PHYSICAL THERAPY RESEARCH SCIENTIFIC RESEARCH ARTICLE Efficacy of physical exercise using the balance board game on physical and psychological function in patients with hematological malignancies confined to a bioclean room Daiyu KOBAYASHI, PT, MS1,2, Reiko WATANABE,MD,PhD3,4, Mitsuru YAMAMOTO,MD,PhD1 and Masahiro KIZAKI,MD,PhD2,4 1) Department of Rehabilitation, Saitama Medical Center, Saitama Medical University 2) Medical Science, Graduate School of Medicine, Saitama Medical University 3) Department of Hematology, International University of Health and Welfare 4) Department of Hematology, Saitama Medical Center, Saitama Medical University ABSTRACT. Objective: This study aimed to define the efficacy and features of physical therapy (PT) using the Nintendo Wii Fit U (Nintendo Inc., Kyoto, Japan) in patients with hematological malignancies confined to a bioclean room. Method: A total of 33 patients with hematological malignancies confined to a bioclean room were enrolled in this study. This study was designed as a randomized crossover test between two week- long interventions: PT program (Therapist PT) and Wii Fit U program (Wii PT). We compared the efficacy of Wii PT and Therapist PT with regard to physical and psychological function test scores. Results: Of the 33 patients, 22 were analyzed. The validity of the crossover design was demonstrated, as there were no sig- nificant differences in period and carryover effects between the two groups. Therapist PT resulted in signifi- cantly better improvements in fatigue scores and total mood disturbance (TMD) scores in the Profile of Mood States short-form Japanese version compared to Wii PT (fatigue score, -5.2±8.3 vs 2.7±8.2; TMD score, -22.5±32.8 vs -2.6±20.5; p<0.05). Physical function improved post-Wii PT and post-Therapist PT in- terventions (p<0.05), and there was no difference in treatment effect. Conclusion: Improvements in physical function were clearly observed following the use of Wii PT in patients confined to a bioclean room. However, compared to Therapist PT, Wii PT was less effective in improving the psychological function of patients. Key words: physical therapy, Virtual game, Hematological malignancies (Phys Ther Res 23: 172-179, 2020) Patients with hematological malignancies are prone to in- and physical disuse syndromes because they spend long pe- fection, anemia, and bleeding due to cytopenia and require riods bedridden due to neutropenic fever and general fa- long-term treatment. Patients with hematological malignan- tigue1). Additionally, patients with hematological malignan- cies receive steroid medications during cytotoxic chemo- cies can lose physical and psychological conditioning be- therapy and have to remain in a limited tight space, such as cause of the narrow space and their disease 2,3 ) . Therefore, a bioclean room, during intensive therapy, to prevent infec- physical therapy (PT) interventions play an important role tion. in the prevention of complications, including disuse syn- These patients are at risk for psychological disorders drome and depression, especially in patients confined to a bioclean room. Previous studies on PT in patients with he- Received: January 6, 2020 matological malignancies have demonstrated that using a Accepted: May 11, 2020 bicycle ergometer and strength training can successfully Advance Publication by J-STAGE: August 20, 2020 maintain a patient’s physical and psychological activities4-6). Correspondence to: Daiyu Kobayashi, Department of Rehabilitation, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Despite this, patients often cannot undergo scheduled Kawagoe, Saitama 350-8550, Japan PT sessions conducted by a therapist because of nausea, di- # e-mail: [email protected] arrhea, and general fatigue, with high fever during and after doi: 10.1298/ptr.E10021 intensive chemotherapy or total body irradiation before he- Efficacy of physical exercise using the balance board game 173 matological stem cell transplantation. Although these 2．Design and study procedure symptoms are usually temporary, it is difficult for patients This was a randomized, open-label, crossover study. to fit themselves into the therapist’s schedule due to the ef- The interventions included 1 week of PT conducted by a fects of chemotherapy. Recently, the Nintendo Wii Fit therapist (Therapist PT) and 1 week of PT using the Wii Fit (Nintendo Inc., Kyoto, Japan) has been recognized as a U (Wii PT). Each patient was randomly assigned to one of unique and effective tool for maintaining physical activity two groups using a random number table. A random num- in patients7-10). Previous studies have reported that PT using ber table was created by a computer operated by individuals a virtual game was effective in improving physical and psy- unrelated to the study. In one group (Wii PT/Therapist PT), chological function in older adults 7-9 ) . Another study re- the patients received Wii PT for the first week (Period I) vealed that the Wii Fit was used successfully and safely as and Therapist PT the following week (Period II). In the a form of PT for elderly patients with hematological malig- other group (Therapist PT/Wii PT), the patients received nancies10). PT for the first week (Period I) and Wii PT the following The Wii Fit U is a virtual game that uses software and week (Period II) (Figure 1). a balanced Wii board (wireless type Gravicorder; Nintendo Inc., Kyoto, Japan). Wii Fit U is relatively inexpensive, and 3．