Exergaming as a Supportive Tool for Home-Based Rehabilitation in the COVID-19 Pandemic Era

In December 2019, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appeared in Wuhan, China.^1,2 Despite the attempts to limit its diffusion in the frame of a global containment strategy, SARS-CoV-2 reached pandemic levels in March 2020. ³

SARS-CoV-2 infection can determine the coronavirus disease 2019 (COVID-19), a condition with a broad spectrum of clinical manifestations, ranging from a flu-like disease to an acute respiratory distress syndrome (ARDS) requiring intensive care unit (ICU) management. ⁴

To date, considering the number of dark points, the long-term outcomes of COVID-19 are still to be determined. In particular, little is known about the possibility to return to a baseline functional status and to baseline levels of health care needs after SARS-CoV-2 infection. However, based on literature data, some preliminary reflections can be made on this topic.

In recent years, the advanced treatment strategies in ICU significantly reduced mortality among ARDS patients. ⁵ Spirometry reveals a good capacity of recovery in terms of lung function after ARDS, with a complete resolution of consolidation in all survivors and <10% of patients with mild residual computed tomography alterations. ⁶

If the lung is an organ with a good healing capacity, some residual limitations in quality of life and activities of daily living have been reported after ICU stay, thus resulting in the so-called postintensive care syndrome. ⁷

A reduced distance at the 6-minute walking test with a corresponding reduction in the physical component of the 6-Item Short Form Health Survey has been reported among 109 ARDS survivors after 5 years from ICU discharge, with cumulative postdischarge costs being comparable with those of older subjects with important comorbidities. ⁸

The fact that young subjects without significant comorbid conditions may not return to their previous functional status and to a baseline utilization of health servicies after ARDS and ICU stay could be a major concern in the current global emergency due to the SARS-CoV-2 pandemic.

At present, the reasons for the functional sequelae of ARDS are a matter of study, and different hypotheses have been put forward (e.g., organizing pneumonia, secondary pulmonary fibrosis, and chronic thromboembolic pulmonary hypertension).^9–11 However, if we also consider the high incidence of cardiac and neurologic manifestations among severe COVID-19 patients^12,13 and the number of ICU-related complications (e.g., postextubation dysphagia, bedsores, and urinary dysfunction), ⁷ the need of a rehabilitative intervention after discharge seems to be a natural consequence for critically ill patients with SARS-CoV-2 infection. ¹⁴ In keeping with this, some preliminary data showed a high prevalence of residual functional limitations (e.g., sleep and mood disorders) even among patients with mild disease. ¹⁵ Given the complexity and variability of clinical manifestations and long-term outcomes, the implementation of multidisciplinary and personalized rehabilitation strategies for COVID-19 patients may represent a step forward in the management of these patients after the acute phase.

Overall, it is reasonable to assume that the unmet need of rehabilitative interventions will be further worsened by the pandemic, as a consequence of both the severe rules of social distancing and of the increased demand. To date, >18 million cases and 680,000 COVID-19 deaths have been recorded worldwide. Considering the rapidly increasing number of confirmed cases with at least one in five COVID-19 patients needing semi-intensive or intensive supportive care, ⁴ the health providers had to rethink their organization, being forced to rapidly increase the critical care capacity. As a result, many rehabilitation hospitals have been converted into medical emergency wards, whereas others have been closed or their access has been reduced by regional laws aimed at limiting SARS-CoV-2 spread. This rearrangement of health care facilities has negatively impacted the possibility to access the rehabilitation services even for non-COVID-19 patients. ¹⁶ Thus, although the major concern so far has been the shortage of ICU beds, now a “tsunami of rehabilitation needs” is expected. ¹⁷

A further aspect to consider is that some COVID-19 patients who have physically recovered and found negative to the swab test may result positive again up to 13 days later when using a different manufacturer's test kit. ¹⁸ Moreover, it has been shown that the virus may also persist in the oropharyngeal cavity or in the stools for up to 15 days after a patient has been declared cured of COVID-19 (no fever, no respiratory symptoms, and two negative swab tests). ¹⁹ This is of particular concern for patients intending to be directed to rehabilitation facilities or long-term care, because they may still be able to transmit the disease.

Overall, new solutions are urgently needed to meet the increased rehabilitation demand while facing the current difficulties imposed by the pandemic.

