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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">The Effect of a Virtual Reality Exercise Program on Physical Fitness, Body
Composition, and Fatigue in Hemodialysis Patients</title><author><name sortKey="Cho, Hyeyoung" sort="Cho, Hyeyoung" uniqKey="Cho H" first="Hyeyoung" last="Cho">Hyeyoung Cho</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Sohng, Kyeong Yae" sort="Sohng, Kyeong Yae" uniqKey="Sohng K" first="Kyeong-Yae" last="Sohng">Kyeong-Yae Sohng</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25364137</idno><idno type="pmc">4210422</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4210422</idno><idno type="RBID">PMC:4210422</idno><idno type="doi">10.1589/jpts.26.1661</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">000296</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000296</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">The Effect of a Virtual Reality Exercise Program on Physical Fitness, Body
Composition, and Fatigue in Hemodialysis Patients</title><author><name sortKey="Cho, Hyeyoung" sort="Cho, Hyeyoung" uniqKey="Cho H" first="Hyeyoung" last="Cho">Hyeyoung Cho</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Sohng, Kyeong Yae" sort="Sohng, Kyeong Yae" uniqKey="Sohng K" first="Kyeong-Yae" last="Sohng">Kyeong-Yae Sohng</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Physical Therapy Science</title><idno type="ISSN">0915-5287</idno><idno type="eISSN">2187-5626</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>[Purpose] The aim of the present study was to investigate the effects of a virtual
reality exercise program (VREP) on physical fitness, body composition, and fatigue in
hemodialysis (HD) patients with end-stage renal failure. [Subjects and Methods] A
nonequivalent control group pretest-posttest design was used. Forty-six HD patients were
divided into exercise (n=23) and control groups (n=23); while waiting for their dialyses,
the exercise group followed a VREP, and the control group received only their usual care.
The VREP was accomplished using Nintendo’s Wii Fit Plus for 40 minutes, 3 times a week for
8 weeks during the period of May 27 to July 19, 2013. Physical fitness (muscle strength,
balance, flexibility), body composition (skeletal muscle mass, body fat rate, arm and leg
muscle mass), and fatigue were measured at baseline and after the intervention. [Results]
After the VREP, physical fitness and body composition significantly increased, and the
level of fatigue significantly decreased in the exercise group. [Conclusion] These results
suggest that a VREP improves physical fitness, body composition, and fatigue in HD
patients. Based on the findings, VREPs should be used as a health promotion programs for
HD patients.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Ponngeon, O" uniqKey="Ponngeon O">O Ponngeon</name></author><author><name sortKey="Chaunchaiyakul, R" uniqKey="Chaunchaiyakul R">R Chaunchaiyakul</name></author><author><name sortKey="Vareesangthip, K" uniqKey="Vareesangthip K">K Vareesangthip</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Johansen, Kl" uniqKey="Johansen K">KL Johansen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Song, Wj" uniqKey="Song W">WJ Song</name></author><author><name sortKey="Sohng, Ky" uniqKey="Sohng K">KY Sohng</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jang, Ej" uniqKey="Jang E">EJ Jang</name></author><author><name sortKey="Kim, Hs" uniqKey="Kim H">HS Kim</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Elder, Se" uniqKey="Elder S">SE Elder</name></author><author><name sortKey="Bommer, J" uniqKey="Bommer J">J Bommer</name></author><author><name sortKey="Fissell, Rb" uniqKey="Fissell R">RB Fissell</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cheema, Bs" uniqKey="Cheema B">BS Cheema</name></author><author><name sortKey="Singh, Ma" uniqKey="Singh M">MA Singh</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Son, Hs" uniqKey="Son H">HS Son</name></author><author><name sortKey="Lee, Mj" uniqKey="Lee M">MJ Lee</name></author><author><name sortKey="Kang, Sm" uniqKey="Kang S">SM Kang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Manfredini, F" uniqKey="Manfredini F">F Manfredini</name></author><author><name sortKey="Mallamaci, F" uniqKey="Mallamaci F">F Mallamaci</name></author><author><name sortKey="Catizone, L" uniqKey="Catizone L">L 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Rosie</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lee, Sw" uniqKey="Lee S">SW Lee</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Curtin, Rb" uniqKey="Curtin R">RB Curtin</name></author><author><name sortKey="Becker, B" uniqKey="Becker B">B Becker</name></author><author><name sortKey="Kimmel, Pl" uniqKey="Kimmel P">PL Kimmel</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cruz, Mc" uniqKey="Cruz M">MC Cruz</name></author><author><name