The Effects of Virtual Reality Physiotherapy Interventions on Cardiopulmonary Function and Breathing Control in Cystic Fibrosis: A Systematic Review

Abstract

Motivation and adherence are the main factors that limit participation in physiotherapy exercise sessions and airway clearance in cystic fibrosis (CF) population. One of the newly developed techniques is to use virtual reality (VR) games to increase motivation and adherence during exercise sessions for this population. However, this area is still poorly investigated. This review aims to evaluate, summarize, and review published literature regarding the effects of VR exercise on cardiopulmonary function and the use of VR games as a tool for airway clearance technique in CF population. A systematic search was conducted using PEDro, MEDLINE, AMED, CINAHL Plus, and relevant associated keywords. Seventy-three citations were identified from the search, of which 10 were included in this review. Overall, the use of VR was found to have positive effects on cardiac function and improved adherence and motivation during the exercise sessions in people with CF. Incorporating VR into exercise and airway clearance interventions may be beneficial for people with CF. However, further studies with larger sample size and wider range of disease severity are required to be conducted in future.

Introduction

Cystic fibrosis (CF) is a genetic disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, affecting >70,000 adults, adolescence, and children worldwide.¹ CF affects multiple body regions, but mainly targets the respiratory system and the gastrointestinal system.² This therefore leads to infections and progressive inflammatory processes impairing pulmonary function and exercise capacity.² Symptoms of CF include wheezing, coughing, shortness of breath (dyspnea), weight loss, jaundice, and diarrhea or constipation,³ which may affect adults, adolescents, and children with quality of life.

Although there is no cure for CF, certain interventions reduce or delay associated complications. These include antibiotics; inhaled medicines; pancreatic enzyme supplements; CFTR modulator combination therapy; airway clearance techniques (ACT); and pulmonary rehabilitation programs.⁴ The new CFTR modulator combination therapy include elexacaftor/tezacaftor/ivacaftor (Trikafta) and this therapy was approved by the FDA for CF treatment in October 2019.⁵ Pulmonary rehabilitation programs for CF focus on both resistance and aerobic exercises.^6,7 Aerobic exercise contribute to the reduction in dyspnea, improving aerobic capacity and exercise tolerance, improving mucociliary clearance, reducing depression, and improving quality of life.^4,7 ACT such as huffing is an essential physiotherapy technique as part of autogenic drainage for children with CF.⁴

However, most people with CF do not adhere to both pulmonary rehabilitation, physical exercises, and ACT.⁸ Previous studies reported that enjoyment and engagement are the main factors that limit adherence and compliance with physiotherapy programs for people with CF.⁹ Other factors include perceptions of physical activity, value attributed to physical activity, and social influences.¹⁰

With the revolution and rapid advancement of technology, games started to take an important role in self-management physiotherapy programs in different populations. For example, virtual reality (VR) games were used as a physiotherapy intervention to improve physical functioning in: stroke survivors¹¹; cerebral palsy¹²; adults, adolescents, and children with acquired brain injuries¹³; orthopedic conditions¹⁴; cancer¹⁵; burn injuries¹⁶; people with Parkinson's¹⁷; and multiple sclerosis.¹⁸

It is well documented and known that adolescents and children in the general population are interested in different means of entertainment including VR games.¹⁹ Therefore, using videogames to physically challenge children and adolescents with CF might help to increase their motivation and engagement in pulmonary rehabilitation exercises and in ACT. Several studies have investigated the effects of VR physiotherapy interventions for people with CF.^20–29 In addition, VR physiotherapy interventions showed that although clinical or community-based rehabilitation might need to purchase the required equipment, it will still be more cost-effective than the supervised traditional physiotherapy sessions.^30–32 Furthermore, VR exercises allowed physiotherapy to expand in terms of home-unsupervised rehabilitation programs and hospital-based programs.^30–32

However, prescribing exercise using videogames remains challenging in terms of intensity of the game used, type of console used, and accuracy of sensors to movement. Thus, this systematic review aims to evaluate, summarize, and review published literature about (1) the effects of VR exercise on cardiopulmonary function in CF; and (2) the use of VR games as a tool for ACT in pediatrics, adolescents, and adults with CF.

