 key sets of limb motions that are described asfollows. The first motion was a Whac-A-Mole–like game thatinvolved the abduction of the shoulder (no more than 90°).
The second motion was wiping a table and involved external
forearm rotation. The third motion was combing one’s hairand involved flexion of the shoulder (no more than 90°)
(Figures 1-3). This study used the PC-based Oculus Quest 2
head-mounted display (HMD) to provide the most immersive
VR experience possible.

Table 1. Summary of our design principles and strategies based on recommendations for best practices in VR1 (virtual reality phase 1) studies [20].
Design principles and strategies
Inspiration through empathy, recruitment,
observation, patient interviews, and expert
interviews
Ideation through team collaboration, sharing
stories and notes, and generating ideas

Prototyping through continuous feedback,building a prototype, and repeatedly testing
the prototype

Our practices
Two patients with breast cancer who had experienced axillary web syndrome were invited forindividual interviews regarding their relevant needs, experiences, fears, and expectations; a group
discussion was then conducted to determine the patients’ needs.
We analyzed, aggregated, and discussed the stories and data obtained in the previous phase. Our
team then formulated 10 ideas for rehabilitation actions. After considering the restrictions on drainage
tube indwelling the day after surgery (shoulder joint movement must not exceed 90°), we extracted
3 motions: (1) Whac-A-Mole, which involved abduction of the shoulder; (2) wiping a table, which
involved external forearm rotation; and (3) combing one’s hair, which involved flexion of theshoulder.
We drew the height of a mallet on a wall and placed a picture of a gopher on a table to simulate
the Whac-A-Mole game. For the wiping the table and combing hair scenarios, we used a table and acomb, respectively, and we then collected feedback from the patients after their first use. Our teamfound that the Whac-A-Mole game was difficult to perform owing to the different heights of thepatients and seats (eg, a patient may need to raise their shoulder angle excessively to pick up themallet, leading to pain and an inability to perform the exercise, forcing it to be abandoned). Thus,
the software engineer adjusted the height of the controllable mallet and the adjustable gopher table tomeet the need of each individual patient.

Figure 1. Whac-A-Mole–like scenario.

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Wu et alFigure 2. Wiping a table scenario.

Figure 3. Combing one’s hair scenario.

Study Design

Setting

This qualitative study was guided by the phenomenological methodology; it focused on investigating the perceived
experience of using VR rehabilitation and then used an
inductive approach and the Colaizzi [25] interview data
analysis method to identify themes from the VR rehabilitation
experiences.

This study was conducted at a medical center in Taiwan thatreceives up to 20 new patients with breast cancer per month.

Ethics Approval
Ethical approval for this study was granted by the Human
Trials Ethics Committee of Chang Gung Memorial Hospital,
Taiwan (202001617A3C501). All the participants provided
written informed consent to participate in this study.
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Participants and Recruitment
The criteria for participation in this study were as follows:(1) a new diagnosis of breast cancer and being hospitalized
for surgical treatment; (2) being aged 20 to 65 years; (3)being able to read and speak Mandarin Chinese or Taiwanese; (4) being willing to use a wearable VR HMD andhaving sufficient cognitive ability to understand and follow
instructions, as well as to interact with the VR environment;(5) having sufficient physical ability (self-reported) to use
the VR equipment in the VR rehabilitation program; andJMIR Serious Games 2024 | vol. 12 | e44025 | p. 4
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JMIR SERIOUS GAMES(6) being willing to be interviewed. After surgical treatment for breast cancer, patients were invited to a rehabilitation consultation to ask about their willingness to try VR
rehabilitation and were recruited to participate in this study.
The recruitment period ran from September to December
2021, with 18 patients interviewed.

