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Exergame: A Gamelike Exercise to Improve Motor Functions and Physical Activities in Diabetic Patients Undergoing Hemodialysis
Background: Balance mobility falls and foot problems are serious detriments for the diabetic patients undergoing hemodialysis (HD) treatment. In addition the HD process often leaves them too fatigued to engage in any physical activity or daily exercise further deteriorating their motor functions. Exercise would be effective for this population. However due to the time availability post-dialysis fatigue as well as limitation of transportation to exercise facility the conventional exercise is impractical. Objective: We are developing an interactive foot and ankle exercise game that can be played during HD sessions to improve mobility and balance as well as reduce foot problems. In this study we examined the feasibility and effectiveness of this innovative wearable sensor based non-weight bearing exercise (Exergame) to improve daily physical activity in diabetic patients undergoing HD treatment. Methods: Thirty-three diabetic subjects receiving HD treatment were recruited and randomized into an intervention group (IG: n = 15 age = 62.2 ± 7.6 years BMI = 29.1 ± 6.1 kg/m2) and a control group (CG: n = 18 age = 66.6 ± 8.7 years BMI = 32.5 ± 9.0 kg/m2). Both groups underwent a 4-week ankle and foot exercise program (30 minutes per session two sessions per week) during HD process. The IG received exercise via the Exergame program which uses wearable sensors attached on subject's feet. The subject's 3-dementional ankle and foot movements were visualized in real-time on a computer screen placed in front of him/her. The subject played some game-like tasks by moving and rotating the foot and ankle. The difficulty level of the task was gradually increased depends on ability of the subject (like a game) from a simple flexion-extension movement to more complex movements including medial-lateral movement with different range of motion. The CG received traditional foot and ankle exercise without technology. Daily physical activity data was assessed for 48 hours (day and night) at baseline and post 4-week exercise using a validated wearable sensor (PAMSysTM). Daily physical activity was quantified by duration spent in each main posture (i.e. lying sitting standing and walking) and activities (e.g. postural transition sedentary behavior etc). Results: All IG subjects achieved to complete all exercise tasks indicating the feasibility of the Exergame platform. No adverse event or difficulty were reported indicating practicality of the exercise program. None subject in the IG was dropped out during the 4-week exercise program. Low dropout rate may indicate acceptability of the proposed Exergame platform. At the end of intervention subjects in the IG were more active than subjects in the CG. In summary the IG performed 53% more posture transitions to walking (Cohen's d effect size = 0.5) and 39% more posture transitions between sitting and walking (d = 0.5) when compared to the CG. Subjects in the IG also had significant less sedentary behavior than subjects in the CG. In summary subjects in the IG spent 5% less time on sitting and lying (p = 0.049 d = 0.7) as well as 47% more time on standing and walking (p = 0.049 d = 0.7) when compared to subjects in the CG. Conclusions: This study demonstrated feasibility acceptability and effectiveness of an innovative Exergame program to improve daily physical activity in diabetic patients undergoing HD treatment. The key innovation of the proposed intervention is its practicality to be done during HD process which could address the limitations of prior exercise interventions in HD patients for example the low adherence of therapeutic exercise. Further studies should be addressed to confirm the observation with larger sample sizes.
GameBased NonWeight Bearing Exercise to Improve Postural Balance in Diabetic Patients Underjoining Hemodialysis
Background: Poor balance falls and foot problems are serious detriments for the diabetic patients due to the obesity and diabetic foot ulcer. In addition for the diabetic patients undergoing hemodialysis (HD) treatment the HD process often leaves them too fatigued to engage in any physical activity or daily exercise further deteriorating their motor functions and increasing risk of falling. Exercise would be effective for this population. However due to the time availability post-dialysis fatigue as well as limitation of transportation to exercise facility the conventional exercise for this population is impractical. Objective: We are developing an interactive foot and ankle exercise game that can be played during HD sessions to improve foot region blood flow as well as reduce foot problems. In this study we examined the feasibility and effectiveness of this innovative wearable sensor based non-weight bearing exercise (Exergame) to improve postural balance in diabetic patients undergoing HD treatment. Methods: Sixty diabetic subjects receiving HD treatment were recruited and randomized into an intervention group (IG: n = 29 age = 63.3 ± 7.9 years BMI = 31.2 ± 6.5 kg/m2 female = 41%) and a control group (CG: n = 31 age = 66.5 ± 10.7 years BMI = 32.3 ± 8.2 kg/m2 female = 55%). Both groups underwent a 4-week ankle and foot exercise program (30 minutes per session two sessions per week) during HD process. The IG received exercise via the Exergame program which uses wearable sensors attached on subject's feet. The subject's 3-dementional ankle and foot movements were visualized in real-time on a computer screen placed in front of him/her. The subject performed some game-like tasks by moving and rotating the foot and ankle. The difficulty level of the task was gradually increased depending on ability of the subject (like a game) from a simple flexion-extension movement to more complex movements including medial-lateral movement with different range of motion. The CG received traditional foot and ankle exercise without any technology. Postural balance was assessed in the semi-tandem test. Balance tests were performed at baseline and conclusion of the program under both eyes-open and eyes-closed conditions. Balance parameters included ankle sway and hip sway in anterior-posterior (AP) direction (degree) medial-lateral (ML) direction (degree) as well as in area (degree2). Results: All IG subjects achieved to complete all exercise tasks indicating the feasibility of the Exergame platform. No adverse event or difficulty were reported indicating practicality of the exercise program. None subject in the IG was dropped out during the 4-week exercise program. Low dropout rate may indicate acceptability of the proposed Exergame platform. Under eyes-open condition the IG had significant ankle sway reduction in the AP direction (Cohens’ d effect size = 0.55 p = 0.037) when comparing with the CG. At conclusion the AP direction ankle sway reduced 18% in the IG while in the CG it increased 58%. More significant improvements of postural balance were observed under eyes-closed condition. When comparing with the CG the IG had significant ankle and hip sway reductions in both AP and ML directions as well as in area (p < 0.050). The highest effect size contrasting changes between the IG and CG was also observed for ankle sway in ML direction (Cohens’ d effect size = 0.76 p = 0.005). Conclusions: This study demonstrated feasibility acceptability and effectiveness of an innovative Exergame program to improve postural balance in diabetic patients undergoing HD treatment. The key innovation of the proposed intervention is its practicality to be done during HD process which could address the limitations of prior exercise interventions in HD patients for example the low adherence of therapeutic exercise.