Intervention exercises are performed on the balance Wii board using Therapist PT comprised an aerobic exercise using a center-of-gravity transfer. The greatest advantage of using bike ergometer, strength training using a “TheraBand” and Wii Fit U for PT is that it requires only a 1.4 m × 1.4 m the patient’s own weight, stretching, and educational guid- square area during use. Thus, we introduced Wii Fit U as a ance regarding daily exercise. Aerobic exercise was per- PT intervention, especially designed for use in the bioclean formed with 40% to 60% intensity of target heart rate in the room in our hospital. Karvonen formula and with an intensity between 11 and 13 This study aimed to clarify whether PT using the Wii on the Borg scale. Strength training was performed with an Fit U improved the physical and psychological function of intensity between 11 and 13 on the Borg scale, and the patients with hematological malignancies confined to a bio- number of exercises was 3 to 5 sets (10 exercises per set). clean room. Wii PT comprised “cycling,” “table tilt,” and “balance Mii” and other activities based on the patients’ preference Method and if time permitted, including aerobic exercise, transverse and back-and-forth balancing, and strength training based 1．Participants on a previous study7). Each intervention was conducted by a Patients were included if they: 1) had a hematological therapist, with an exercise duration of 30 min/day for 5 malignancy, 2) received PT in the bioclean room at Saitama days a week. This program lasted a total of 2 weeks for Medical Center, Saitama University, between April 2016 each patient. and March 2017; 3) were aged ! 18 years; 4) had an East- ern Cooperative Oncology Group Performance Status 4．Outcome measures (ECOG-PS) score of 0 or 1, and 5) had no organ dysfunc- We evaluated general characteristics, including age, tion. Performance status was evaluated by a physical thera- sex, body mass index, disease diagnosis, disease treatment, pist before hospitalization and in a bioclean room. Patients period from start of treatment to Assessment I, patient’s with grade 2 or worse Common Terminology Criteria for stage according to CTCAE (fever, pain, malaise, vomiting, Adverse Events version 4.0 (CTCAE) were excluded. Writ- nausea, diarrhea, constipation), ECOG-PS, and Barthel in- ten informed consent was obtained from all patients. Fi- dex (BI) from patients’ medical records. We also measured nally, 33 consecutive patients who were treated in the bio- general characteristics just before the start of PT (Assess- clean room at Saitama Medical Center, Saitama Medical ment I). University, were enrolled in this study. All patients had se- To assess the physical function of patients, we used vere neutropenia with absolute neutrophil count < 500/μl the Timed Up and Go (TUG) test11), functional reach (FR) after high-dose chemotherapy. We calculated the sample test12), and 30-s chair stand (CS-30) test13) as indicators of size using R software version 2.8.1 (The R Foundation for physical condition. The TUG test required participants to Statistical Computing, Vienna, Austria). With an α-error of stand from a sitting position, walk for 3 m, turn 180°, walk 0.05, β-error of 0.8, effect size of 10, standard deviation of back 3 m, and sit down again. The TUG walking speed was 25, and individual difference quotient of 1.5, the sample the maximum effort, and the time taken to complete the size was calculated as 32. TUG test was measured. The FR test required the patient to This study was approved by the local institutional re- stand with arms extended with 90° shoulder flexion. Then, view board of Saitama Medical Center, Saitama Medical the maximum forward reach was measured. The CS-30 test University (permit number, 1403). was performed with the patient’s arms in front of their chest, and the number of times the patient could sit and 174 Kobayashi,etal. Enrollment Assessed for eligibility (n=33) Randomized Allocation Group of Wii PT / Therapist PT (n=13) Group of Therapist PT / Wii PT (n=20) Assessment I Intervention of Wii PT (n=13) Intervention of Therapist PT (n=20) Lost to follow-up (n=3) Lost to follow-up (n=5) Period I • Worsening general condition (n=2) • Worsening general condition (n=3) • Disease progression (n=1) • Disease progression (n=2) Assessment II Cross-over Intervention of Therapist PT (n=10) Intervention of Wii PT (n=15) Lost to follow-up (n=3) Period II • Worsening general condition (n=2) • Withdrawal of consent (n=1) Assessment III Analysis Analyzed (n=10) Analyzed (n=12) Figure 1.