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Research Report
Background and Purpose. Virtual reality (VR) technology has gained impor-
tance in many areas of medicine. Knowledge concerning the application and
the influence of VR-enhanced exercise programs is limited for patients
receiving coronary artery bypass grafting. The purpose of this study was to
evaluate the effect of a virtual “country walk” on the number of sessions
necessary to reach cardiac rehabilitation goals in patients undergoing coro-
nary artery bypass grafting. Subjects. Twenty subjects who were seen for
cardiac rehabilitation between January and June 2004 comprised the study
sample. Methods. The protocol for this study included an initial maximum
graded exercise tolerance test, given to determine the subsequent training
goals for the subject, followed by biweekly submaximal endurance training
sessions. All subjects were assigned by lot to 1 of 2 submaximal endurance
training programs, one (group 2) with and the other (group 1) without the
added VR environment. In all other respects, the 2 programs were identical.
Each training session lasted for 30 minutes and was carried out twice per week
for about 3 months. The primary outcome measures were maximum load
during the work sessions, target oxygen consumption, target heart rate (beats
per minute), and number of training sessions required to reach rehabilitation
goals. Results. By the end of 20 training sessions, only 4 of the 10 control
subjects had reached the heart rate target goal of 85% their maximum heart
rate. In contrast, 9 of the 10 subjects in the VR program had attained this goal
by 9 or fewer training sessions. When target metabolic cost (75% peak oxygen
consumption) was used as the training goal, all 10 subjects in the VR program
had reached this target after 2 training sessions (or, in some cases, 1 training
session), but not until training session 15 did a cumulative number of 9
control subjects reach this goal. Discussion and Conclusion. These study
outcomes clearly support the notion that incorporating a VR environment
into cardiac rehabilitation programs will accelerate maximum recovery of
patients’ cardiovascular function. [Chuang TY, Sung WH, Chang HA, Wang
RY. Effect of a virtual reality– enhanced exercise protocol after coronary artery
bypass grafting. Phys Ther. 2006;86:1369 –1377.]
TY Chuang, MD, is Attending Physician and Associate Professor, Department of Physical Medicine and Rehabilitation, Taipei Veterans General
Hospital, No. 201, Shih-Pai Rd, Sec. 2, Taipei, 11217 Taiwan, and School of Medicine, National Yang-Ming University, Taipei, Taiwan. Address all
correspondence to Dr Chuang at: tychuang@vghtpe.gov.tw.
WH Sung, PhD, is Assistant Professor, Department of Biomedical Engineering, I-Shou University, Kaohsiung, Taiwan.
HA Chang, PT, MS, is Physical Therapist and Research Associate, Department of Physical Medicine and Rehabilitation, Taipei Veterans General
Hospital.
RY Wang, PT, PhD, is Professor and Acting Chairman, Institute and Faculty of Physical Therapy, National Yang-Ming University.
Dr Chuang and Dr Sung provided concept/idea/research design and facilities/equipment. Dr Chuang provided writing. Ms Chang provided data
collection and analysis. Dr Chuang and Ms Chang provided subjects. Dr Wang provided research consultation (including review of manuscript
before submission).
This study was approved by the Ethics Committee of the Institutional Board of Taipei Veterans General Hospital.
This study was supported by a grant from the National Science Council (NSC 92-2314-B-075-030).
This article was received October 19, 2005, and was accepted May 10, 2006.
DOI: 10.2522/ptj.20050335
c
Each level was used for 5 minutes. 85% HRmax, 75% V̇o2peak, or both, as
There was a 3-minute warm-up period.
recorded during the exercise testing
session. These target intensities were
chosen on the basis of guidelines from
a mountain background.10 Once the treadmill was the American College of Sports Medicine11,12 and, being
attached to the PC system, the rate of the subject’s 15% to 25% lower than those used for subjects who are
movement matched the environmental flow on the healthy, were thought to be safe for the compromised
screen at a rate of 30 frames per second. The VR group in our study. Heart rate, V̇o2 , and treadmill
programs also offered immediate biofeedback on the grades and speeds were recorded for each subject during
subject’s condition with free-run (ie, continuously dis- each session. Blood pressure was measured in these
played without recording) HR, respiratory rate, and sessions every 5 minutes, before an increase in the
electromyography waveforms (I-330-C2†) of both thighs treadmill grade or speed. The subject was connected to
on an additional window at the right upper corner of the an electrocardiography machine for recording of HR.