Considering the need to limit contacts and contagion opportunities during the SARS-CoV-2 pandemic, telemedicine with home-based interventions is becoming a useful tool to support remote health care for several clinical conditions. ²⁰ In keeping with this, telerehabilitation may be an emerging and innovative approach for both COVID-19 and non-COVID-19 patients. ²¹ However, technologies and health care providers may not be ready to manage an everyday telerehabilitation approach. Moreover, further studies are needed to optimize techniques.

In the frame of a home-based approach during a period of global emergency, exercise games (exergames) may be particularly suited to implement the rehabilitative interventions, ensuring an adequate level of physical activity at home with long-term adherence to exercise. ²² Commercially available exergames are made for recreation and fitness and, of course, they cannot achieve all the goals of a multidisciplinary inhospital rehabilitation. However, the use of this technological support for an unsupervised physical activity may be particularly tailored for rehabilitative purposes in a pandemic era.

Exergaming is based on the use of videogames and devices converting body movements into avatar's movements on screen, ²³ thus offering the possibility of an immersive experience in a realistic three-dimensional setting (immersive virtual reality) or a nonrealistic experience with no sensation of being immersed in the virtual world (nonimmersive virtual reality). ²⁴ In other words, besides the different simulation technologies, physical activity is translated into the game activity, thus ensuring the primary objective of exercise, which is exercise itself. However, the lack of supervision does not ensure the secondary objective of exercise, which is “how” the exercise should be performed. Moreover, the lack of therapist's supervision may potentially increase the risk of falls in older and fragile patients.

These potential limitations of commercially available exergames call into question some considerations. First, the limited research that has been conducted on movement quality and patterns in exergaming mainly involved younger subjects, showing that the movements performed during exercise are highly variable, with different exergames being tested before obtaining the intended movement characteristics for a specific clinical setting. ²⁵ Moreover, it should be considered that younger patients, who may have a lower susceptibility to SARS-CoV-2 infection and a lesser propensity to show clinical symptoms,^26,27 are conversely the most likely to be compliant to the use of videogames, particularly outside the rehabilitation hospital. ²⁴

Overall, it seems clear that commercial exergaming may support—not replace—traditional rehabilitation of younger patients during the pandemic, thus contributing to cope with the increased demand. However, a minimum of supervision should be ensured (at least remotely by a therapist), particularly in the early phases of the rehabilitative intervention and for those patients using home-based exergaming as the sole exercise-based rehabilitative approach. In this regard, the use of a web conferencing software could help patients to choose the games and to identify the correct movement patterns.

Of course, although exercise remains the cornerstone of intensive and extensive rehabilitation, a multidisciplinary approach (e.g., nutrition counseling, psychological support, and pharmacological intervention) is usually required for patients discharged from the acute setting, ²⁸ and exergaming may only partially address the needs of COVID-19 and non-COVID-19 patients requiring rehabilitation. Thus, considering the necessity to maintain social distancing, exergaming may be used to support another home-based and more structured approach, namely telerehabilitation. Exergaming and telerehabilitation share many advantages and limitations. Thus, as a supportive tool, exergaming may be integrated in the programs of telerehabilitation for younger patients in the COVID-19 era. In this regard, if commercially available exergames cannot guarantee correct movement quality and patterns, the development of new “therapeutic exergames” supporting both primary and secondary goals of exercise could be implemented to promote a safe and autonomous home-based intervention.

Several studies have already shown the effectiveness of exergaming and virtual reality in the rehabilitation of poststroke patients, ²⁹ of those with Parkinson's disease, ³⁰ or with acquired brain injury. ³¹ Furthermore, we recently demonstrated the usefulness of exergaming in prolonging the benefits of inhospital rehabilitation for young patients with rheumatoid arthritis. ²⁴ Further supporting its potential use in a pandemic era, a recent study suggested the use of exergaming as a coping strategy for preventing and treating anxiety disorders in a home-based environment during the COVID-19 quarantine period. ³²

Overall, despite being designed for recreational purposes, commercially available exergames may help to cope with the rehabilitation needs of a population that, due to the limitations imposed by the lockdown and the containment strategies, does not have access to traditional rehabilitation therapy. In addition, it has been shown that exergaming may prolong the benefits of traditional exercise-based rehabilitation after inhospital stay and potentially reduce the time spent in hospital for rehabilitation. This may be of major interest during the current pandemic, to limit both the duration and the number of hospitalizations to rehabilitate COVID-19 and non-COVID-19 patients.

In conclusion, exergames may have the potential to be strongly implemented in the near future in the rehabilitation setting, also considering that such a constant increase in rehabilitation demand cannot be sustained in the long term.