Effects of Exergame in Patients at High Cardiovascular Risk.
Condition: Aerobic Exercise; Cardiorespiratory Fitness; Cardiovascular Diseases
MeSH terms: Cardiovascular Diseases
Study type: Interventional

Summary: 
      Background: Exergaming is thought to have a similar effect on cardiovascular (CV) responses
      as aerobic fitness activities. The aim of this study was to compare the cardiovascular
      effects of exergaming and traditional treadmill exercises in patients with high CV risk.

      Methods: Sixty-four patients with high CV risk were randomized among exergame (EG: n = 22),
      treadmill (TM: n = 22), and control (n=20) groups. The EG group was engaged in the
      running-based exergame using Exer Heart and the TM group walked or jogged on a treadmill.
      Cardiorespiratory fitness (CRF), brachial artery flow-mediated dilation (FMD), endothelial
      progenitor cell numbers (EPCs), epicardial fat thickness (EFT), metabolic parameters and
      anthropometric parameters were measured in patients before and 3 months after the training.
    

Detailed description: 
      Introduction Cardiovascular (CV) disease is a major cause of premature death and morbidity
      worldwide. It is widely known that age, sex, hypertension, dyslipidemia, diabetes, and
      smoking are the main risk factors which can cause CV disease[1]. Many other CV risk factors
      and their markers have been identified in recent studies. Among these, cardiorespiratory
      fitness (CRF) and endothelial dysfunction are strong predictors of the risk of developing CV
      disease[2, 3]. In addition, epicardial adipose tissue is a visceral fat which accumulates in
      the epicardium of the heart, and has recently been considered as a new index of CV risk[4,
      5].

      It is well established that regular exercise (physical activity) is effective in preventing
      and treating CV risk factors by improving health-related fitness[6]. Despite the health
      benefits of regular exercise, many patients with CV risk factors often do not participate in
      regular exercise for reasons including lack of time, motivation, or interest.

      In recent years, a new exercise program called exergame has been developed as a result of the
      technical advancements in gaming and virtual reality programs. Exergames are interactive
      video games which provide the opportunity to increase physical activity by requiring movement
      of the entire body[7] and are proving to be an alternative exercise modality. In addition,
      exergames are used to fight pediatric obesity[8], improve senior physical performance[9], and
      facilitate poststroke motor rehabilitation[10]. However, only a few studies have examined the
      effects of exergaming on CV or chronic disease related risk factors. Furthermore, in order
      for exergames to progress as a rehabilitation program for the prevention and treatment of CV
      disease in the future, it is necessary to compare it to traditional aerobic exercises.

      Therefore, the aim of this study was to compare the effects of exergame versus treadmill
      exercises on cardiorespiratory fitness (CRF), endothelial function, epicardial fat,
      cardiometabolic, and anthropometric parameters in patients with high CV risk.

      Methods Participants and Study Design This single-center study was approved by the
      Institutional Review Board of Kosin University Gospel Hospital (Protocol no. KUGH
      2016-06-029). Sixty-four female patients with a Framingham CV disease 10-year risk score
      above 20% were enrolled in this study[11, 12]. All participants voluntarily participated in
      the study and signed a consent form agreeing to the study process. In order to reduce the
      margin of error due to sex differences and physiological responses to the greatest degree
      possible, only post-menopausal women were recruited considering the hormonal changes which
      occur during menstruation. The inclusion criteria were post-menopausal women aged ≤80 years
      who did not have a history of participating in regular exercise within the past 3 months. The
      exclusion criteria were resistant hypertension, any systemic disease including significant
      liver disease, neurologic disorders, malignant disease, renal failure, chronic obstructive
      pulmonary disease, valvular heart disease, a positive treadmill test, a history of acute
      coronary syndrome, myocardial infarction or any revascularization procedure, or
      musculoskeletal patients for whom exercise was impossible. Patients were randomized to the
      exergame (EG: n=22), treadmill (TM: n=22), or control (n=20) groups.

      All subjects were tested over a two-day period before and after 3 months of training. On the
      first visit, the subject's height, weight, waist circumference (WC), blood sampling, and
      blood pressure (BP) were obtained after 8 hours of fasting. On the second visit, brachial
      artery flow mediated dilatation (FMD), epicardial fat thickness (EFT) measured by
      echocardiography, and CRF tests were performed after 4 hours fasting. In addition, subjects
      were asked to refrain from excessive exercise, overeating, and caffeine consumption for 24
      hours before all tests.

      Cardiorespiratory Fitness CRF was assessed using a treadmill testing protocol[13]. The test
      was carried out on a programmable treadmill (GE CASE T2100; GE Medical Systems, Milwaukee,
      WI, USA) using a Ramp protocol until exhaustion in a temperature-controlled room (21-23°C).
      The cardiac rhythm was continuously monitored with a 12-lead electrocardiogram system. BP
      monitoring was carried out using an automated device (Suntech Tango; Suntech Medical,
      Morrisville, NC, USA). Ventilation (VE), oxygen uptake (VO2), and carbon dioxide output
      (VCO2) were measured using a computerized system (Cosmed K4b2, Cosmed Ltd., Rome, Italy). The
      termination of the test occurred when the subject's rated perceived exertion (RPE) was
      greater than 17, the respiratory exchange ratio was greater than 1.05, the oxygen intake had
      plateaued despite an increased workload, or the subject requested test termination. The
      highest recorded oxygen intake was defined as the VO2 peak of each person.