sortKey="Andrade, C" uniqKey="Andrade C">C Andrade</name></author><author><name sortKey="Urrutia, M" uniqKey="Urrutia M">M Urrutia</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kouidi, E" uniqKey="Kouidi E">E Kouidi</name></author><author><name sortKey="Grekas, D" uniqKey="Grekas D">D Grekas</name></author><author><name sortKey="Deligiannis, A" uniqKey="Deligiannis A">A Deligiannis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Goldberg, Ap" uniqKey="Goldberg A">AP Goldberg</name></author><author><name sortKey="Geltman, Em" uniqKey="Geltman E">EM Geltman</name></author><author><name sortKey="Gavin, Jr" uniqKey="Gavin J">JR Gavin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Barcala, L" uniqKey="Barcala L">L Barcala</name></author><author><name sortKey="Grecco, La" uniqKey="Grecco L">LA Grecco</name></author><author><name sortKey="Colella, F" uniqKey="Colella F">F Colella</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="D Ngelo, M" uniqKey="D Ngelo M">M D’Angelo</name></author><author><name sortKey="Narayanan, S" uniqKey="Narayanan S">S Narayanan</name></author><author><name sortKey="Reynolds, Db" uniqKey="Reynolds D">DB Reynolds</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Yen, Cy" uniqKey="Yen C">CY Yen</name></author><author><name sortKey="Lin, Kh" uniqKey="Lin K">KH Lin</name></author><author><name sortKey="Hu, Mh" uniqKey="Hu M">MH Hu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lee, Sh" uniqKey="Lee S">SH Lee</name></author><author><name sortKey="Ko, Ds" uniqKey="Ko D">DS Ko</name></author><author><name sortKey="Jung, Di" uniqKey="Jung D">DI Jung</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Song, Ch" uniqKey="Song C">CH Song</name></author><author><name sortKey="Shin, Ws" uniqKey="Shin W">WS Shin</name></author><author><name sortKey="Lee, Kj" uniqKey="Lee K">KJ Lee</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lee, Hm" uniqKey="Lee H">HM Lee</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lee, Yk" uniqKey="Lee Y">YK Lee</name></author><author><name sortKey="Kim, C" uniqKey="Kim C">C Kim</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Phys Ther Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Phys Ther Sci</journal-id><journal-id journal-id-type="publisher-id">JPTS</journal-id><journal-title-group><journal-title>Journal of Physical Therapy Science</journal-title></journal-title-group><issn pub-type="ppub">0915-5287</issn><issn pub-type="epub">2187-5626</issn><publisher><publisher-name>The Society of Physical Therapy Science</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25364137</article-id><article-id pub-id-type="pmc">4210422</article-id><article-id pub-id-type="publisher-id">jpts-2014-205</article-id><article-id pub-id-type="doi">10.1589/jpts.26.1661</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>The Effect of a Virtual Reality Exercise Program on Physical Fitness, Body
Composition, and Fatigue in Hemodialysis Patients</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Cho</surname><given-names>Hyeyoung</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Sohng</surname><given-names>Kyeong-Yae</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref rid="cor1" ref-type="corresp"><sup>*</sup></xref></contrib><aff id="aff1"><label>1)</label> Department of Emergency Medical Service, Daewon University, Republic of Korea</aff><aff id="aff2"><label>2)</label> The Catholic University of Korea, Republic of Korea</aff></contrib-group><author-notes><corresp id="cor1"><label>*</label>Corresponding author. Kyeong-Yae Sohng, The Catholic University of Korea: 222 Banpodaero, Socho-gu,
Seoul 137-701, Republic of Korea. (E-mail: <email xlink:href="sky@catholic.ac.kr">sky@catholic.ac.kr</email>)</corresp></author-notes><pub-date pub-type="epub"><day>28</day><month>10</month><year>2014</year></pub-date><pub-date pub-type="ppub"><month>10</month><year>2014</year></pub-date><volume>26</volume><issue>10</issue><fpage>1661</fpage><lpage>1665</lpage><history><date date-type="received"><day>02</day><month>6</month><year>2014</year></date><date date-type="accepted"><day>15</day><month>7</month><year>2014</year></date></history><permissions><copyright-statement>2014©by the Society of Physical Therapy Science</copyright-statement><copyright-year>2014</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. </license-p></license></permissions><abstract><p>[Purpose] The aim of the present study was to investigate the effects of a virtual
reality exercise program (VREP) on physical fitness, body composition, and fatigue in
hemodialysis (HD) patients with end-stage renal failure. [Subjects and Methods] A
nonequivalent control group pretest-posttest design was used. Forty-six HD patients were
divided into exercise (n=23) and control groups (n=23); while waiting for their dialyses,
the exercise group followed a VREP, and the control group received only their usual care.