Data Collection
First, the participants filled out a questionnaires on demographic data (including age, gender, and type of breast
surgery), the Distress Thermometer (DT) questionnaire, andthe Chinese Health Questionnaire–12 (CHQ-12). The DT
is a visual analog scale for routine screening for distressin all patients with cancer; scores range from 0 (indicating
no distress) to 10 (indicating extreme distress). A cutoff
score of ≥7 is optimal for distress in patients with a new
diagnosis [26]. The CHQ-12 was modified from the General
Health Questionnaire–12, a widely used psychometric test
for screening mental problems, with a score of ≥4 indicating
psychological distress [27].
After completing the questionnaires, a face-to-faceinterview was conducted with each participant for approximately 30 minutes. Interview guides were developed by the
research team, which included an expert in qualitative studies
and a clinical nurse specialist in breast cancer. After thecontent of the first interview was analyzed, the interview
questions were discussed and modified with the research
team.

Wu et alproduce an exhaustive description. Seventh, the results were
presented to each participant for feedback and to verify theiraccuracy.

TrustworthinessTo enhance the trustworthiness of our study, we referredto the Guba and Lincoln [29] quality criteria of credibility,transferability, dependability, and confirmability.
To establish confidence in the credibility of the findings,
triangulation was used to examine the consistency of thedata. Researchers presented their summaries of the categories
and themes from data analysis and discussed any uncertainty
about any category or theme by replaying and reanalyzing theinterview recording.
High transferability was ensured through the interview
process, including the stability of observations and theinterrater reliability. As an interviewer, the researcher wasattentive to the interviewees’ experiences and avoided bias
arising from their values and beliefs. The interviewer wasconscious about avoiding misperceptions about what theinterviewees were saying to ensure the stability of observations. There was only 1 interviewer, hence interrater
reliability was not measured.
The study had high dependability, as the data collecting procedures were approved by an expert in qualitative
methodology, and the themes and subthemes that emerged
were consistent among all researchers after the coding andrecoding procedure during the data analysis.

During the interview process, the researchers actively
listened and continuously clarified any perspectives andmeanings that the participants wanted to express. Participants
were allowed to freely express their views. All interviews
were audiorecorded. After the data analysis, the researchers
reviewed the data with the patients to ensure data accuracy
and completeness.

Finally, during the data analysis stage, 3 researchers who
were not part of the study team confirmed the collected databy distinguishing between the units of the main themes andsubthemes to verify the main themes’ theoretical saturationand thus achieved confirmability.

Inductive Content Analysis

Results

According to Kyngäs [28], an inductive approach, which iscommon in qualitative research, should be used when noprior research has addressed a specific phenomenon or if
existing knowledge is fragmented. Because prior studies had
not investigated the experiences of patients with breast cancer
to evaluate the effectiveness of VR-based rehabilitation, ourstudy used an inductive approach to content analysis, which
involved data reduction, data grouping, and, finally, concept
formation. The content was analyzed with the Colaizzi [25]phenomenological analysis method, which involves a 7-stepprocedure for content analysis. Specifically, 3 researchers
analyzed the data and grouped them into themes to enhancecomprehension. First, the interview transcript was read to
obtain an idea of its overall meaning. Second, a researcher
extracted significant statements relevant to the purpose of
the study. Third, each statement considered meaningful wasrecorded for accurate representation of the research data.
Fourth, the researcher classified significant statements into
categories based on their meaning. Fifth, the researchergrouped similar categories together and organized theminto themes. Sixth, all themes presented were combined tohttps://games.jmir.org/2024/1/e44025

Characteristics of Participants
Table 2 shows the participants’ characteristics. The mean ageof the participants was 46.66 (SD 8.05) years; 17 participants
were female (95%) and 1 was male (5%); 11 were married (61%); 11 (61%) were full-time workers; and 7 (39%)
were housekeepers or had no formal employment. Regarding
the types of surgery received, 9 participants (50%) underwent mastectomy and sentinel lymph node biopsy, 4 (23%)
underwent mastectomy and axillary lymph node dissection,
2 (11%) underwent mastectomy and reconstruction, and 3(16%) underwent modified radical mastectomy. All participants had DT scores less than 7, indicating no distress. In
the CHQ-12 items, some participants reported having shaking
or numbness of limbs (n=3, 17%), losing a great deal of
sleep because of worry (n=4, 22%), and losing confidence
in themselves (n=4, 22%) (items 4, 5, and 8). However,all participants had CHQ-12 scores less than 4, indicating
no mental problems. Finally, 7 (39%) and 11 (61%) of theparticipants reported moderate (4-6) and mild (1-3) wound
pain on the Numeric Rating Scale for Pain, respectively.
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Wu et alTable 2. Distribution of sociodemographic variables of participants (N=18).
Variables
Sex