      Flow-Mediated Dilation FMD was measured in the brachial artery according to current
      guidelines[14]. After the subject had relaxed sufficiently for 10 to 20 minutes in the supine
      position, the baseline value was measured. Two-dimensional ultrasonography (Vivid 7; General
      Electric, Horten, Norway) was performed using a 10-MHz linear-array transducer probe. After
      the baseline measurement, reactive hyperemia was induced by the inflation of a pneumatic cuff
      to 180-200 mmHg (50 mmHg higher than SBP) for five minutes on the forearm. For the peak
      diameter of the brachial artery, the diameter was recorded 40-60-seconds after sudden
      deflation of the cuff. The percent FMD induced by reactive hyperemia was expressed as the
      relative change from baseline (%FMD = 100 × [diameter after hyperemia-baseline
      diameter]/baseline diameter). At the peak of the R wave of the surface electrocardiogram,
      each diameter was measured three times during two heartbeats and the average values were used
      for the final analysis.

      Epicardial Fat Thickness Epicardial adipose tissue was measured by assessing EFT through
      echocardiography[15]. Echocardiographic assessment of the EFT was defined as the echo-free
      space between the outer wall of the myocardium and the visceral layer of the pericardium.
      Standard 2-dimensional echocardiography was performed with the subject in the left lateral
      decubitus position using a 3.5 MHz transducer (Philips iE33, Philips Medical Systems,
      Bothell, WA, USA). The echocardiographic EFT test was conducted vertically from the free wall
      of the right ventricle at the end-systolic point in 3 heart cycles. One of the major problems
      with EFT measurements is the inconsistency of measurement locations. Therefore, in this
      study, the EFT value was recorded by considering the average of the parasternal long axis,
      parasternal short axis, and apical 4-chamber view. In addition, to minimize observational
      bias in a priori and post-hoc analyses, the researcher was blinded to the baseline value.

      Exercise Training The EG group performed exercise using the Exer Heart device (D&J Humancare,
      Seoul, South Korea), which consisted of a running/jumping board and a screen connected to the
      board (Figure 1). The exercise program "Alchemist's Treasure", a running-based exergame,
      moves the avatar according to the user's motions and was used for the exercise session.
      "Alchemist's Treasure" is a game in which the user listens to stimulating music, runs with
      the avatar, avoiding obstacles, and wins items using the front, back, left, and right sensors
      on the exercise board (Figure 2). The subject can control the speed of the avatar movement by
      adjusting the walking or running speed on the board. Furthermore, the Exer Heart game does
      not harm the joints, as the activities are performed on the exercise board's soft material.

      The exergame cannot continuously maintain intensity by fixing the speed and inclination like
      a treadmill motion due to the characteristics of the program. On the other hand, the biggest
      advantage of the exergame is enjoyment. This study did not enforce exercise intensity in
      order to allow patients to enjoy the exergame. Thus, during the training period, the patients
      exercised at a self-selected pace for 40 minutes per day. Instead, we monitored individual
      exercise intensity by monitoring HR (Polar RS400sd; Madison Height, Michigan, USA) and
      recorded the resting, minimum, maximum, and average HR during the exergame training period.
      The resting HR of the patients was 79 ± 12 beats per minute (bpm), the minimum HR was 98 ± 26
      bpm, the maximum HR was 153 ± 28 bpm, and the mean HR was 120 ±19. According to the
      guidelines of the American College of Sports Medicine (ACSM), the range of exercise intensity
      for exergaming is between 42% and 82% of HR reserve.

      The TM group consisted of 40 minutes of walking or jogging at 60-80% of the heart rate (HR)
      reserve. The exercise intensity was determined using the Karvonen method target HR =
      [Exercise Intensity × (HRmax - resting HR)] + resting HR. The HR was recorded during each
      session using an HR monitor (Polar RS400sd; Madison Height, Michigan, USA). The control group
      was asked to maintain their regular physical activity level for 12 weeks.

      Exercise training was conducted at the Kosin University Gospel Hospital U-Healthcare Center.
      All subjects were engaged in exercise training under the expert supervision of a director and
      were trained to immediately notify the director of any abnormal symptoms during the exercise
      training and to consult a doctor if needed. For both the EG and TM groups, exercise training
      was comprised of a 5 minute warm-up, a 40 minute main exercise, and a 5 minute cool-down.
      After a necessary 2 week initial adjustment period, the exercise training was conducted 3
      times per week for 12 weeks. Subjects who did not perform more than 80% of the 12 week
      exercise program were excluded from this study.

      Statistical Analysis All values are presented as the mean ± standard deviation (SD). We used
      the chi-square test for category type variables. The paired t-test was used to compare the
      baseline and data after the 12 week exercise intervention for each group. One-way ANOVA with
      repeated measures (group × time) was used to compare the data between groups. Bonferroni
      post-hoc analysis was performed to evaluate the differences among groups. Pearson's
      correlation was used to evaluate the relationship between variables. Statistical significance
      was set to p<0.05. For statistical analysis, SPSS 21.0 (SPSS, Chicago, IL, USA), a
      statistical program for Windows, was used.
    

Intervention name(s): exergame; treadmill exercise
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Exergame is 'exercise + game'.; traditional aerobic exercise
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: exergame group, treadmill group and control group
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Aerobic exercise; Exergame; cardiorespiratory fitness; endothelial function; epicardial fat