Methodology

Design

A systematic review with quality assessment and narrative synthesis of relevant published literature. The systematic review protocol is registered in the International prospective register of systematic reviews database (PROSPERO) (PROSPERO 2021, CRD42021242496). Outcomes are defined as pulmonary function test (PFT) variables including forced expiratory volume in one second (FEV₁) and vital capacity (VC), cardiopulmonary exercise test (CPET) variables including oxygen uptake at maximal exertion (VO_2max); oxygen uptake at peak exertion (VO_2peak); maximum Heart rate (HR) (HR_max); and peak HR (HR_peak); dyspnea, forced breathing techniques (FBT), motivation, and adherence. The study aimed to conduct a meta-analysis for the outcome measures, where feasible. If conducting a meta-analysis was not possible, the study aimed to conduct a narrative synthesis. PRISMA checklist was used while conducting and writing the systematic review for quality assurance.

Search strategy

A search was completed through EBSCO using the following electronic databases: MEDLINE, AMED, and CINHAL Plus. In addition, the Physiotherapy Evidence Database (PEDro) was used for further searches. The search was limited to full-text English language articles and excluded conference abstracts. The selected databases were chosen because of the likely availability of CF physiotherapy and exercise-related articles. The databases were searched for studies published between January 1, 1970, and April 1, 2022, with results of the searches managed using Endnote Version X7 (Clarivate Analytics, Philadelphia). The Medical Subject Headings (MeSH) were used to allow reproducibility and accuracy of the search. Table 1 summarizes the combinations of keywords included in the search strategies.

Table 1.

Summary of Keywords Used and Search Strategy

Search strategy	Search strategy
P-(population)	1 = Cystic fibrosis (adults or pediatrics with age range between 7 and 40 years old)
I (Intervention)	2 = Virtual reality 3 = Virtual reality games 4 = Video games 5 = Video game 6 = Wii 7 = Nintendo Wii 8 = Kinect Xbox 9 = PlayStation 10 = Computer games 11 = Active video games 12 = 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11
C (comparison)	Search was not limited to a specific comparator
O (outcome measures)	13 = Cardiopulmonary exercise test 14 = Exercise test 15 = 6MWT 16 = Graded exercise test 17 = Pulmonary function 18 = Pulmonary function TEST 19 = Spirometry 20 = Spirometer 21 = Oxygen uptake 22 = VO_2max 23 = VO_2peak 24 = Heart rate 25 = Pulse rate 26 = Dyspnea 27 = Dyspnea 28 = Shortness of breath 29 = Peak expiratory flow 30 = Expiratory high flow events 31 = Inspiratory flow 32 = Expiratory flow 33 = 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32
S (study design)	Cross-sectional studies, randomized controlled trials, controlled clinical trials, controlled quasi-experimental studies, and case studies
Combined final search	1 AND 12 AND 33

To allow reproduction of the results, adapted searches for each database was conducted according to the PRISMA guidelines. Figure 1 is a screen shot of the adapted search for the MEDLINE database.

FIG. 1.

A screenshot showing MEDLINE separate search as an example about reproducibility of the results.

To have a broader idea about ongoing research, gray literature was explored using the World Health Organization (WHO) International Clinical Trials Registry platform.

Inclusion and exclusion criteria

PICOS system (population, Intervention, comparison, outcome measures, and study design) was used for the inclusion and exclusion. Cross-sectional studies, randomized controlled trials, nonrandomized controlled trials, controlled quasi-experimental studies, and case studies investigating the effects of VR exercise on cardiopulmonary function in CF were included. Studies that did not include either exercise testing, spirometry, motivation/adherence assessment, or breathing control exercises were excluded. Preclinical studies (animal model studies) were excluded (Table 1). Primary outcomes were defined as exercise test outcomes (heart rate, oxygen consumption, distance walked, or workload). Secondary outcomes included number of FBT and FEV₁, VC, ACT, motivation, and adherence.

Study selection

Following the search and subsequent removal of duplicates, titles and abstracts were screened by two researchers (M.Z.D., A.A.) for relevance. Full texts of relevant studies were then screened for eligibility against the inclusion and exclusion criteria.