screen. To estimate 75% V̇o2peak during the endurance train-
ing session, we recorded the speed and incline of the
In some VR experiments, the users wear head-mounted treadmill at 75% V̇o2peak during the exercise testing
displays and thus experience “total immersion” in VR. session and used attainment of this speed and incline as
We chose to use large “wraparound” screens instead of evidence that 75% V̇o2peak had been achieved.13 This
head-mounted displays because head-mounted displays procedure has been used for years in exercise training,
produce “simulation sickness” in some users. In addi- because it is impossible to use the precise procedure
tion, head-mounted displays prevent users from being (use of a mask) to record oxygen and carbon dioxide
able to see their own bodies, and this situation, for some, levels. Oxygen consumption was chosen as a second
can be a highly unpleasant experience.4 exercise endpoint because many of the subjects were
taking beta-adrenergic blockers, which affect HRmax. In
Cardiorespiratory Testing the training protocol, the subject exercises on a tread-
Cardiorespiratory testing was done initially to find each mill, starting with 3 minutes of very low-level exercise
subject’s HRmax and V̇o2peak. These data were used to (warm-up), after which the work rate is increased every 5
determine the specific goals for the subject to reach minutes, as shown in Table 1. In this way, the work rate
during the subsequent exercise training sessions. We adds 1% and 0.8 km/h (0.5 mph) during each 5-minute
described cardiorespiratory testing in previous period until the subject reaches a score of 16 for
reports.7,9 The anaerobic threshold, which is the point at perceived level of exertion on the Borg 6- to 20-point
which the steepness of the slope of the curve for V̇o2 rating scale (that is, an effort somewhere between “hard”
versus work output lessens as anaerobic glycolysis begins, and “very hard”) or until the subject reaches the target
also was measured. HR and V̇o2.
In brief, for the exercise testing protocol used in the Depending on the subject’s condition, the training may
current investigation, subjects took part in up to 10 be stopped before 30 minutes or may last a little longer
exercise periods of 3 minutes’ duration. This protocol than 30 minutes. In addition, the work rate increment is
adjusted downward if required by the subject’s cardio-
respiratory status; that is, if, during a given work rate
†
J&J Engineering, 22797 Holgan Ct NE, Poulsbo, WA 98370.
Data Analysis
Data entry and statistical analyses were
performed with SPSS version 10.0.‡
The 2-sample t test for independent
samples was used to compare the base-
line characteristics of the 2 groups.
With the Kaplan-Meier method, the
number of training sessions that the
subjects in each training group under-
went before the target event occurred
was analyzed to evaluate the effect of
VR on the time required to achieve the
target goals. This method is used to
analyze discontinuous “yes/no” events
and takes into account the phenome-
non that some subjects may exit a study
before the target event has been
reached. We defined the event to be
evaluated as the achievement of target
exercise capacity (ie, 85% HRmax, 75%
V̇o2peak, or both). That is, the value of
the response variable was equal to 1 if
the target aerobic power was reached
and equal to 0 if the subject failed to
achieve the specified target. Compari-
sons of the resulting exercise goal
achievement graphs (VR versus non-
VR) were based on the log-rank and
Breslow tests. The acceptable level for
statistical significance was set at P⬍.05.
Figure 2. Results
Consort flow chart diagram outlining the progress of participants through the various phases of Of the 24 subjects selected, 4 were
the randomization. Subjects who completed the trial were included in the statistical analyses. found to be unable to tolerate the
Some subjects (see Figs. 3 and 4) left the trial when only one target goal had been achieved.
endurance training sessions because of
their medical conditions, which were as
follows: unstable angina (n⫽1), uncon-
increment, a subject’s blood pressure increased to more trolled symptomatic heart failure (n⫽2), and uncon-
than 220 mm Hg systolic or 120 mm Hg diastolic or a trolled cardiac arrhythmias causing symptoms or hemo-
subject’s HR increased more than 10 beats per minute,11 dynamic compromise (n⫽1) (Fig. 2). These subjects
the therapist decreased the next slope or speed incre- therefore were excluded from the analyses, leaving 20
ment somewhat from the preset protocol. We did not outpatients (20 men) in the study. The clinical charac-
always insist on the preset protocol for ethical reasons. teristics of this final sample are shown in Tables 2 and 3.