The VREP was accomplished using Nintendo’s Wii Fit Plus for 40 minutes, 3 times a week for
8 weeks during the period of May 27 to July 19, 2013. Physical fitness (muscle strength,
balance, flexibility), body composition (skeletal muscle mass, body fat rate, arm and leg
muscle mass), and fatigue were measured at baseline and after the intervention. [Results]
After the VREP, physical fitness and body composition significantly increased, and the
level of fatigue significantly decreased in the exercise group. [Conclusion] These results
suggest that a VREP improves physical fitness, body composition, and fatigue in HD
patients. Based on the findings, VREPs should be used as a health promotion programs for
HD patients.</p></abstract><kwd-group><title>Key words</title><kwd>Hemodialysis</kwd><kwd>Virtual reality exercise</kwd><kwd>Physical fitness</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="s1"><title>INTRODUCTION</title><p>In late 2011, there was a total 63,341 patients receiving renal replacement therapy in
South Korea; 42,596 of these were hemodialysis (HD) patients, accounting for 67.2% of the
total, and the number of maintenance hemodialysis patients is on the rise<xref rid="r1" ref-type="bibr">1</xref><sup>)</sup>. Because the physical fitness level of HD
patients tends to improve their functional levels<xref rid="r2" ref-type="bibr">2</xref><sup>)</sup>, exercise therapy is an important nursing intervention for HD
patients in improving their physical performances<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>. Various exercise interventions including strength training, aerobic
exercise, and resistance exercise using sandbags and elastic bands for HD patients have been
studied and reported to be effective in obtaining physical and physiological
improvements<xref rid="r4" ref-type="bibr">4</xref>,<xref rid="r5" ref-type="bibr">5</xref>,<xref rid="r6" ref-type="bibr">6</xref>,<xref rid="r7" ref-type="bibr">7</xref><sup>)</sup>. Despite the effective results from previous studies, exercise
intervention programs have not been established as an active practice<xref rid="r8" ref-type="bibr">8</xref><sup>)</sup>, with the participation rate being low<xref rid="r8" ref-type="bibr">8</xref><sup>)</sup>, the rate of high dropout from programs being 20–30%, and
the rarely exercising rate being, 48% in HD patients. The reasons for the lack of exercise,
according to the hemodialysis patients, include tiredness following dialysis treatments,
unexplainable fear of exercise, time and locational constraints, and lack of motivation<xref rid="r5" ref-type="bibr">5</xref><sup>)</sup>. From the medical professionals’ point of
view, the possibility of damage and other barriers have been discouraging them against
strongly recommending an exercise intervention for dialysis patients<xref rid="r9" ref-type="bibr">9</xref><sup>)</sup>. It should also be noted that even the most effective
exercise programs would not be able to keep the interest of patients if they are composed
only of repetitive routines. Therefore, careful planning of the content of the exercise
programs with the motivation and continued participation of the patients in mind is
essential<xref rid="r10" ref-type="bibr">10</xref><sup>)</sup>. In recent years, utilizing
virtual reality to increase the amount of physical activity of patients while overcoming
some of the aforementioned limitations of exercise programs has been gaining ground in
clinical practices<xref rid="r11" ref-type="bibr">11</xref><sup>)</sup>. Virtual reality has
been applied as a clinical intervention for improving mobility or cognitive functions and
has also been demonstrated to be a positive nursing intervention for chronic patients, as
illustrated by the results of a 10-week virtual reality exercise program applied to elderly
diabetes patients, who showed improved balance, muscle strength, walking, and falls
efficacy<xref rid="r12" ref-type="bibr">12</xref>,<xref rid="r13" ref-type="bibr">13</xref>,<xref rid="r14" ref-type="bibr">14</xref><sup>)</sup>. The aim of this study
was to propose a new nursing intervention method for hemodialysis patients through a virtual
reality exercise program and investigate its effects on fitness, body composition, and
fatigue.</p></sec><sec sec-type="methods" id="s2"><title>SUBJECTS AND METHODS</title><sec><title>Subjects</title><p>The subjects were adult (≥18 years) men and women receiving HD treatment for the
management of end stage renal disease. Sample size was calculated based on previous
study<xref rid="r7" ref-type="bibr">7</xref><sup>)</sup>. For sufficient statistical
power (0.95), setting at effect size at 1.19<xref rid="r7" ref-type="bibr">7</xref><sup>)</sup>, alpha at 0.05, a total 40 subjects were estimated to be required
for the independent t-test, according to G power 3.0 software. In the present study, the
sample size was adjusted to 48 to account for an anticipated dropout rate of 20%. The
exercise (n=24) and control (n=24) groups were recruited between May 2013 and August 2013
from a C dialysis clinic in Kyeonggi Province, South Korea. This study meets the ethical
standards of the Declaration of Helsinki (1975, revised 1983,) and the Institutional
Review Board of C University approved all procedures. Written informed consent was
obtained from all subjects.</p><p>The patients who received HD on Monday, Wednesday, and Friday were assigned to the
