Virtual Reality-Assisted Exercise Therapy during Inpatient Treatment after Intensive Chemotherapy for Acute Myeloid Leukemia (AML) and after Autologous or Allogeneic Stem Cell Transplantation
Authors: Wortmann Friederike , Koch Philipp , Khandanpour Cyrus , Von Bubnoff Nikolas 
Published: December 2023

Background and Objectives
Medical advances in treatment of hematologic malignancies have led to improved survival. However, aggressive treatments come with the potential of significant side effects that can affect quality-adjusted life years. During treatment, physical activities are markedly reduced and immobility and psychologic burden, especially during long isolation processes, result in fatigue and decline of quality of life as well as loss of cognitive function. Physiotherapy and exercise therapy positively impact muscle strength, quality of life, cognitive functioning and fatigue, but sufficient implementation of training in the inpatient setting is often limited by shortage in human resources.
The aim of this study was to assess the feasibility of a virtual reality (VR) based exercise program during inpatient stay of patients undergoing intensive treatment for hematologic malignancies, including autologous and allogeneic hematologic stem cell transplantation (HSCT).
Method
Patients aged 18 or above, admitted to the hematology ward for HSCT or intensive chemotherapy for acute leukemia were included. As this was a feasibility trial, there was no randomization. After consent, patients were asked to use the VR training device on a daily basis for the length of their stay, accompanied by medical personal. The training program consisted of customized VR-applications addressing movement, concentration and alertness as well as relaxation. An individual program was developed for every patient at the beginning of treatment and continuously readjusted according to individual needs and preferences. Patients who did not want to or were not able to use the VR device were asked to participate in the control group and received the standard-of-care treatment consisting of once daily physiotherapy. As objectives, quality of life, fatigue, strength and cognitive function were assessed once weekly until discharge as well as two weeks post discharge in both groups. The time of usage was recorded by the VR device. A structured interview was conducted after discharge to evaluate the patients' perspective on the intervention.
Results
Over a three-months period, a total of 10 patients were enrolled in the study, seven patients with intervention, three patients in the control group. The usage was feasible and well tolerated. No unpleasant side effects such as dizziness, nausea or fatigue were reported. Mean time of usage varied between patients (132.6±68.6 minutes, min 12.4, max 463.5 minutes) on 31±28.2% of hospitalization days.
Patients in the intervention group achieved a higher overall score in EORTC QLQ-C30 after discharge (s). Moreover, the use of VR was associated with a trend towards improved mean symptom burden (60 vs 43.3 pts), cognitive function (83.3 vs. 16.7pts) and physical strength (63.3 vs 26.7pts) post discharge (significance was not calculated due to the small number of cases). VR occupation time was markedly affected by age and general condition during treatment. The patients perception of the intervention was positive.
Conclusions
The results show that the use of a VR based exercise program during inpatient stay of patients receiving intensive treatment for hematologic malignancies is feasible and safe, and can improve QoL. Because of the small number of subjects and distinctive differences in time of usage we can only recognize a trend towards positive effects so far. In view of these promising results a larger prospective, randomized trial has been designed.