Female17 (95)

Male

1 (5)

Age group (years)
35-44

6 (33)

55-64

4 (3)

45-54

8 (44)

Educational level

Distress

Participants, n (%)

Senior high school

9 (50)Yes (DTa score ≥7)

0 (0)College

9 (50)No (DT score <7)

10 (100)

Mental problems

Yes (CHQ-12b score ≥4)0 (0)No (CHQ-12 score <4)

Numerical Rating Scale for Pain score
1-3
4-6

18 (100)
11 (61)
7 (39)

Marital status

Married or in a domestic partnership

11 (61)

Separated or divorced

2 (11)

SingleEmployment status

Employed

5 (28)

11 (61)

Unable to work

7 (39)

Type of breast surgery

Mastectomy with sentinel lymph node biopsy

9 (50)

Mastectomy with reconstruction
Modified radical mastectomy

2 (11)
3 (16)

Mastectomy with axillary lymph node dissection

aDT: Distress Thermometer.
bCHQ-12: Chinese Health Questionnaire–12.

Themes
The following 3 themes were inductively extracted fromthe interview data: (1) VR was powerful in facilitating
rehabilitation, (2) early and repetitive upper limb movements

4 (23)

were an advantage of VR rehabilitation, and (3) extensive
VR use had challenges to be overcome. Tables 3-5 present
these themes in greater detail alongside their subthemes andinterviewee statements.

Table 3. Subthemes and interviewee quotes related to theme 1: virtual reality (VR) was powerful in facilitating rehabilitation.
Subthemes
Obtaining knowledge

Companionshiphttps://games.jmir.org/2024/1/e44025

Quotes• “It turns out that some actions are unsuitable [because of the drainage tube]; after use, I have a betteridea of the angle of movement” (participant 2).
• “After practicing with this system [VR] and being discharged from the hospital, I know that someactions are not suitable for me to do, so I will not do them randomly” (participant 3).
• “I was anxious, thinking that not moving my arms was suitable for wound healing” (participant 13).
• “I can adjust my range of motion according to my tolerance, and I will not feel frustrated”(participant 17).
• “This way of rehabilitation [VR] is like a kind of support for me when exercising because
thephysiotherapist does not always accompany me” (participant 9).

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JMIR SERIOUS GAMESSubthemes

Wu et alQuotes• “The usage process is very simple. I think it is well executed in the hospital and I can concentrate onpracticing” (participant 5).
• “The physiotherapist was very busy and left after teaching me the rehabilitation movement, so I had
to do it independently” (participant 11).
• “I didn’t understand what this was at first, and I was a little scared, but it turned out that I was doing
rehabilitation while playing games” (participant 1).

Table 4. Subthemes and interviewee quotes related to theme 2: early and repetitive upper limb movements are an advantage of virtual reality (VR)rehabilitation.
Subthemes
Reduced fear of movement

Enhanced motivation to engage inrehabilitation

Quotes• “The VR rehab game method is more fun than the traditional rehab method because it lets me know I
need to do rehab exercises; I think I can do it a few more times” (participant 1).
• “My time in the hospital was short, and it was a pity that I didn’t do VR many times” (participant 6).
• “I experienced no pain or discomfort during the VR rehab; I want to do it a few more times”(participant 7).
• “After playing Whac-A-Mole, I attempted to move my arm” (participant 11).
• “While using it, I temporarily forgot that I had surgery” (participant 14).
• “Initially, I was terrified of moving my arms, but now, I’m having so much fun that I don’t realize
I’m doing rehab” (participant 18).
• “The VR program can be performed as soon as possible; I have been performing VR for seven days
since surgery. In the execution of the Whac-A-Mole and wiping the table exercises, I did not have toomuch discomfort or pain, and I am doing better and better” (participant 15).
• “Although there is no VR at home, I can continue to do the VR movements, and I will not worry
about my arm’s limited range of motion in the future” (participant 16).
• “After using VR for rehabilitation, I found that my condition was not as bad as I thought” (participant
7).