exercise group; those who received HD on Tuesday, Thursday, and Saturday were assigned to
the control group. Without giving any information about the rest of the study, the same
intervention was applied to the control group 8 weeks later. Demographic, laboratory, and
baseline characteristics of the two groups were not different (<xref rid="tbl_001" ref-type="table">Table 1</xref><table-wrap id="tbl_001" orientation="portrait" position="float"><label>Table 1.</label><caption><title>Characteristics of the patients</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="center" rowspan="1" colspan="1">Characteristics</th><th align="center" rowspan="1" colspan="1">Exer</th><th align="center" rowspan="1" colspan="1">Cont</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Age (year)</td><td align="center" rowspan="1" colspan="1">60.8 ± 6.9</td><td align="center" rowspan="1" colspan="1">57.7 ± 9.5</td></tr><tr><td align="left" rowspan="1" colspan="1">Height (cm)</td><td align="center" rowspan="1" colspan="1">166.1 ± 6.9</td><td align="center" rowspan="1" colspan="1">167.8 ± 9.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Gender</td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">Male</td><td align="center" rowspan="1" colspan="1">15 (65)</td><td align="center" rowspan="1" colspan="1">13 (57)</td></tr><tr><td align="left" rowspan="1" colspan="1">DM </td><td align="center" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">Yes</td><td align="center" rowspan="1" colspan="1">14 (61)</td><td align="center" rowspan="1" colspan="1">18 (78)</td></tr><tr><td align="left" rowspan="1" colspan="1">Dry weight (kg)</td><td align="center" rowspan="1" colspan="1">62.3 ± 13.7</td><td align="center" rowspan="1" colspan="1">60.6 ± 8.8</td></tr><tr><td align="left" rowspan="1" colspan="1">Duration of HD (months)</td><td align="center" rowspan="1" colspan="1">54.4 ± 49.2</td><td align="center" rowspan="1" colspan="1">38.2 ± 25.2</td></tr><tr><td align="left" rowspan="1" colspan="1">Kt/V urea</td><td align="left" rowspan="1" colspan="1">1.2±0.1</td><td align="left" rowspan="1" colspan="1">1.2±0.1</td></tr><tr><td align="left" rowspan="1" colspan="1">Hemoglobin (g/dl)</td><td align="center" rowspan="1" colspan="1">10.5±0.7</td><td align="center" rowspan="1" colspan="1">10.2±0.7</td></tr><tr><td align="left" rowspan="1" colspan="1">Physical fitness</td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">Back strength (kg)</td><td align="center" rowspan="1" colspan="1">61.1 ± 13.7</td><td align="center" rowspan="1" colspan="1">56.9 ± 12.9</td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">Grip strength (kg)</td><td align="center" rowspan="1" colspan="1">29.7 ± 8.6</td><td align="center" rowspan="1" colspan="1">26.3 ± 7.9</td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">Leg strength (kg)</td><td align="center" rowspan="1" colspan="1">35.4 ± 14.0</td><td align="center" rowspan="1" colspan="1">32.6 ± 12.6</td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">Flexibility (cm)</td><td align="center" rowspan="1" colspan="1">6.5 ± 5.6</td><td align="center" rowspan="1" colspan="1">5.7 ± 3.5</td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">Balance (sec)</td><td align="center" rowspan="1" colspan="1">6.9 ± 3.5</td><td align="center" rowspan="1" colspan="1">7.3 ± 3.1</td></tr><tr><td align="left" rowspan="1" colspan="1">Body composition</td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">SMM (kg)</td><td align="center" rowspan="1" colspan="1">25.1 ± 5.1</td><td align="center" rowspan="1" colspan="1">25.9 ± 5.7</td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">AMM (kg)</td><td align="center" rowspan="1" colspan="1">5.0 ± 1.1</td><td align="center" rowspan="1" colspan="1">5.5 ± 1.3</td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">LMM (kg)</td><td align="center" rowspan="1" colspan="1">14.1 ± 3.3</td><td align="center" rowspan="1" colspan="1">14.7 ± 3.7</td></tr><tr><td align="left" style="padding-left:15pt" rowspan="1" colspan="1">BFR (%)</td><td align="center" rowspan="1" colspan="1">24.8 ± 8.8</td><td align="center" rowspan="1" colspan="1">24.8 ± 8.2</td></tr><tr><td align="left" rowspan="1" colspan="1">Fatigue (score)</td><td align="center" rowspan="1" colspan="1">6.7 ± 0.8</td><td align="center" rowspan="1" colspan="1">6.8 ± 1.0</td></tr></tbody></table><table-wrap-foot><p>Values are means ± SD or numbers (%). Exer, exercise group (n=23); Cont, control
group (n=23);DM, diabetes mellitus; HD, hemodialysis; K, dialyzer clearance of urea;
t, dialysis time; V, volume of distribution of urea; SMM, skeletal muscle mass; AMM,
arm muscle mass; LMM, leg muscle mass; BFR, body fat rate</p></table-wrap-foot></table-wrap>). The control group did not participate in any of the exercises during the
study. For the HD treatment, the same dialysis machine, needle puncture diameter, blood
flow rate, dialysate, and heparin dosage were used for each dialysis. During the data
collection period of 8 weeks, one patient from the exercise group dropped out due to an
emergency cardiovascular surgery, and one patient from the control group was excluded due
to refusal to participate in post-test measurements, resulting in a dropout rate for the
study of 4.3%. The average participation rate for the exercise group was 94% (88% − 100%)
and 12 patients had an attendance rate of 100%. The patients were notified at the