Data extraction

The following data were extracted from the included studies and presented in a table: study design, sample size, sex, age, console used/games used, exercise test utilized, outcome measures reported, and key findings. Where available, frequency, time, intensity, and type of exercise were noted.

Quality assessment of the included studies

Quality assessment of included studies was assessed using the PEDro scale, a valid and reliable tool for assessment of quality of interventional studies specifically related to physical therapy interventions.^33,34 Studies with cross-sectional design were checked for quality using the STROBE tool. PEDro scores and STROBE results for the studies were not used as an inclusion or exclusion criterion, but as a basis for best evidence synthesis and to determine the strengths and weaknesses of each study.

Results

The systematic search identified 73 citations, of which 23 were duplicates. Consequently, 50 citations were screened from titles and abstracts and 28 were considered not to be relevant owing to not including participants diagnosed with CF. Of the 22 remaining studies, 12 were excluded because they did not include VR aerobic exercise, VR breathing control, VR exercise, exercise test, or PFT. Consequently, 10 studies were included in the review: 4 studies were cross-sectional-controlled studies; 3 crossover trials; 1 nonrandomized trial; 1 case study pilot trial; and only 1 randomized controlled trial. The randomized controlled trial compared active videogames with traditional patient management. Three studies of the total included studies focused on breathing controlled VR exercise. Figure 2 represents a PRISMA flow chart for the findings of the search. In addition to published studies, two studies were identified from the gray literature search. One of these is a randomized controlled trial, and the other one is a crossover randomized controlled trial.

FIG. 2.

PRISMA flowchart for the search results and the included studies.

Quality assessment

PEDro scores for the five trials ranged from 6 to 9 (Table 2). STROBE results for the included cross-sectional studies are reported in Table 3.

Table 2.

Quality Assessment for the Included Trials

PEDro scores for the studies that investigated the effects of VR exercise and breath-control exercise on cardiopulmonary function and adherence in people with CF
Author (year)	1	2	3	4	5	6	7	8	9	10	11	Total PEDro score
Del Corral et al (2018)²³	1	1	1	1	0	1	1	1	1	1	1	9
Kuys et al (2011)²⁶	1	1	0	1	0	0	0	1	1	1	1	6
Salonini et al (2015)²⁸	1	1	1	1	0	0	1	1	1	1	1	8
Bingham et al (2012)²¹	1	1	1	1	0	0	1	1	1	1	1	8
Bingham et al (2010)³⁹	1	0	0	1	0	0	1	1	1	1	1	6
Wetzel et al (2019)²⁹	Not applicable (two participants only)

PEDro criteria: 1: eligibility criteria (not used to calculate the PEDro score); 2: random allocation; 3: concealed allocation; 4: baseline comparability; 5: blind subjects; 6: blind therapists; 7: blind assessors; 8: adequate follow-up; 9: intention-to-treat analysis; 10: between-group comparisons; 11: point estimated, and variability provided.

CF, cystic fibrosis; PEDro, Physiotherapy Evidence Database; VR, virtual reality.

Table 3.

STROBE Results for the Included Cross-Sectional Studies

	Recommendation	Campos et al (2020)²²	Del Corral et al²⁴	Holmes et al²⁵	O'Donovan et al²⁷
Abstract	(a) Indicate the study's design with a commonly used term in the title or the abstract	□	×	×	×
Abstract	(b) Provide in the abstract an informative and balanced summary of what was done and what was found	□	□	□	□
Background/rationale	Explain the scientific background and rationale for the investigation being reported	□	□	□	□
Objectives	State specific objectives, including any prespecified hypotheses	□	□	□	□
Study design	Present key elements of study design early in the paper	□	□	□	□
Setting	Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection	□	□	□	□
Participants	(a) Give the eligibility criteria, and the sources and methods of selection of participants	□	□	□	□
Variables	Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable	□	□	□	□
Data sources/measurement	For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group	□	□	□	□
Bias	Describe any efforts to address potential sources of bias	×	×	×	×
Study size	Explain how the study size was arrived at	×	×	×	×
Quantitative variables	Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why	□	□	□	□
Statistical methods	(a) Describe all statistical methods, including those used to control for confounding	□	□	□	□
Statistical methods	(d) Describe any sensitivity analyses	×	×	×	×
Participants	(a) Report numbers of individuals at each stage of study—e.g., numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analyzed	□	□	□	□
Descriptive data	(a) Give characteristics of study participants (e.g., demographic, clinical, social) and information on exposures and potential confounders	□	□	□	□
Outcome data	Report numbers of outcome events or summary measures	□	□	□	□
Main results	(a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (e.g., 95% confidence interval). Make clear which confounders were adjusted for and why they were included	□	□	□	□
Key results	Summarize key results with reference to study objectives	□	□	□	□
Limitations	Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias	□	□	□	□
Interpretation	Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence	□	□	□	□
Generalizability	Discuss the generalizability (external validity) of the study results	×	×	×	×
Funding	Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based	□	□	□	□