Table 5. Subthemes and interviewee quotes related to theme 3: extensive virtual reality (VR) use has challenges to be overcome.

Subthemes
QuotesSafety of the real-world environment• “I was initially scared because I had never used VR” (participant 4).
• “Wearing a VR HMD, I can’t see the outside world, so I’m worried about hitting something”(participant 5).
• “VR rehabilitation equipment is too expensive to buy and can only be used in hospitals” (participant
Cost of virtual reality rehabilitation5).
equipment is too high to extend to• “Without equipment, there is no way to use VR for rehabilitation” (participant 8).
home use• “VR rehabilitation can only be used in hospitals; at home, we use traditional rehabilitation methods”(participant 17).
• “I hope to rent VR equipment for my home so I can use it anytime” (participant 18).
• “Although there is the Switch, finding a suitable sports game for rehabilitation is difficult”(participant 9).
Motion sickness• “After wiping the table, I felt a little dizzy” (participant 10).
• “My eyes constantly roll when wiping the table, which is a little uncomfortable” (participant 9).

VR Was Powerful in Facilitating
Rehabilitation
Overview
A key concept of this inductive theme was the “power”
obtained from knowledge and companionship. Related
subthemes and interviewee statements are presented in Table
3.

Companionship
Most of the participants stated that playing games enabled
them to feel as though they were interacting with health care
professionals and experiencing companionship and support.

Early and Repetitive Upper Limb
Movements: An Advantage of VR
Rehabilitation

Obtaining Knowledge

Overview

A total of 12 (70%) of the participants described how the
VR content helped them learn the most helpful rehabilitation
movements and the angular limitations of their exercises
and thus enabled them to perform these exercises safely andrelatively early in the rehabilitation process.

After surgical treatment for breast cancer, rehabilitative
exercises must be performed early. In this study, wound painand discomfort during such exercises were the main concernsof the participants, leading to fear of movement. Related
subthemes and interviewee statements are presented in Table
4.

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JMIR SERIOUS GAMESReduced Fear of Movement
A total of 14 (80%) of the participants stated that the gamified
design of VR rehabilitation made it more interesting than
traditional rehabilitation, while 7 of the patients experienced
moderate pain after surgery. However, during the use of
VR for rehabilitation, these patients reported no wound pain
or discomfort. In addition, their willingness to engage inrehabilitation was enhanced by the second day after surgery.

Enhanced Motivation to Engage in
Rehabilitation
Most of the participants described an immersive virtualenvironment that facilitated the performance of earlyrehabilitative exercises. In addition, the participants were
subsequently able to continue performing the aforementioned
3 rehabilitation movements at home without VR.

Extensive VR Use Has Challenges to Be
Overcome
Overview
Most of the patients had safety concerns, mainly because
while wearing the VR HMD, they were unable to pay
attention to the environment around them. Consequently,
some of the patients initially felt apprehensive, fearing
collisions with nearby objects. In addition, high equipment
costs limited the accessibility of the equipment for homeuse, and many of the patients expressed disappointment thatthey were able to use the system only in hospital. Related
subthemes and interviewee statements are presented in Table
5.

Safety of the Real-World Environment
While the patients were wearing the VR HMD and engaging
in VR-based exercise, they were unable to pay attention to theenvironment around them. Thus, patients had the not-unfounded fear that they might collide with nearby objects andwere initially apprehensive. Therefore, patients should be in aclutter-free environment when engaging in VR rehabilitation.

Cost of VR Rehabilitation Equipment Is Too
High to Extend to Home Use
The cost of VR equipment for rehabilitation is high, making
it relatively inaccessible for home use. Each new technology
faces the problem of high equipment cost in its initial stage,
and similarly, the main problem for most of the participantsin this study was that they wanted to continue using therehabilitation equipment at home. They indicated that they
thought it was a pity that the system could be used only in
hospital.