beginning of the study that an attendance rate below 80% would automatically exclude them
from the study.</p></sec><sec><title>Methods</title><p>The Wii Fit Plus software, launched by Nintendo in 2010, was administered as the virtual
reality exercise program (VREP) to the exercise group (<xref rid="tbl_002" ref-type="table">Table 2</xref><table-wrap id="tbl_002" orientation="portrait" position="float"><label>Table 2.</label><caption><title>Protocol of VREP</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="center" rowspan="1" colspan="1">Wk</th><th align="center" rowspan="1" colspan="1">Repetition</th><th align="center" rowspan="1" colspan="1">RPE </th><th align="center" rowspan="1" colspan="1">Exercise type</th><th align="center" rowspan="1" colspan="1">Exercise content</th><th align="center" rowspan="1" colspan="1">Duration (min)</th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1">1–2</td><td align="center" rowspan="1" colspan="1">2–3</td><td align="center" rowspan="1" colspan="1">10–11</td><td align="left" rowspan="1" colspan="1">Game</td><td align="left" rowspan="1" colspan="1">Hula-hoop</td><td align="center" rowspan="7" colspan="1">30</td></tr><tr><td align="center" rowspan="6" colspan="1"></td><td align="left" rowspan="6" colspan="1"></td><td align="left" rowspan="6" colspan="1"></td><td align="left" rowspan="2" colspan="1"></td><td align="left" rowspan="1" colspan="1">Dance step</td></tr><tr><td align="left" rowspan="1" colspan="1">Rhythm parade</td></tr><tr><td align="left" rowspan="2" colspan="1">Strength</td><td align="left" rowspan="1" colspan="1">Twist upper body</td></tr><tr><td align="left" rowspan="1" colspan="1">One arm pull back</td></tr><tr><td align="left" rowspan="2" colspan="1">Yoga</td><td align="left" rowspan="1" colspan="1">Chair position</td></tr><tr><td align="left" rowspan="1" colspan="1">Half moon position</td></tr><tr><td align="center" rowspan="1" colspan="1">3–5</td><td align="center" rowspan="1" colspan="1">2–3</td><td align="center" rowspan="1" colspan="1">12–13</td><td align="left" rowspan="1" colspan="1">Game</td><td align="left" rowspan="1" colspan="1">Flying game</td><td align="center" rowspan="7" colspan="1">30</td></tr><tr><td align="center" rowspan="6" colspan="1"></td><td align="left" rowspan="6" colspan="1"></td><td align="left" rowspan="6" colspan="1"></td><td align="left" rowspan="2" colspan="1"></td><td align="left" rowspan="1" colspan="1">Twist </td></tr><tr><td align="left" rowspan="1" colspan="1">Rhythm Kung Fu</td></tr><tr><td align="left" rowspan="2" colspan="1">Strength</td><td align="left" rowspan="1" colspan="1">Knee flexion and pull</td></tr><tr><td align="left" rowspan="1" colspan="1">Balance walk</td></tr><tr><td align="left" rowspan="2" colspan="1">Yoga</td><td align="left" rowspan="1" colspan="1">Chair position</td></tr><tr><td align="left" rowspan="1" colspan="1">Half moon position</td></tr><tr><td align="center" rowspan="1" colspan="1">6–8</td><td align="center" rowspan="1" colspan="1">2–3</td><td align="center" rowspan="1" colspan="1">14</td><td align="left" rowspan="1" colspan="1">Game</td><td align="left" rowspan="1" colspan="1">Mii Triathlon</td><td align="center" rowspan="7" colspan="1">30</td></tr><tr><td align="left" rowspan="6" colspan="1"></td><td align="left" rowspan="6" colspan="1"></td><td align="left" rowspan="6" colspan="1"></td><td align="left" rowspan="2" colspan="1"></td><td align="left" rowspan="1" colspan="1">Balance bead</td></tr><tr><td align="left" rowspan="1" colspan="1">Juggling</td></tr><tr><td align="left" rowspan="2" colspan="1">Strength</td><td align="left" rowspan="1" colspan="1">Leg wide open, side flexion</td></tr><tr><td align="left" rowspan="1" colspan="1">Lifting the side limbs</td></tr><tr><td align="left" rowspan="2" colspan="1">Yoga</td><td align="left" rowspan="1" colspan="1">Half moon position</td></tr><tr><td align="left" rowspan="1" colspan="1">Knee hugging position</td></tr></tbody></table><table-wrap-foot><p>VREP, virtual reality exercise program; Wk, week; RPE, rating of perceived
exertion</p></table-wrap-foot></table-wrap>). The VREP was applied 3 times a week, 40 minutes each time, for 8 weeks, as
recommended by the Life Options Rehabilitation Advisory Council (LORAC)<xref rid="r7" ref-type="bibr">7</xref><sup>)</sup>. The exercise intensity was individualized
based on the rating of perceived exertion (RPE), which was measured for each patient
before the start of the program, and was gradually intensified over the course of the
exercise program. The exercise group participated in the VREP 3 times a week while waiting
for their dialyses at the on-site gym. Each attendance and exercise score was
automatically logged into a centralized computer system and recorded per patient after
each session; data were managed in batches by the researcher. A previous study conducted
on elderly diabetes patients<xref rid="r14" ref-type="bibr">14</xref><sup>)</sup> was used
as the basis for the VREP; 18 positions from the 69 Wii Fit Plus games, as well as muscle
strengthening movements and yoga movements, were selected. The researcher facilitated the
VREP, which was designed as a group exercise program consisting of warm-up, main exercise,
and cool-down segments. The warm-up and cool-down segments were intended to prepare the
patients for optimal physical results from the main exercise and to prevent accidents.