Previous research also showed that changing the size or Five subjects (4 in the control group and 1 in the VR
length of the increments in an exercise protocol does group) left the study before their second target goal had
not change the maximum load that a subject is able to been achieved. One subject in the control group did not
tolerate.14
‡
SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.
Differences Between the Groups in the Slope and Speed “off the cliff,” but also his HR will go up as in fear, even
Adjustments in the Training Protocol though he knows at the same time that the cliff is not
Except for the incorporation of the VR experience, the real.4 The most likely explanation for our results is that
exercise protocols were the same for both groups of it was this feeling of presence and involvement in an
subjects. However, it is worth noting that even if the alternate experience that allowed the subjects in the VR
incremental steps used had been different, the results group to tolerate higher maximum exercise levels and
would not have been affected, because previous experi- reach their individual exercise goals in a shorter time
ments by others showed that variations in these steps do period. Whether more common distractions, such as
not change the exercise level at which a subject’s maxi- listening to music, also would accelerate attainment of
mum exercise tolerance occurs.14,15 these goals we do not know, because our protocol was
not designed to address this question.
Effect of the VR Experience Itself
The VR experience is a powerful one, quite different in Encouragement From Biofeedback
intensity and quality from ordinary attention diversions, One difference between the subjects in the VR group
such as listening to music or watching television. and the control subjects was that the former subjects
Although participants know that the VR experience is could see their HR, respiratory rates, and electromyogra-
not real, they describe the experience as feeling phy results in the right upper corner of the VR screen.
immersed in the VR scene, as if they are actually there, However, they were not told what their target HR was. It
and they behave as if the virtual is real.4 This immersion is possible that this opportunity for biofeedback was a
is physiological as well as psychological. For example, if factor in their superior performance. The possible expla-
VR shows the participant that his next step will cause him nations are not known at this time but will be investi-
to fall off a cliff, not only will he refuse to step forward gated in a future study.
Heart Rate Versus V̇O2 Goals reason for these results was that the VR experience
Two target goals were used in this study: 85% HRmax lessened the subjects’ awareness of actual physical dis-
and 75% V̇o2peak. Both study groups reached the V̇o2 comfort, and so they exercised to a higher level than
goal in fewer training sessions than were needed to they otherwise would have chosen to do.
reach the HR goal. We used standard nomograms in this
study to calculate the degree of V̇o2 considered to be the Possible Long-Term Benefit
equivalent of the HR goal.16 However, despite this We do not yet know the long-term clinical benefit of
strategy, the V̇o2 goal seems to have been set at a lower early achievement of exercise goals. However, at the
level than the HR goal. Factors unrelated to HR, such as moment, early achievement of these goals would not
ambient temperature or physical fitness, can alter V̇o2 affect insurance reimbursement, because currently the
and the caloric cost of exercise.17 For this reason, HR number of training sessions reimbursed is based on the
and perceived exertion rating are the parameters most patient’s risk level, as determined by the American
frequently used for assessing exercise intensity levels. Association of Cardiovascular and Pulmonary Rehabili-
However, because we were concerned about the effect of tation classification rules, as follows: low risk level, up to
the beta-adrenergic blockers that some of the subjects 6 supervised training sessions; middle risk level, up to 18
were taking on the HR results, we wanted to use another such sessions; and high risk level, more than 36 such
independent, objective estimate of exercise intensity; sessions.18,19
therefore, we included V̇o2 as a second goal.
Conclusion
Effect of VR on V̇O2 Results We cannot explain exactly how VR influences exercise
The subjects in the VR group reached their V̇o2 goal by performance. However, our study showed a powerful
the end of the second training period, a time that seems effect of a VR environment on the progress of cardiac
too short for any substantial physiologic change to have rehabilitation and the results suggest that incorporating
occurred. They also reached greater highest treadmill VR into rehabilitation programs will accelerate the max-
speeds than the control subjects. Presumably part of the imum recovery of a patient’s cardiovascular fitness.
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