Motion Sickness
We found that 3 of the participants reported the side effect of
motion sickness after performing the wiping table exercise.

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Wu et alDiscussion
Principal Findings
To the best of our knowledge, this study is the first phenomenological study to investigate the feasibility of an immersive
VR experience for facilitating postoperative rehabilitationin patients with breast cancer. Through inductive thematic
analysis, our study found VR to be an effective and suitableintervention for our patient population. Tables 3 and 4 address
feasibility in relation to 2 of the 3 inductive themes of thisstudy: “VR was powerful in facilitating rehabilitation” and“early and repetitive upper limb movements are an advantage
of VR rehabilitation.” Table 5 reveals the key finding that thehigh costs of VR hardware and software limit its at-home use.
These results further support the recommendations of the VR
CORE group [20]. However, the high cost of VR equipment
remains a concern.

VR Was Powerful in Facilitating
Rehabilitation
This study found that “power” was an essential concept andthat power was cultivated through knowledge and companionship. One key finding related to this inductive theme was
the knowledge obtained by the individual. In our study, mostof the participants were skeptical about their early postoperative rehabilitation, and some had no idea how to proceed with
it; however, through VR, these patients gained information
about rehabilitation, which then led to behavioral changes. A
previous study noted the importance of people’s need to know
which approach they should adopt to improve their health[30]. In addition, most patients with breast cancer desire
information concerning recovery details; in particular, theywant real-time, transparent information regarding appropriate rehabilitative measures [21]. Our findings were consistent with those of the 2 aforementioned studies. Anotherpresent finding was related to companionship; specifically,
the participants reported that they felt as if a medicalcare team was with them in their rehabilitation in the VR
world. This finding is notable because not every patientwith breast cancer receives a rehabilitation exercise consultation after surgery. Our interactive VR system provides clear
information regarding the commencement and completion ofrehabilitation exercises, and its prompts align with how theclinical rehabilitation program operates (eg, 20 prompts foreach motion). The literature notes that an ideal user experience must include interaction with VR applications in orderto encourage and support users to complete clinical activities;
this assertion is consistent with our findings [31].

Early and Repetitive Upper Limb
Movements: Advantage of VR
Rehabilitation
VR elicited engagement in early postoperative rehabilitationin most of this study’s patients, seemingly stemming fromtheir reduced fear of movement and their enhanced motivation. Early postoperative rehabilitation in patients who
have undergone breast cancer surgery aims to improve
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shoulder mobility, arm mobility, or both. VR is believed to
be as effective as conventional physiotherapy in improving
upper limb function to facilitate the maintenance of activities of daily living [32]. Some of the participants in thisstudy were initially apprehensive to undertake postoperative
rehabilitation primarily because of fear related to insufficientknowledge of the appropriate degree of movement. Nevertheless, our VR rehabilitation system was based on the concept of gamification; the participants who used the systemwere attracted to the game screen, and consequently, their
negative feelings—including fear, pain, and discomfort—
were temporarily alleviated. In this manner, the VR system
considerably enhanced the participants’ motivation to engage
in rehabilitation; this finding was consistent with those ofprevious studies [18,33]. In addition, the game design canbe adjusted according to the needs of the patient to prevent
patients from giving up on movements that are either difficult
or so simple that the desired training outcomes cannot be
achieved by performing them.

Challenges of Extensive VR Use to Be
Overcome
The participants in this study were required to wear HMDs;
thus, they could not see their surroundings during rehabilitation. Related studies that have recommended VR have statedthat when using such technology, a space of at least 70 cm ×70 cm is required; however, in our study, the participants took
a seated position to minimize the risk of tripping and thus
needed only to pay attention to whether the seat back wasaffecting exercise safety. Although research has shown thatthe cost of HMDs has fallen in recent years [15], VR devices
remain unaffordable for many people in Taiwan. Therefore,
even if patients with breast cancer are interested in using thisemerging technology for rehabilitation, doing so without an
HMD is difficult. In addition, the development and maintenance costs of VR software and hardware are high, and thus,
the cost of VR equipment remains a challenge for large-scale
implementation in postoperative rehabilitation.
Motion sickness (MS) is a common physiological response
to VR immersion [34]. Previous studies have shown thatbehavioral and dietary strategies and physical therapy, suchas listening to music or chewing gum [35], are effective
in alleviating MS symptoms. Although each movement in
our VR rehabilitation system was accompanied by musicwith a brisk tempo, 3 of the patients in this study still
experienced MS due to unsuitable seat height. A previous