To assess the feasibility of conducting a meta-analysis, data were extracted and summarized in Table 4 and focused on PFT variables; the protocols used for CPET; mode of the test: treadmill, cycle test, or field-based test; CPET test primary outcomes (VO_2max and VO_2peak); HR_max, and HR_peak. Only one study investigated the effects of VR games on spirometry. Meta-analysis of data was not conducted owing to the heterogeneity of the studies, specifically inclusion/exclusion criteria, exercise test protocol, mode of exercise test (cycle, treadmill, or field-based test), exercise intensity (maximum or sub-maximum), and physiological outcomes (HR, VO_2peak, VO_2max). Instead, a narrative review was conducted.

Table 4.

Summary of Studies That Investigated the Effects of Virtual Reality Exercise and Breath-Control Exercise on Cardiopulmonary Function and Adherence in People with Cystic Fibrosis

Author (year)	Study design	Sample size	Male:female	Age (years), mean (SD)	Console/game used	Exercise prescription	Exercise test used	Outcomes used	Key findings
Campos et al (2020)²²	Cross-sectional controlled study	30 CF 25 HC	32:23	CF = 16.9 (5.1) C = 16.2 (5.0)	Nintendo Wii/Wii Fit Plus: Obstacle Course, Rhythm Boxing and Free Run. Xbox One/Just Dance 2015: Love Me Again, Summer and Happy	10-minute games, in a random sequence, with a 10-minute interval between games	Treadmill CPET. 2 minutes warm-up with a speed of 3 km/h and no incline. Then, the speed was increased by 0.5 km/h every minute with 3% incline until the end of the test	VO_2peak, maximal minute ventilation (V_E), RER, dyspnea and the modified Borg scale, HR_max	Very similar responses in VR gaming between patients with CF and healthy controls. Both Xbox One and Nintendo Wii raised HR, V_E, and VO₂ to levels close to those obtained in the CPET (AT values). Some games were able to increase cardiorespiratory responses to the level of intensity recommended for aerobic training
Del Corral et al (2018)²³	Single blind RCT	39 CF (19 EG and 20 CG)	20:19	EG = 12.6 (3.4) CG = 11 (3)	Nintendo Wii™ with the game EA SPORTSTM ACTIVE 2.	30- to 60-minute sessions, 5 days/week, for 6 weeks	Exercise capacity was measured by the 6MWT and MSWT	HR_max, walked distance for 6MWT and MSWT	VR training showed significant improvement in exercise capacity: 6MWT walked distance, 38.4 m (P < 0.01), and MSWT walking distance, after the intervention
Del Corral et al (2014)²⁴	Observational cross-sectional study	24 CF	16:8	12.6 (3.7)	Nintendo Wii with three games: (1) Wii Fit Plus (Wii-Fit); (2) Wii Active (Wii-Acti), and (3) Wii Family Trainer in random order during 5 minutes	5 minutes for each game	6MWT	VO_2peak, HR_max and V_E	Higher levels of HR in Wii-Acti = 80%; and Wii-Trainer = 82% and lower in Wii-Fit = 62% HR_max
Holmes et al (2013)²⁵	Observational cross-sectional study	10 Adults with CF	6:4	CF = 29 (6)	Xbox Kinect™ Your Shape Fitness Evolved (boxing, yoga, dance and other aerobic programs with increasing levels of difficulty)	No intervention. But comparing VR exercise with CPET. 20 minutes of VR exercise	CPET (cycle) with 1 minutes warm-up, then the rate at which the work rate increased by 20 W/min (aims to achieve symptoms within 8 to 12 minutes)	VO_2peak, dyspnea, maximal minute ventilation (V_E), HR_max and MVV	VR exercise intensity achieved an average of 80% HR_max VR exercise represents high intensity exercise for CF and may be an alternative to traditional exercise modalities