Starting from upper to the lower extremities, the VREP consisted of 8 stretching positions
as suggested by the LORAC and lasted for 5 minutes. Each target position, designed to be
an RPE level of 8–9 points (very easy), was held for 5–10 seconds and repeated twice. The
main exercise segment was allocated 30 minutes, with the purpose being improvement of
muscle strength, flexibility, and balance. It consisted of 3 games, 2 muscle strengthening
movements, and 2 yoga movements, and was conducted in that order. With individual
differences in fitness in mind, a minimum of 2 repetitions with no limit on the maximum
was set for each movement. Tailoring to individual fitness levels and gradually focusing
on the number of repetitions and accuracy of each movement, the routine allowed patients
to exercise autonomously; a bell was rung in order to direct the patienst to the next
movement after 10 minutes. Every movement was demonstrated on a screen for the patient to
watch and follow. The sequence of the exercise program and the types of movements are as
shown in <xref rid="tbl_002" ref-type="table">Table 2</xref>. The effect of the exercise
program was measured by a physical therapist using physical fitness measuring equipment
(Helmas III, O2run, Seoul, South Korea). The measurements were taken the day after HD, as
stable blood pressure and cardiovascular function should be regained by that time.</p><p>Back, handgrip, and leg strength were measured for each patient. Back strength was
measured twice in kilograms using a digital dynamometer, with the patient in a standing
position while holding the measuring bar with both arms spread wide and the waist slightly
bent; the higher of two measurements was selected. Handgrip strength was measured in
kilograms with the patient holding onto the measuring device in hand with full grip. Two
measurements were made and the higher of the two was recorded. Leg strength was measured
twice in kilograms based on the force exerted when the patient pushed forward on a pedal
with both legs and ankles in a sitting position with the back up against a backrest; the
higher of the two measurements was chosen. Flexibility was measured by using sit-and-reach
box. Sitting on the box with his/her feet firmly planted on one end, the patient was asked
to extend his/her hands towards his/her feet as far as possible without bending his/her
knees; the better of two tries was recorded in centimeters. To measure balance, the
patient was asked to stand on one leg with both eyes closed. The duration of until the
patient lost his/her balance and touched the ground with his/her other foot was recorded
in seconds, and the longer of two tries for each of the legs was recorded. Body
composition, based on skeletal muscle mass (SMM), arm muscle mass (AMM), leg muscle mass
(LMM), and body fat rate (BFR), was measured using an Inbody s10 body composition analyzer
(Biospace, Seoul, South Korea). Fatigue was assessed with the Visual Analogue Scale, with
1 denoting the lowest level of fatigue and 10 denoting. The data collected were analyzed
using the SPSS statistics (version 18.0) and a homogeneity test between the two groups was
conducted with the χ<sup>2</sup>-test and t-test. The post-test comparison regarding the
effects of the VREP between the two groups was analyzed with an unpaired t-test.</p></sec></sec><sec sec-type="results" id="s3"><title>RESULTS</title><p>The back strength of the patients noticeably increased in the exercise group, after VREP,
from 61.1 kg to 63.1 kg (p= 0.001), however, there was almost no change in the control
group. Similar improvements in leg strength were observed in the exercise group, improving
from a pre-test value of 35.4 kg to a post-test value of 37.2 kg (p < 0.001), but no
difference was observed in the control group (p= 0.032). The difference in flexibility (sit
and reach test) between the two groups after the VREP was not dramatic, as the flexibility
in the exercise group increased by 1.0 cm, although the flexibility of the control group
also increased by 0.2 cm. The difference in balance between the two groups after the VREP
improved significantly (p< 0.001), as the duration until the patients lost their balance
in thee exercise group increased by 1.0 second, while that in the control group showed an
increase of only by 0.3 seconds. The differences between the pre- and post-test physical
strength figures for both the control and exercise groups are shown in <xref rid="tbl_003" ref-type="table">Table 3</xref><table-wrap id="tbl_003" orientation="portrait" position="float"><label>Table 3.</label><caption><title>Comparison of the effect of the VREP on physical fitness between the exercise and
control groups</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="center" rowspan="1" colspan="1">Variables</th><th align="center" rowspan="1" colspan="1">Group</th><th align="center" rowspan="1" colspan="1">Pre-test</th><th align="center" rowspan="1" colspan="1">Post-test</th></tr></thead><tbody><tr><td align="left" rowspan="2" colspan="1">Back strength (kg)</td><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">61.1 ± 13.7</td><td align="center" rowspan="1" colspan="1">63.1 ± 15.0**</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">56.9 ± 12.9</td><td align="center" rowspan="1" colspan="1">57.0 ± 13.0</td></tr><tr><td align="left" rowspan="2" colspan="1">Grip strength (kg)</td><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">29.7 ± 8.6</td><td align="center" rowspan="1" colspan="1">29.5 ± 8.4</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">26.3 ± 7.9</td><td align="center" rowspan="1" colspan="1">26.2 ± 8.0</td></tr><tr><td align="left" rowspan="2" colspan="1">Leg strength (kg)</td><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">35.4 ± 14.0</td><td align="center" rowspan="1" colspan="1">37.2 ± 13.9*</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">32.6 ± 12.6</td><td align="center" rowspan="1" colspan="1">31.5 ± 12.7</td></tr><tr><td align="left" rowspan="2" colspan="1">Flexibility (cm)</td><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">6.5 ± 5.6</td><td align="center" rowspan="1" colspan="1">7.5 ± 5.1</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">5.7 ± 3.5</td><td align="center" rowspan="1" colspan="1">5.9 ± 3.1</td></tr><tr><td align="left" rowspan="2" colspan="1">Balance (sec)</td><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">6.9 ± 3.5</td><td align="center" rowspan="1" colspan="1">8.2 ± 3.5**</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">7.3 ± 3.1</td><td align="center" rowspan="1" colspan="1">7.5 ± 3.2</td></tr></tbody></table><table-wrap-foot><p>Values are means ± SD. VREP, virtual reality exercise program; Exer, exercise group