Wu et alstudy demonstrated that positive emotions can relieve MS[36]; we found that most patients have positive emotions
while using VR for rehabilitation. Accordingly, this paper
suggests that the use of VR should be combined withemotional assessments to effectively prevent MS. With
regard to feasibility, we found that the present VR system met the patients’ needs, conformed to their values,
and satisfied their expectations. The system also provided
an engaging and interactive rehabilitation environment that
stimulated the patients’ motivation to engage in early andcontinuous rehabilitation and, in turn, reduced their risk ofdeveloping defensive functional impairments. Nevertheless,the accessibility of VR proved to be a challenge becauseof the difficulty of using VR technology at home. Thus,
such interventions may tend to be limited to in-hospitaluse because not every patient can afford to purchase VR
equipment and software.

Study Limitations
This study has some limitations. First, we did not conduct
a pilot study of the interview guide. However, after thecontent of the first interview was analyzed, the interview
questions were discussed and modified with the researchteam to identify and address any potential issues in the datacollection methods. It may be recommended to incorporate apilot study in future research to ensure validity and robustness. Second, the development of VR technology to facilitate
postoperative rehabilitation in patients with breast cancer isstill in its infancy. In this study, only 3 rehabilitation exercises
were developed and clinically tested. The facilitators of andbarriers to rehabilitation were investigated. To determine theclinical efficacy of the proposed VR system, a large-scalerandomized controlled trial is needed.

Conclusion
Feasibility research related to health care is crucial for
generating novel ideas and improvements to provide more
effective care for patients. From the perspective of this study,
rehabilitation is an iterative, active, and educational processof problem-solving that must focus on a patient’s behavior.
VR technology was effective in facilitating rehabilitationby providing knowledge and companionship to participants.
It helped reduce fear of movement and enabled early andrepetitive upper limb movements. However, safety concerns,
high equipment costs, and potential side effects like MS werereported as challenges to extensive VR use.

Acknowledgments
We are grateful to Mei-Ling Li and Su-Fang Li in for their informative comments during the development of the virtual reality
rehabilitation system. This research was partially supported by Kaohsiung Chang Gung Memorial Hospital, part of the Chang
Gung Medical Foundation, Taiwan (grant CMRPG8L0081), for the development of the virtual reality system and partially
supported by the China Medical University Project (grant CMU108-MF-21).
Authors’ Contributions
SCW and CWC were responsible for the study design and coordination. CWC, HHS, and CFL extracted the data. SCW and
WCL drafted the manuscript. All authors have contributed to, read, and approved the final manuscript.

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Wu et alConflicts of Interest
None declared.
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Abbreviations
CHQ-12: Chinese Health Questionnaire–12
CORE: Clinical Outcomes Research Experts
DT: Distress Thermometer
HMD: head-mounted display
MS: motion sickness
ROM: range of motion
VR: virtual reality

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Wu et alEdited by Gunther Eysenbach, Tiffany Leung; peer-reviewed by Sissel Schär, Xiaoyu Liu; submitted 03.11.2022; final
revised version received 31.10.2023; accepted 30.12.2023; published 16.04.2024
Please cite as:
Wu S, Chuang C, Liao W, Li C, Shih H
Using Virtual Reality in a Rehabilitation Program for Patients With Breast Cancer: Phenomenological StudyJMIR Serious Games 2024;12:e44025
URL: https://games.jmir.org/2024/1/e44025
doi: 10.2196/44025© Shih-Chung Wu, Chia-Wen Chuang, Wen-Chun Liao, Chung-Fang Li, Hsin-Hsin Shih. Originally published in JMIR
Serious Games (https://games.jmir.org), 16.04.2024. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The
complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright andlicense information must be included.

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