Kuys et al (2011)²⁶	Randomized cross-over trial	19 CF	10:9	CF = 28 (7)	Nintendo Wii EA Sports Wii Active (boxing, jogging, dancing) VS moderate intensity interval training using a treadmill or cycle ergometer	Two sessions of exercise (15 minutes each), intensity: aiming for a Borg scale score between 3 and 5	No exercise test used but measures were recorded during both interventions	HR_max, dyspnea, and energy expenditure (METs)	Similar HR response (mean difference 3 beats/min, 95% CI, −3 to 9), and similar energy expenditure (0.1 MET, 95% CI −0.3 to 0.5) between the two interventions
O'Donovan et al (2014)²⁷	Observational case-controlled study	30 HC and 30 CF	34:26	HC = 12.2 (2.7) CF = 12.3 (2.6)	Nintendo Wii Sports Boxing and Free Jogging	15 minutes for each game (total of 30)	6MWT	VO_2peak, HR_max	Jogging generated 78% HR_max whereas boxing generated 63% HR_max No significant differences between the two groups
Salonini et al (2015)²⁸	Randomized cross-over trial	30 CF	11:19	12 (2.5)	Xbox Kinect (Kinect Adventures River Rush 2), compared with stationary cycling	20 minutes	No exercise test used but measures were recorded during cycling and gaming	HR_max, dyspnea	No significant difference in the HR_max between the Xbox Kinect (165.0 [23.6]) and stationary cycle (170.8 [13.2], P = 0.2)
Bingham et al (2012)²¹	Pilot cross-over trial	13 CF	3:10	9.4 (2.5)	(1) VR period: A spirometer connected to a computer (newly developed game aiming to improve ACT and forced expiratory maneuvers) (2) Control period: traditional ACT	15 minutes daily for 2–3 weeks	Not applicable	PFT and engagement to ACT	Higher duration spent in ACT while playing the game versus traditional ACT (control period) (P = 0.07). No significant differences between the two periods (P = 0.71). Positive correlation between minutes of play and change in FEV₁ from baseline (r = 0.50, P = 0.09). VR period showed increase in vital capacity (P = 0.05).
Bingham et al (2010)³⁹	Pilot non randomised trial	10 CF	4:6	12 (5)	A spirometer connected to a computer (new breath biofeedback game aiming for control of RR, inspiratory and expiratory flow (tidal volume), and Peak inspiratory or expiratory flows	6 sessions with 15 minutes for each	Not applicable	Engagement to breathing exercise	Positive feedback and adherence to breathing exercise. Improvement in eye–breath coordination over five sessions (P = 0.026). The breath game is safe and can improve breath awareness among children with CF.
Wetzel et al (2019)²⁹	Case study	2 CF	1:1	18 and 20	VR glasses with newly developed diving game that incorporates breathing exercise by translating it into through the underwater world movements using PEP device	15 to 20 minutes with five phases of a cycle of airway clearance exercise with PEP	Not applicable	Engagement to breathing exercise	The game increased adherence to exercise more regularly. Overall experience of both players was positive. The game needs to be more challenging in future research

ACT, airway clearance techniques; AT, aerobic threshold; CG, Control group; CI, confidence interval; CPET, cardiopulmonary exercise test; EA, Early Access; EG, exercise group; FEV₁, forced expiratory volume in one second; HC, Healthy control; HR, heart rate; MET, metabolic equivalent; MSWT, modified shuttle walk test; MVV, maximum voluntary ventilation; MWT, minutes walk test; PEP, positive expiratory pressure; PFT, pulmonary function test; RCT, randomised controlled trial; RER, respiratory exchange ratio; RR, respiratory rate; SD, standard deviation.