(n=23); Cont, control group (n=23). * p<0.05; **p<0.01.</p></table-wrap-foot></table-wrap>.</p><p>Of the body composition measures, skeletal and leg muscle mass changed significantly
between the two groups after the VREP (<xref rid="tbl_004" ref-type="table">Table
4</xref><table-wrap id="tbl_004" orientation="portrait" position="float"><label>Table 4.</label><caption><title>Comparison of the effect of the VREP on body composition between the exercise and
control groups</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="center" rowspan="1" colspan="1">Variables</th><th align="center" rowspan="1" colspan="1">Group</th><th align="center" rowspan="1" colspan="1">Pre-test</th><th align="center" rowspan="1" colspan="1">Post-test</th></tr></thead><tbody><tr><td align="left" rowspan="2" colspan="1">SMM (kg)</td><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">25.1 ± 5.1</td><td align="center" rowspan="1" colspan="1">26.2 ± 4.9***</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">25.9 ± 5.7</td><td align="center" rowspan="1" colspan="1">26.0 ± 5.7</td></tr><tr><td align="left" rowspan="2" colspan="1">AMM (kg)</td><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">5.0 ± 1.1</td><td align="center" rowspan="1" colspan="1">5.1 ± 1.1</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">5.5 ± 1.3</td><td align="center" rowspan="1" colspan="1">5.4 ± 1.3</td></tr><tr><td align="left" rowspan="2" colspan="1">LMM (kg)</td><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">14.1 ± 3.3</td><td align="center" rowspan="1" colspan="1">14.2 ± 3.3*</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">14.7 ± 3.7</td><td align="center" rowspan="1" colspan="1">14.6 ± 3.7</td></tr><tr><td align="left" rowspan="2" colspan="1">BFR (%)</td><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">24.8 ± 8.8</td><td align="center" rowspan="1" colspan="1">24.6 ± 8.4</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">24.8 ± 8.2</td><td align="center" rowspan="1" colspan="1">24.8 ± 8.2</td></tr></tbody></table><table-wrap-foot><p>Values are means ± SD. VREP, virtual reality exercise program; Exer, exercise group
(n=23); Cont, control group (n=23); SMM, skeletal muscle mass; AMM, arm muscle mass;
LMM, leg muscle mass; BFR, body fat rate. *p<0.05; ***p<0.001.</p></table-wrap-foot></table-wrap>). Skeletal muscle mass showed a significant increase in the exercise group,
from 25.1 kg to 26.2 kg (p< 0.001), while no change was observed in the control group.
Leg muscle mass also increased noticeably in the exercise group, from 14.1 kg to 14.2 kg (p=
0.016), but no change was observed control group. .</p><p>The level of fatigue in the exercise group showed a dramatic decrease, from 6.7 points to
4.9 points (p> 0.001), while almost no changes were noted in the control group (<xref rid="tbl_005" ref-type="table">Table 5</xref><table-wrap id="tbl_005" orientation="portrait" position="float"><label>Table 5.</label><caption><title>Comparison of the effect of the VREP on fatigue between the exercise and control
groups</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="center" rowspan="1" colspan="1">Group</th><th align="center" rowspan="1" colspan="1">Pre-test</th><th align="center" rowspan="1" colspan="1">Post-test</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Exer</td><td align="center" rowspan="1" colspan="1">6.7 ± 0.8</td><td align="center" rowspan="1" colspan="1">4.9 ± 1.1***</td></tr><tr><td align="left" rowspan="1" colspan="1">Cont</td><td align="center" rowspan="1" colspan="1">6.8 ± 1.0</td><td align="center" rowspan="1" colspan="1">6.7 ± 1.2</td></tr></tbody></table><table-wrap-foot><p>Values are means ± SD. Exer, exercise group (n=23); Cont, control group (n=23).
***p<0.001.</p></table-wrap-foot></table-wrap>).</p></sec><sec sec-type="discussion" id="s4"><title>DISCUSSION</title><p>The increase of elderly HD patients and the duration of HD treatments point to the
increasing importance of systematic exercise programs for dialysis patients<xref rid="r15" ref-type="bibr">15</xref>, <xref rid="r16" ref-type="bibr">16</xref><sup>)</sup>. Despite the positive effects reported on maintaining and improving
patients’ physical functions<xref rid="r17" ref-type="bibr">17</xref>, <xref rid="r18" ref-type="bibr">18</xref><sup>)</sup>, exercise programs for HD patients are not yet a part of
the typical care plan<xref rid="r6" ref-type="bibr">6</xref><sup>)</sup>. This study
investigated the effects of a VREP on HD patients, and it had no limitations regarding the
types of participants, and the benefit of providing visual feedback, or the interest to the
participants. Virtual reality is a simulated reality in which the participant can experience
an environment as if it is reality by means of a television or computer screen<xref rid="r19" ref-type="bibr">19</xref><sup>)</sup>; the image of the user appears on the
screen as an avatar, and the objects and tasks the user interacts with in reality create a
life-like virtual feedback on the screen<xref rid="r12" ref-type="bibr">12</xref><sup>)</sup>. Virtual reality has been used in the medical field for
rehabilitating patients’ cognitive and motor functions and has proven effective in improving
physical functions, such as posture, balance, and motor functions<xref rid="r20" ref-type="bibr">20</xref><sup>)</sup>. It has been reported to have contributed positively to
self-efficacy and life satisfaction of patients with low back pain, and to have improved
upper extremity function, quality of life, walking, balance, and daily life skills in stroke
patients<xref rid="r13" ref-type="bibr">13</xref><sup>)</sup>. It has been reported that,
through virtual reality based programs, walking speed, time, and abilities were improved
significantly in amputation patients<xref rid="r19" ref-type="bibr">19</xref><sup>)</sup>,
while physical health was reportedly improved in patients with cognitive impairments<xref rid="r21" ref-type="bibr">21</xref><sup>)</sup>. Nintendo’s Wii Fit Plus, launched in
2011, was used as the virtual reality exercise software in this study. It reflects the
movements of the user in real time using a balance board system. The accuracy of movements
and balancing by the participant is reflected as a scoring system generated by the software.