Consoles used and games developed

Four studies used the Nintendo Wii™,^23,24,26,27 two studies used the Xbox Kinect™,^25,28 and one study used both Wii™ and Xbox™.²² Games used in these studies included activities like boxing, running, jogging, jumping, dancing, balance, and coordination. The three breath-control studies used spirometers connected to computers.^20,21,29 The two unpublished/ongoing trials include both the Wii and the Xbox as part of their interventions.

Key difference between Xbox Kinect and Nintendo Wii is that the Xbox Kinect can recognize voice commands, has voice and facial recognition, whereas Nintendo Wii does not have these features. In addition, Xbox Kinect uses a camera, whereas Nintendo Wii uses a wireless remote controller, and only one Xbox Kinect is needed for multiplayer gaming, whereas in Nintendo Wii multiple Wii remotes are needed.³⁵

None of the studies reported that the patients have worn VR glasses. All the games in the included studies used 3D environment platforms.

Effects of VR exercise programs on cardiopulmonary function

Heart rate

Seven articles included in the study assessed the effects of VR exercise on HR in CF. VR exercise showed to have similar HR response compared with exercise testing.^22–24 Although HR achieved in stationary cycling was higher, HR response in VR training showed acceptable range to the recommended exercise intensity levels (50%–86%).²⁸ Furthermore, O'Donovan et al²⁷ reported that HR response in CF was similar to healthy controls in VR training (ranges between 63% and 78% of HR_max). Holmes et al²⁵ compared VR exercise with CPET and reported that people with CF achieved 86% of their HR_max indicating high intensity achieved. Similarly, Campos et al reported very similar responses in VR gaming between patients with CF and healthy controls.²² Furthermore, VR training showed similar intensities to aerobic treadmill running and cycling.²⁶

Oxygen consumption and exercise capacity

When comparing oxygen consumption in different VR games, Campos et al, found that the Summer game for Xbox and the Free Run game for Nintendo Wii had similar responses to aerobic threshold achieved in CPET, indicating the ability to achieve high-intensity training in these games. On the contrary, children with CF achieved lower oxygen consumption while playing the Love Me Again game.²² When compared with the 6-minute walk test (6MWT), VR training showed higher VO₂ levels in CF.²⁷ Similarly, Del Corral et al²⁴ reported higher VO₂ response in CF who played Wii-Acti and Wii-Train games compared with the 6MWT, but lower levels when playing the Wii Fit game. Moreover, Nintendo Wii Fit Free Jogging game achieved higher VO₂ levels compared with Nintendo Wii Sports Boxing in CF.²⁷

Dyspnea and fatigue

Campos et al reported no significant differences between CF and healthy children who played Wii and Xbox when assessed the subjective sensation of dyspnea (Borg for dyspnea), lower limb muscle fatigue (Borg for leg fatigue) and exertion (OMNI scale). Decreased lower limb fatigue was found after VR training in two studies,^25,28 whereas Kuys et al²⁶ found no change in dyspnea after the VR training. When comparing fatigue between three Wii games (Wii Fit Plus, Wii Active, and Wii Family Trainer), Del Corral et al found no significant differences in dyspnea.²⁴

Airway clearance/breath-controlled games

FBT and FEV₁ was similar in VR training and traditional ACT (for example, huffing; coughing; active cycle breathing technique; or autogenic drainage).²¹ However, increased number of minutes played showed significant positive correlation with FEV₁.²¹ In addition, VC showed similar correlations with the game period.²¹ The other two studies did not assess physiological changes, but were case studies to develop and improve the games for future trials.²⁹ Wetzel et al reported positive feedback for both players (adolescents) who were included with the need for more challenging levels.²⁹ Moreover, Bingham et al²⁰ reported that repeated measures analysis of variance of a tracking fidelity statistic showed improvement in eye–breath coordination over five sessions of VR training (P = 0.026).