The virtual exercise trainer provides audio and video feedback to enable the participant to
follow the exercise movements more accurately. The rate of accuracy is scored and made
available to the participant upon completing the whole routine; the scoring system provides
motivation for the participant to keep improving<xref rid="r22" ref-type="bibr">22</xref><sup>)</sup>.</p><p>According to this study, the 8-week VREP improved leg strength, back strength, flexibility,
and balance significantly, but did not have much impact on handgrip strength. This result is
consistent with a previous study on elderly diabetes patients, in which a 10-week VREP
performed twice a week noticeably improved leg strength and balance in the exercise
group<xref rid="r14" ref-type="bibr">14</xref><sup>)</sup>, as well as an 8-week VREP in
elderly patients that showed improvements in leg strength and balance<xref rid="r23" ref-type="bibr">23</xref><sup>)</sup>. Previous exercise studies for HD patients that combined
resistance training and aerobic exercise using elastic bands demonstrated significant
improvements in handgrip strength<xref rid="r4" ref-type="bibr">4</xref>, <xref rid="r5" ref-type="bibr">5</xref><sup>)</sup>, but this was not the case in this study.
The fact that this particular study had fewer movements that required gripping and pulling
with the upper body compared with the previous studies is thought to be the reason. The 3.2%
improvement shown in back strength, which is closely related to handgrip strength, suggests
that longer administration of the VREP and addition of movements involving more of the upper
body could improve grip strength. Consistent with a previous study on stroke patients using
a Nintendo Wii system for balance improvement<xref rid="r24" ref-type="bibr">24</xref><sup>)</sup>, flexibility and balance in the exercise group improved as a result
of the VREP in this study, which consisted of games, muscle strengthening movements, and
yoga movements that prompted the participants to repeatedly bend and straighten the waist,
neck, and knees while supporting themselves against the floor. As in previous studies
involving stretching and other flexibility exercises<xref rid="r25" ref-type="bibr">25</xref><sup>)</sup>, the VREP showed a positive effect on balance and standing on one
leg with the eyes closed.</p><p>In terms of body composition, the exercise group in this study showed a significant
increase in skeletal muscle mass and leg post-test measurements but while displayed no
difference in body fat ratio and arm muscle mass. The body composition results differ from
those of a previous study that showed an increase in muscle mass and a significant decrease
in body fat ratio after a 12-week resistance exercise program<xref rid="r4" ref-type="bibr">4</xref><sup>)</sup>. The relatively short duration and low intensity of the VREP
administered in this study could have been a factor, as body fat rate is affected by the
rate of muscle mass increase as well as the duration and intensity of physical activity.
That said, the exercise group did display a decrease in body fat of 0.8%, a promising result
to consider in case the VREP continues over a longer term.</p><p>This study showed significant improvements in leg muscle mass only, which can be explained
by the lack of movements focusing on the arm muscle mass, as most movements involved having
both feet on the ground. A more balanced program involving both upper and lower body
movements is recommended for the future. The improvements in leg muscle mass, on the other
hand, show the potential of the VREP as an effective nursing intervention in terms of
physical independence for many HD patients.</p><p>Fatigue in the exercise group after taking part in the VREP decreased noticeably, and this
was thought to be due to the general improvement in physical fitness in the patients, which
reduced the amount of fatigue perceived.</p><p>No injuries or side effects were incurred as a result of the VREP, as the intensity of each
exercise routine, consisting of games, muscle strength movements, and yoga, was tailored to
the individual patients. The fact that the VREP was conducted while the patients waited for
HD, as well as the assistance provided by the virtual trainer, increased accessibility to
exercise. The individual scoring system, the scores from which were subsequently managed in
batched, made it easy to track the progress and attendance of each patient. The reduced
demand on the researchers’ time to facilitate and manage the exercise program<xref rid="r4" ref-type="bibr">4</xref><sup>)</sup> was a distinctive benefit provided by the
virtual reality system compared with previous studies based on real-life exercise
sessions<xref rid="r26" ref-type="bibr">26</xref><sup>)</sup>. The participation rate for
this study averaged 95%, significantly higher than that of previous studies (70–88%)<xref rid="r4" ref-type="bibr">4</xref>, <xref rid="r5" ref-type="bibr">5</xref><sup>)</sup>.
The sense of achievement provided as part of the VREP through the game format with a scoring
system while improving physical fitness could be the reason.</p><p>As the VREP is relatively new and does not have many precedent clinical studies, more
studies with a variety of parameters are needed to verify the results yielded in this study.
The VREP performed in this particular study appeared to be less effective in reducing the
body fat ratio, although 8 weeks is a short period to fully understand the impact of the
exercise program. On that note, a longer VREP lasting 6 months to 1 year is desirable to
look into its long-term impacts. Additional research and development to diversify the
instruments and software used in the exercise programs for clinical environments would also
be beneficial. The main aim of this study was to bring physical benefits to dialysis
patients through an effective exercise program while improving the previously documented
limitations of accessibility and motivation. It is a positive stride towards providing a
nursing intervention that improves the physical health of HD and other chronic patients.</p></sec></body><back><ref-list><title>REFERENCES</title><ref id="r1"><label>1</label><mixed-citation publication-type="eref">Korean Society of Nephrology:
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