Motivation and adherence

All studies included reported high adherence to VR training. In 2018, Del Corral et al²³ reported 95% adherence to the sessions in CF who played 6 weeks VR games. Campos et al reported high motivation levels for children with CF who played both Xbox One and Nintendo Wii.²² Similarly, motivation to VR training was higher than traditional exercise therapy and more preferable for children with CF.²⁷ In addition, Salonini et al²⁸ and Kuys et al²⁶ reported that higher satisfaction level was achieved when exercising with Xbox compared with stationary cycling (when assessed by visual satisfaction scales). Similarly, the three breath-controlled VR training studies reported high engagement and adherence to the interventions,^20,21,29 and more minutes were spent using VR training than traditional ACT.²¹

Discussion

This review has shown that only a limited number of studies have investigated the effects of VR exercise on cardiopulmonary function in CF, and it has indicated that VR training could help achieve the targeted heart rate needed for this population. VR games are considered to be a cheap, self-management intervention compared with traditional physiotherapy exercise and ACT sessions. However, only one study has assessed pulmonary function using spirometer. In addition, studies included in this review were investigating short-term effects only. Therefore, future studies are recommended to investigate the long-term effects of VR exercise on pulmonary function, with an appropriate calculated sample size and different disease stages. The range of games/levels available also requires consideration to allow exercise prescription for different severities of the condition and to allow more choices for children and adolescents with CF.

In addition, this review revealed that there are three studies that developed VR breath-control exercise games and investigated its effect on respiration, motivation, and adherence. All the 10 studies included showed high adherence and motivation to VR exercise in CF. This finding is important, as adherence is considered the most limiting factor for ACT performance and pulmonary rehabilitation in CF.⁹ Patient adherence to recommended self-management interventions such as ACT depends on perceived reward value, which could be achieved through games. In addition, Swisher et al (2008) found that the unpleasantness associated with physical activity outweigh any positive associations in people with CF who do not enjoy physical activity sessions.³⁶ Thus, VR training might address this problem.

This is the second systematic review addressing the effects of VR exercise on cardiopulmonary function in CF. In 2016, Carbonera et al conducted the first systematic review that included five articles.³⁷ However, the review excluded breath-control exercise. Thus, this systematic review has run the search again, taking into consideration the fast development of technology and included breath-control VR exercise. In addition, this systematic review included outcomes for cardiopulmonary exercise testing and exercise tolerance in general, PFT, fatigue, motivation, and adherence. Furthermore, this systematic review included 10 studies, compared with 5 studies only for the previous systematic review. Moreover, this review included ongoing trials from gray literature that could give further insights about the future of this field in management of CF.

Limitations of the study

This systematic review is not without any limitation. It was not feasible to conduct a meta-analysis owing to the heterogeneity of the data, different study designs, outcome measures, methods, protocols used in the included studies, and potential for missing unpublished data. In addition, the systematic review included only 10 studies, with only one randomized controlled trial. Accordingly, this systematic review findings need to be further enhanced by running more randomized controlled trials with larger sample size.

Impact

This review summarizes the effects of VR exercises on cardiopulmonary function and increased adherence to aerobic exercise and breath-control exercise in CF. As reported in a previous study that interviewed physiotherapists regarding including VR in their rehab programs, VR helped to improve pediatrics' motivation toward aerobic exercise, but it is still a challenge for therapists to choose the correct game for each specific case.¹³ Moreover, taking into consideration the current circumstances regarding the COVID-19 (corona virus disease) pandemic, and for any future unexpected circumstances, physiotherapists started to adapt their programs remotely to continue delivering their programs and to avoid deteriorations in different populations.³⁸ Subsequently, findings of this review revealed that using VR games may help in airway clearance interventions and cause a positive effect on cardiac function, and improve adherence and motivation during the exercise sessions in people with CF. In addition. This review provides an insight about the importance of further investigating this mode of physiotherapy service delivery in CF in light with the limited number of studies.

Footnotes

Authors' Contributions

M.Z.D. and A.A. were responsible for the data collection, data interpretation, study design, and writing the first draft of the article. S.D. was responsible for revising the article and data interpretation. All authors have participated in editing and completion of the article. All authors have read and agreed to the published version of the article.

Data Availability

All data are fully available without restriction.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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